**USAID Policy Paper**

**Nutrition**

Bureau for Program and Policy Coordination

U.S. Agency for International Development

Washington, D.C. 20523

May 1982

**TABLE OF CONTENTS**

Page

Executive Summary

Preface

I. Introduction

II\. Objective of the nutrition policy and its accomplishment

III\. Elements of the policy

A. Problem identification

B. Designing programs to address nutrition problems

1\. Agriculture and Rural Development

2\. Health

3\. Food Assistance

4\. Population

5\. Education and Training

C. Targeting based on nutrition

D. Evaluating nutrition impacts

E. Complementing sectors\[ programs with nutrition projects

F. Utilizing the private sector

G. Improving host country policies

H. Coordination

Conclusions

Selected Bibliography

**Executive Summary**

Estimates indicate that six hundred million people in less developed
countries (LDCs) are in danger of not getting enough to eat. As a
result, their productivity, health, and life expectancy are jeopardized.
If the U.S. is to make progress toward helping LDