Nutrition for Health: An Agenda for Action

Table of Contents

1. Overview

2. Current Situation

3. How Nutritional Health is Determined

4. Strategic Directions

5. International Dimensions

6. Indicators of Change

7. Action -- A Shared Responsibility

Appendix 1:The World Declaration on Nutrition and Global Plan of Action: Highlights

Appendix 2: Members of the Joint Steering Committee

Appendix 3: Background Working Documents

Spring 1996

Dear Partners,

The health and well-being of individuals and the prosperity of the nation require a well nourished population. We all have a role to play in improving the nutritional health of Canadians.

Nutrition for Health: An Agenda for Action is the result of a multisectoral, Canada-wide process that gathered the collective wisdom of groups, organizations, and individuals. Communities and organizations can use this Agenda for Action to develop plans specific to their needs and capacities.

Implementation is up to all of us. The Joint Steering Committee recommends the establishment of a multisectoral network at the national level to provide leadership and co-ordination to this Agenda for Action.

Nutrition for Health: An Agenda for Action is focused on stimulating and accelerating action by all sectors towards achieving healthier people. Working together we can make a difference.

Joint Steering Committee

1. Overview

The purpose of Nutrition for Health: An Agenda for Action is to ensure integration of nutrition considerations into health, agriculture, education, social and economic policies and programs.

Why an Agenda for Action ...

Achieving "nutritional well-being for all people in a peaceful, just and environmentally safe world"¹ is an important goal and Canadians can make a significant contribution. Efforts to improve nutritional health require action by many sectors. Nutrition for Health: An Agenda for Action provides a model to address nutrition issues in communities across Canada. It includes a discussion of international issues and how foreign policy interconnects with domestic policy with regard to nutrition.

This document recognizes the following reasons to broaden support for nutrition.

• A well nourished population contributes to a healthier, more productive population, lower health care and social costs, and better quality of life.
• While the nutritional health of Canadians is good, it is not optimal.
• Eating patterns of many Canadians contribute to the high incidence of nutrition-related chronic diseases.
• Diet and activity patterns are second only to tobacco when considering non-genetic factors that contribute to mortality.
• Inequities in nutritional well-being exist, particularly for the socio-economically disadvantaged.
• Food choices are complex decisions which are influenced by a dynamic relationship between individual and environmental factors.

How it will work ...

It is the intent of Nutrition for Health: An Agenda for Action to stimulate widespread action in mutually supportive directions, creating momentum and positive results for nutritional health.

The action that communities undertake will be as unique as communities are unique. Local partners may differ, a community's needs and capacities will vary, but the sum of the actions will be significant.

Building on current knowledge and accomplishments, Nutrition for Health: An Agenda for Action encourages policy and program development that is coordinated, multisectoral, supports new and existing partnerships and promotes the efficient use of limited resources.

Who it is for ...

Nutrition for Health: An Agenda for Action is targeted to community leaders and decision makers in a broad range of sectors. The policies and actions of governments, industry, non-government and voluntary organizations, affect the nutritional health of Canadians.

This Agenda for Action can be used by anyone committed to improving the nutritional health of the population. It has been specifically designed to facilitate nutrition planning at all levels. Its directional, rather than prescriptive nature, allows for application by many different players, in many different settings.

What it consists of ...

It describes our current situation, builds on the Framework for Population Health, identifies priority areas for action, considers the implications of our international context, and includes indicators to monitor change in conditions related to nutritional health.

Where it all began ...

Rome, 1992: At the International Conference on Nutrition, a joint venture of the World Health Organization (WHO) and the Food and Agriculture Organization (FAO), participating countries endorsed a World Declaration on Nutrition (Appendix 1) and made a committment to develop national plans of action for nutrition.

With representation from diverse sectors across the country, Health Canada established a Joint Steering Committee (Appendix 2) to prepare a national nutrition plan. The Joint Steering Committee commissioned a series of studies (Appendix 3), drafted a plan, consulted stakeholders across Canada and then revised the plan. This document, Nutrition for Health: An Agenda for Action, is the result.

2. Current Situation

Nutrition-related conditions contribute to spiralling health care costs, lost economic productivity and decreased quality of life. The changing social, physical and health system environments can have a significant impact on nutritional health.

The Canadian people are changing. The population is aging, the elderly are staying in their homes longer, cultural diversity is increasing and the structure of the family is changing. Only 10% of families have a stay-at-home-spouse. Seventy percent of preschool children are in care arrangements while parents work or attend school. With growing time pressures, and less time to devote to food related activities, convenience foods and the food service sector play an increasingly important role in food choices and eating patterns.

The economic climate is suffering from new pressures. Accumulated debt, deficits, globalization, liberalizing trade, and the impact of technology are contributing to a fundamental restructuring of the economy. Domestic markets face increased competition. New export markets provide opportunity for wealth generation. At the same time, some people have become more vulnerable during this transition. Many Canadians have been affected by unemployment and reduced real income. Poverty among young families, lone seniors and socially isolated people is on the rise.

The social climate is undergoing change. For some, the primary influences on behaviour and life choices remain the traditional ones such as family, school, and religion, but for others, the media and peer groups are major sources of information and serve as role models for eating habits. Healthy food options must be provided in a variety of settings and the widespread promotion of healthy eating messages is needed.

Social programs are being re-evaluated as governments struggle with balancing budgets and reducing debt. Under review are traditional Canadian values such as universality, an income safety net, and the extent of social policy in general. The resulting shifts in social policies can have a significant impact on nutritional health.

Nutrition-related concerns do exist. In fact, nutrition problems contribute to spiralling health care costs, lost economic productivity and decreased quality of life. These problems are documented in the background papers outlined in Appendix 3.

Nutrition-related chronic diseases prevail. Cardiovascular disease, diabetes, osteoporosis and cancer result in premature death and disability for many people each year. The role of healthy eating and lifestyle in reducing the incidence of these multifactorial diseases is significant. Food choices of many Canadians result in inadequate amounts of some essential nutrients and excess amounts of fat and saturated fat.

Almost one quarter of Canadians are overweight. Physical inactivity combined with excess food energy intake, contribute to this problem. Obesity in children is increasing and appears to be related to inadequate exercise. Eating disorders remain a significant problem.

Disparities in nutritional well-being are evident. Health and nutritional problems are more common among vulnerable groups. There is evidence of micronutrient deficiency in some vulnerable groups, for example iron deficiency is seen in children within the aboriginal community.

Among those of lower socio-economic status, the incidence of low birth weights is higher and the rate of breastfeeding initiation is lower, than among the general population. Programs exist for groups such as high risk pregnant women, but they are not available to all who need them.

Some individuals see their access to foods threatened. The ability of certain vulnerable groups to obtain the food they need for their nutritional well-being without jeopardizing other basic needs, is of real concern. The use of food banks has risen dramatically and more food provision programs appear every day. Underlying causes of income insufficiency need effective solutions.

Health systems are being reformed, changing the way services are delivered, who delivers them and how resources are allocated. Health services are shifting from institutions to community-based delivery systems and the role of regional planning groups in decision making is expanding. Greater recognition is being given to the benefits of health promotion and disease prevention. Focused efforts to integrate nutrition services into existing and evolving health systems are necessary.

Nutrition research is lacking. Nutrition research includes a range of activities and methods - all integral to the understanding of nutrition problems and to the identification of solutions. Current priorities and existing research efforts are not aligned. Nutrition research is underfunded generally, and funding lies almost totally in biological sciences. The availability of nutrition expertise is threatened by insufficient funding of nutrition research. Monitoring the nutritional health of the population is essential, but is hampered by a lack of national data.

The food supply is being reshaped by many factors; new technologies in plant breeding, crop disease control, production, processing and novel ingredients; trade agreements that aim at a free flow of food between countries; and consumer demand for certain foods. Canada produces a safe, high quality food supply for domestic consumption and export, and imports many processed foods as well as out-of-season, tropical and non-traditional foods. Interest in the long term sustainability of the food supply is high. Issues related to sustainability of natural resources, including food, require cooperation between producers, food processors, retailers, governments and consumers.

The international context has always been important to Canada. It is becoming increasingly so. The rapid evolution of regional trading blocs and the liberalization of trade, the swift and relatively free flow of people across borders, Canada's significant immigration levels and the development of almost instantaneous communications capabilities have brought Canada closer to the rest of the world. Food and nutrition issues are no exception to this trend.

System wide reform is underway, resulting in policy and program re-direction in many environments. Efforts to reduce nutrition problems will need to work within the climate of accelerated reform and must focus on innovative and collaborative solutions. The next section, How Nutritional Health is Determined, discusses the Framework for Population Health, a model that is both comprehensive and responsive to today's complex nutritional health issues.

Selected Nutrition-Related Concerns

• Cardiovascular disease accounts for 37% of all male deaths and 41% of all female deaths.
• Cancer accounts for 28% of all male deaths and 27% of all female deaths.
• Approximately 23% of Canadians are overweight.
• The prevalence of obesity in children has increased in the past decade from 14% to 24% among girls and from 18% to 26% among boys.
• Breastfeeding initiation and continuation varies widely across Canada, from an average of 75% initiation and only 30% continuation for 4-6 months.
• The rate of low birth weight in Canada is 5.7% while in certain subpopulations of the very poor living in the inner city, low birth weights are as high as 10%, rates comparable to those in developing countries.
• There are approximately 460 food banks helping 2,400,000 Canadians including 900,000 children.
• There are approximately 600 meal programs, with over 40,000 volunteers delivering meals to dependent seniors and shut-ins across the country.

3. How Nutritional Health is Determined

Powerful economic and social forces, combined with individual practices and capacities, influence what foods are available, and what foods are chosen.

Canada has advanced understanding about the effect of people's lifestyles and socio-economic circumstances on their health and well-being. Reports such as the "Lalonde Report" (A New Perspective on the Health of Canadians, 1974), Achieving Health for All (1986) and the 1988 Ottawa Charter on Health Promotion have helped to create this understanding.

A more recent report, Strategies for Population Health, Investing in the Health of Canadians, (1991)² builds on earlier work and positions determinants of health within the Framework for Population Health. This population health model has application to nutritional health.

Food choices, which play a direct role in nutritional health, significantly influence health status. Taking personal responsibilty for one's health is important, however food choices are not simply a matter of personal choice. Economic and social forces, together with factors related to the physical environment, influence what foods are available and a person's individual capacity to make choices.

Actions by policy makers and community leaders must consider all determinants of health and must be based on a foundation that includes research, information and public policy.

Individual Factors

Basic biology, genetic endowment, health status and individual health practices impact on nutritional health. Nutrition programs have long recognized the importance of knowledge, attitudes and skills in developing positive health practices such as appropriate food choice behaviour. The individual's capacity to adopt a healthy pattern of eating is influenced by both the availability and understanding of information provided by sources such as Canada's Food Guide to Healthy Eating and food labels. Individual capacity involves more than knowledge about what to eat. It includes food preparation skills, time to prepare, and personal buying power, all of which are profoundly influenced by the following environmental factors.

Collective Factors

Social and Economic Environment

Economic conditions influence the ability of individuals to acquire a healthy diet. Unemployment and inadequate financial resources reduce individual capacity to meet daily need for food. The social environment, with its diverse social mores, cultural values, support networks, traditions and practices, influences people's food choices. Settings vary -- home, school, workplace, recreational site, restaurants -- each affecting food choices. Advertising and the media are key sources of nutrition information.

Physical Environment

Food is part of the physical environment. The type of food available in grocery stores, workplaces, schools and from the food service sector is a powerful influence on food choices. The composition of food can support the consumption of a diet consistent with nutrition guidelines and label information can assist consumers in making healthy food choices.

Not all consumers are in a position to choose their own food. Children at home, in day care and at school; individuals in hospitals and chronic care facilities; prison inmates; military personnel; individuals receiving meal services, such as Meals on Wheels; those in congregate dining programs, and others fed in institutional settings, are in environments where food is provided.

Health Services

Access to the full range of health, social and community services, including nutrition services, is essential. Appropriate nutrition services encompass healthy eating programs, public education, and access to individual care and counselling. Those with special nutrition needs or health conditions, such as pregnant women, breastfeeding mothers, the elderly, the sick and those with therapeutic nutrition needs, require access to care, counselling and education.The collective and individual factors are intrinsically connected to the third component of the Framework for Population Health the tools and supports that are the foundation for action.

Foundations For Action

Research, information and public policy must form the foundations for action. Nutrition research encompasses a continuum of activity including research in basic biological sciences, epidemiology, clinical nutrition, determinants of food choices, dietary surveys, and the evaluation of programs, practices and policies. Information is essential for informed decision making at all levels from individual consumer decisions to organizational and public policy decisions. Public policy can help to create an environment that will promote health and nutritional well-being. Public policy must be based on informed decision making and research must provide relevant information to policy makers.

The Framework for Population Health provides an overview of the determinants of health and their interrelationships. The next section, Strategic Directions, builds on this population health model and describes a multilevel, multisectoral approach to improving the nutritional health of the population.

Canada does not exist in isolation. The world trade system increasingly affects domestic policy and programs. Internationally, Canada has a long tradition of assistance to developing countries. These linkages are discussed in section 5, International Dimensions.

4. Strategic Directions

Reinforce healthy eating practices

Support nutritionally vulnerable populations

Continue to enhance the availability of foods that support healthy eating

Support nutrition research

Nutritional health depends on several elements including comprehensive health and social policies, nutrition recommendations and guidelines, a safe food supply, and consumer interest in health and nutrition.

The four Strategic Directions arise from an analysis of the current situation in Canada. For each Direction, actions were considered to address the determinants identified in the Framework for Population Health, including individual factors, collective factors, and foundations for action. The selected actions are all high priority actions where resource allocation will have the greatest impact on health.All actions are interrelated, overlapping, and complementary.

Many communities across the country are already conducting health-enhancing activities. The intent of Nutrition for Health: An Agenda for Action is to build on these strengths, support activity already aligned with the Strategic Directions and stimulate new activity to achieve healthier people.

Nutrition issues are complex and involve many sectors. Intersectoral solutions are encouraged, with the formation of networks and coalitions being an essential component of successful action. The formation of a multisectoral co-ordinating network of interested partners will be an important first step. Sustained cooperation between sectors will require commitment, a willingness to align efforts, and the existence of facilitating structures. Involving people and their communities in comprehensive, multidisciplinary planning will yield positive health results.

Reinforce healthy eating practices

National nutrition policies provide the foundation for healthy eating programs. Nutrition Recommendations, Canada's Guidelines for Healthy Eating, and Canada's Food Guide to Healthy Eating all contribute to our understanding of healthy eating practices.

Canadians need to improve their food choices and be more physically active in order to minimize the risk of nutrition-related chronic diseases. Eating patterns need more emphasis on bread, cereals, grains, fruit and vegetables, and adequate intakes of essential nutrients, and less emphasis on fat and saturated fat. Lack of physical activity, combined with excess food energy intakes, contributes to the continued prevalence of obesity.

Dietary change has been positive, but slow. Focused action to support healthy eating must occur in policies governing availability of nutrition services in health and community agencies, in programs enhancing consumer skills, and in services delivering care to individuals from birth to old age.

Healthy eating practices will be strengthened by the following: community-based services that include nutrition; schools that provide age-appropriate nutrition education; programs that emphasize practical skill development in reinforcing positive food choices; support for breastfeeding as the cultural norm; media and advertising which disseminate consistent, accurate messages; and food that is labelled to facilitate knowledgeable choice.

Key Actions:

1. Work to include and maintain nutrition services as part of comprehensive health services in both existing and evolving community-based settings.
2. Incorporate nutrition into curricula for children and youth and include quality daily physical education as part of all school programs.
3. Include nutrition in both the training and continuing education programs for health and other community service providers.
4. Improve usefulness of nutrition labelling, increase its availability, and broaden public education on its use.
5. Emphasize practical skill development (food selection, storage and preparation skills) in nutrition education programs for the public.
6. Work with the media to provide responsible public information on healthy eating and physical activity.
7. Protect and promote breastfeeding and improve access to community-based breastfeeding support groups.

Support nutritionally vulnerable populations

Vulnerability may result from several factors such as physical or mental disabilities, lack of education, acute and chronic illness, growth and aging. Poverty is frequently related to increased vulnerability and is often inter-related with other factors. Most at risk are those who are both physiologically vulnerable and socio-economically disadvantaged.

Nutritional vulnerability related to poverty is more prevalent within subgroups of the population including aboriginal people, seniors, refugees, high risk pregnant women, single mothers, low birth weight babies and children. The effects of poor nutrition prenatally and during infancy and childhood will be felt throughout the lifecycle. Data, however, are limited on the nutritional status of these vulnerable groups.

An increasing number of Canadians are turning to food banks in an attempt to meet their food needs. Food banks, originally seen as a temporary system of food relief, now provide charitable food support to growing numbers of Canadians. A variety of smaller scale, community food initiatives, such as collective kitchens, community gardens, food buying clubs, school-based breakfast and lunch clubs, have emerged to address the problem. The risk of chronically compromised food consumption is a serious public health concern.

Vulnerable groups require special support. Employment creation, income support and community-based food related policies and programs must be implemented to protect the nutritional health of vulnerable groups.

Key Actions:

1. Work with social policy decision makers to address the nutritional needs of vulnerable people.
2. Develop a data base to better define the vulnerable populations and to better understand their food and nutrition issues.
3. Monitor the cost of a nutritious food basket and use this information in the development of education programs and income support initiatives.
4. Strengthen the food and nutrition component of community programs and services for vulnerable groups, including acute and chronically ill people.
5. Provide broader and more consistent access to prenatal nutrition programs for vulnerable pregnant women.
6. Ensure that families have the supports they need to nourish their children adequately.
7. Ensure that nutrition is part of the continuing care programs in the community.
8. Support community meal programs to meet the nutritional needs of seniors or those who cannot leave home.

Continue to enhance the availability of foods that support healthy eating

Consumers value their access to quality foods. In Canada the food supply provides safe, nutritious food at both the retail and food service levels.

Policies that govern food production, pricing, composition, preparation, labelling, claims, and advertising influence the nutritional quality of the food supply. Food consumed away from home is making an increasingly important contribution to nutritional health. Small positive changes in the composition of food can have a significant impact on the nutrient content of the Canadian diet.

New technologies in food production and processing require ongoing evaluation. Public apprehension with respect to biotechnology in food production covers a range of issues including product safety, quality, and choice. Continued consumer participation in identifying their issues is fundamental.

Sustainability of all resources, including food, is essential to maintain a physical environment that supports health. In its broadest sense, sustainability refers to conserving or enhancing natural resources and the quality of the environment for future generations. This has special significance for indigenous food supplies which can be affected by environmental contamination as well as by physical changes to the land resulting from development activity.

Food imports and liberalized trade bring new challenges for policy makers and food inspection. Healthy eating patterns are supported by the continued review and evolution of policies which influence the sustainability, safety, availability and nutritional composition of food.

Key Actions:

1. Ensure that policies relating to food production, composition, addition of nutrients to foods, and marketing of food, promote increased availability of foods with compositional characteristics that support healthy eating.
2. Work with the food service sector to increase the availability of foods that support healthy eating.
3. Implement policies and incentives in publicly funded organizations (e.g. schools, hospitals, government agencies) to promote increased availability of foods that support healthy eating.
4. Maintain high standards of food safety through multisectoral cooperation to evolve food regulation, inspection, quality control and consumer safe food handling practices.
5. Engage in active dialogue with consumers about issues of food safety, food quality and new food technologies.
6. Support agriculture and food policies that are consistent with environmentally sustainable practices.

Support nutrition research

Nutrition research covers a broad scope of activity. Biochemistry, molecular biology, clinical research, epidemiology and dietery surveys provide basic building blocks to better define the link between nutrition and chronic disease as well as essential nutrient requirements. Research on determinants of food choice and research to evaluate programs, practices and policies are equally important. Recognition of the value and importance of research across the continuum is essential.

There is inadequate total funding for nutrition research and an urgent need for long-term stable funding. Existing funds, while limited, are most often directed towards basic research. Program and practice-based research in clinical and population health settings needs strengthening. The availability of nutrition expertise is threatened by inadequate support for nutrition research.

Research efforts are not aligned with current nutrition priorities. Strengthening research to support nutrition priorities is vital.

Collaborative, multidisciplinary projects involving many sectors encourage combining of expertise and financial resources. Traditional scientific methods are being complemented with diverse methodologies such as qualitative research, program evaluation and case study discussions.

Improving the nutritional health of Canadians is dependent on our ability to monitor nutritional health and respond appropriately. A mechanism is needed to integrate and disseminate data to ensure it is available for practice, program and policy decisions.

Key Actions:

1. Establish research priorities that are aligned with the Strategic Directions and that consider the continuum of nutrition research activity.
2. Find effective mechanisms to expand access to research dollars from granting organizations for basic, clinical and applied research.
3. Access research funds from local, non-traditional sources (e.g. service clubs, industry).
4. Develop a data base on relevant indicators affecting nutritional health including nutritional status, food practices, social, economic, cultural and educational data.
5. Develop mechanisms to integrate and disseminate data to enable evidence-based program and policy decisions.

5. International Dimensions

Canada is part of the global community. Nutrition is integral to Canada's official development assistance, trade, and related knowledge and technologies.

The international context is increasingly important to nutrition at home and abroad. Canada is committed to a policy of strong international trade. To facilitate trade, Canada supports the international harmonization of regulations and the removal of trade barriers. In food trade the implications are important. By choice, and by necessity, Canada relies on importation for a substantial part of its food usage and on export of Canadian-produced food commodities to balance the trade picture. In a very real sense, Canada's food security depends upon the stability of world food trade. Canada has made a commitment to populations in developing countries and recently re-stated its commitment on making progress towards official development assistance as 0.7% GNP when the fiscal situation allows it. Featured in this commitment is Canada's involvement in health and nutrition worldwide.

Food, nutrition and health are priorities for Canadian Official Development Assistance (ODA). The United Nations currently estimates that approximately eight hundred million people in developing countries are malnourished. Many more suffer from micronutrient malnutrition. Malnutrition, even in mild to moderate cases, multiplies the number of child deaths caused by infections. Given the importance of well nourished populations for world peace and security, Canada is contributing resources to help alleviate this situation. Canada has identified six development program priorities, one of which is basic human needs, including nutrition.

Canada is collaborating with international organizations to promote breastfeeding, improve the nutrition of young children, and eliminate micronutrient malnutrition for all age groups in developing countries. Canada has taken a leadership role in the global program to eliminate iodine deficiency disorders and vitamin A deficiency. It is estimated that 2.8 million children under five suffer from clinical vitamin A deficiency (xerophthalmia) exists. Another 251 million children live where vitamin A depletion is prevalent, putting them at increased risk of mortality and blindness. Approximately 1,570 million people live in regions where iodine deficiency diseases are common, 656 million exhibit goitre and 5.7 million overt cretinism. Children born in these situations are at risk of impaired brain development. There is room for Canada to expand its work in the control of these disorders and other forms of malnutrition.

Canada's development assistance is used in activities to alleviate poverty and improve food access. One focus is to increase incomes of the absolute poor, including landless labourers and subsistence farmers. Canada continues to play an important role in the international Expanded Programme of Immunization. There are three fundamental needs for improvement of young child nutrition: control of infection (including health care, immunization, water and sanitation), adequate care including feeding practices, and access to adequate food (quantity and nutritional quality). This thrust characterizes Canada's approach in the basic needs aspect of official development assistance. A recent Canadian target in this area is to commit 25% of its ODA to basic human needs.

Research can improve food security and nutrition. Over the last three decades, international research has helped stimulate the production of staple foods for many countries. This research has solved problems related to yields, pests, diseases, management as well as food storage and preservation. Through international collaboration in the collection, exchange and study of agricultural and wild plant materials, crop varieties with superior agronomic and nutritional characteristics have been developed. Higher yields have improved the incomes and diets of poor farm families and rural labourers, provided more affordable food and better nutrition for urban dwellers, and stimulated economic growth in many countries. With superior crop varieties made available world wide, the farm and food sectors of all countries benefit in terms of improved productivity, better disease resistance and more sustainable use of natural resources. International research centres also help preserve global biodiversity, the rich endowment of plant and animal species.

Food safety and quality benefit from global networks. Canadians consume a growing volume of imported foods. In order to ensure that foreign products meet the same high quality standards as Canadian products, the exporting countries must have appropriate food safety and quality programs. In addition, foods imported into Canada are monitored to ensure that they meet the standards Canada sets for our own producers and processors. International organizations such as the Food and Agriculture Organization (FAO) help developing countries establish their own food safety and quality programs through technical assistance. The FAO and the World Health Organization (WHO) have developed international food standards through the Codex Alimentarius Commission. Canadians have contributed to the development of these international standards. As developing countries put into place their own food safety and quality programs, international food standards are increasingly being used. In addition to ensuring food quality, this harmonization of standards facilitates international trade and access to global food markets.

6. Indicators of Change

Monitoring change is an important part of efforts to maintain and improve the nutritional health of the population. A system based on core indicators can provide valuable information.

Sixteen core indicators are included in Nutrition for Health: An Agenda for Action. Thirteen have a national focus and three relate to international issues. A rationale for the selection of each indicator, plus measurement specifications and data sources, are provided in a background paper (Appendix 3).

It is recognized that a limited number of indicators cannot capture the full breadth and depth of nutrition-related conditions, or replace a comprehensive nutrition monitoring system. However, a system based on core indicators can provide information in order to:

• monitor changes over time in nutrition-related conditions;
• provide a warning of need to consider planned actions; and
• maintain awareness of the state of nutrition among the various sectors involved in nutrition planning.

Key criteria for the selection of the core indicators include a recognition of their importance with regards to nutrition, the availability of data on an ongoing basis, and the feasibility of data collection. In order to develop a workable nutrition indicator system, it was essential to make use of existing and readily available data. Certain indicators considered, therefore, were eliminated due to lack of data. The core indicators presented here will be reviewed and revised as dictated by need and the availability of data. In time, health promotion as well as health problem indicators will be more fully incorporated.

Data for the core nutrition indicators are available at the national level and for many of the indicators at the provincial and regional levels as well. In addition, data for many of the indicators are reported according to age groups, sex, and by proxy measures of socio-economic status.

The categories of core indicators are based on the Framework for Population Health. Core indicators include those that relate to outcomes, determinants and process.

The Framework for Population Health can be used for the development of national core indicators, and also provides a model for the collection of data according to the needs of different jurisdictions.

Core nutrition-related indicators

NATIONAL

Outcome Indicators:

• potential years of life lost due to ischemic heart disease and stroke prevalence of hypertension
• incidence of certain site-specific cancers
• incidence of low birth weight
• prevalence of overweight and underweight

Determinant Indicators:

• estimated intake of grains, fruits and vegetables
• estimated intake of fat
• level of recreational physical activity
• initiation and duration of breastfeeding
• nutrition awareness/attitudes
• food bank use
• cost of a "nutritious food basket" in relation to income

Process Indicator:

• existence of a national multisectoral co-ordinating network

INTERNATIONAL

Outcome Indicators:

• prevalence of iodine deficiency disorders worldwide
• prevalence of vitamin A deficiency worldwide

Process Indicator:

• Canada's total Official Development Assistance (ODA) as % of GNP and proportion of ODA allotted to Basic Human Needs

7. Action -- A Shared Responsibility

Implementation, the next step, is the responsibility of all of us. The formation of networks of interested partners will allow for sharing of ideas and collaboration.

Implementation is the next step to Nutrition for Health: An Agenda for Action and is a shared responsibility. Individual commitment to improving nutritional health will be the stimulus for action. That action will be as unique as communities are unique. The flexible design and broad scope of this framework was intentional, in that it allows users to choose options best suited to their own needs and capacities.

The Joint Steering Committee believes that the formation of networks will be pivotal to implementation. Through networks, interested partners can share ideas, support one another, learn, collaborate and monitor progress. Joint Steering Committee members encourage users to establish networks appropriate for their own nutrition initiatives.

The cooperation of diverse sectors, brought Nutrition for Health to this stage. That same cooperative spirit is needed to mobilize resources for the next phase. The establishment of a multisectoral network at the national level is recommended to provide leadership, coordination and ongoing support to the Agenda for Action.

Use Nutrition for Health: An Agenda for Action as a catalyst and support for:

• dialogue with decision makers and politicians;
• setting policy and advocating for policy change;
• discovering new channels of action;
• creating partnerships;
• gaining cooperation among agencies;
• establishing local goals and responsibilities;
• broadening support for nutrition;
• developing new products and services;
• expanding existing effective programs and services;
• setting priorities in programs, research, product development and resource allocation; and
• educating communities, community leaders, decision makers, media, clients, groups and agencies about the role of nutrition in health and their role in taking action.

Appendix 1

The World Declaration on Nutrition and Global Plan of Action: Highlights

Participating countries endorsed a World Declaration on Nutrition and a Global Plan of Action for Nutrition. The World Declaration on Nutrition affirms that "access to nutritionally adequate and safe food is a right of each individual." It further identifies nutrition as a precondition for the development of societies and a key objective of progress in human development. Asserting that nutritional well-being "must be at the centre of ... socio-economic development plans and strategies," the Declaration calls on countries to set measurable goals and timeframes for action on nutrition and food issues, with the overall goal of "nutritional well-being for all people in a peaceful, just and environmentally safe world." The Global Plan of Action sets out the following as universal objectives.

• Ensuring continued access by all people to sufficient supplies of safe foods for a nutritionally adequate diet
• Achieving and maintaining health and nutritional well-being of all people
• Achieving environmentally sound and socially sustainable development to contribute to improved nutrition and health
• Eliminating famines and famine deaths

To support achievement of these universal objectives, the Global Plan proposes nine theme areas for action, spanning the health, social, economic, environmental and foreign policy domains.

• Incorporating nutrition objectives, considerations and components into development policies and programmes
• Improving household food security
• Protecting consumers through improved food quality and safety
• Preventing and managing infectious diseases
• Promoting breastfeeding
• Caring for the socio-economically deprived and the nutritionally vulnerable
• Preventing and controlling specific micro-nutrient deficiencies
• Promoting appropriate diets and healthy lifestyles
• Assessing, analyzing and monitoring nutrition situations

Appendix 2

Members* of the Joint Steering Committee

Mr. E.M. Aiston (Chair)
Director General
International Affairs Directorate
Policy and Consultation Branch
Health Canada

Mrs. Iowne Anderson
Aboriginal Community Representative
Ohsweken, Ontario

Ms. Carolyn Barber
Nutrition Coordinator
Department of Public Health
City of Toronto

Ms. Susan Beaubier
Nutrition Specialist
Indian and Northern Health Services
Directorate
Medical Services BranchHealth
Canada

Dr. Micheline Beaudry
Professeure
Departement de nutrition humaine et de consommation
Faculté des sciences de l'agriculture et de l'alimentation
Université Laval

Ms. Helen Brown
Senior Nutrition Consultant
Public Health Branch
Ontario Ministry of Health

Ms. Mary Bush
Nutrition Programs Officer
Systems for Health Directorate
Health Promotion and Programs Branch
Health Canada

Ms. Anne Carrow
Director, Nutrition
Health Promotion and Disease Prevention
British Columbia Ministry of Health

Ms. Carmen Connolly
Chief, Nutrition Programs Unit
Health Promotion Directorate
Health Programs and Services Branch
Health Canada

Mrs. Mary Jane Green
Senior Advisor
International Affairs Directorate
Policy and Consultation Branch
Health Canada

Ms. Suzanne Hendricks
President
National Institute of Nutrition

Mr. H. Philip Hepworth
Director, Program Information and Training
Cost Shared Programs Directorate
Social Development, Education and Employment Group
Human Resources Development Canada

Mr. Wardie Leppan
Executive Director
World Food Day Association of Canada

Dr. Guy Nantel
Senior Scientific Advisor
Health Affairs Division
International Affairs Directorate
Health Canada

Mrs. Heather Nielsen
Nutrition Programs Officer
Systems for Health Directorate
Health Promotion and Programs Branch
Health Canada

Dr. Sonya Rabeneck
Senior Nutrition Specialist
Multilateral Programs Branch
Canadian International Development Agency

Mrs. Lina Robichon-Hunt
Technical Advisor -- Nutrition Food Programs
Centre for Food and Animal Research
Agriculture and Agri-Food Canada

Ms. Marsha Sharp
Chief Executive Officer
The Canadian Dietetic Association

Ms. Christina Zehaluk
Nutritionist Food Directorate
Health Protection Branch
Health Canada

*Position at the time of involvement with the Joint Steering Committee (JSC). The work spanned the period of 1993 to 1996; some members moved to new positions and were not able to continue their involvement with the JSC.

Acknowledgement: The Joint Steering Committee would like to acknowledge the contribution of Barbara Davis, Lavada Pinder and Norman Tape in the development of Nutrition for Health: An Agenda for Action.

Appendix 3

Background Working Documents

In developing Nutrition for Health: An Agenda for Action, the following documents were commissioned:

• Country Paper Canada Supplement, an updated and expanded version of the country paper submitted by Canada's delegation to the International Congress on Nutrition (ICN), that provides information and data on nutrition issues and activities in Canada.
• Environmental Scan, commissioned to elicit insights and views from leaders in industry, health, social services and economics on how to position nutrition as an integral element of a health strategy for Canada.
• Nutrition in Action Survey, a survey of activities in the area of nutrition and food, that assessed progress in key sectors on implementation of the 106 Action Towards Healthy Eating recommendations and action on the ICN theme areas.
• Summary of the Regional Think Tank Sessions, a series of "Think Tank" sessions held in Vancouver, Toronto, Halifax and Montreal, and drawing upon expertise from governments, the academic community, industry and non-governmental organizations, developed proposals for objectives, strategies and actions.
• Food Quality and Safety Programs in Canada, review of federal food regulatory programs, assessment/management of foodborne risk, new initiatives and emerging issues in food quality and education on safe food handling.
• Review of National Programs, review of Canadian programs relative to three ICN Themes; monitoring, preventing micronutrient diseases and preventing and managing infectious diseases.
• A Report on the Use of Indicators in "Nutrition for Health: An Agenda for Action", identifies and describes key issues relating to the use of indicators, proposes core indicators and discusses rationale, measurement issues and sources of data.
• The Consultation Summary Report, a consolidation of the results of the nation-wide consultation process.

Nutrition for Health: An Agenda for Action and the above background working papers are available through Internet at: http://www.hc-sc.gc.ca or by contacting a member of the Joint Steering Committee.

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1. World Declaration on Nutrition

2. Prepared by the Federal, Provincial and Territorial Advisory Committee on Population Health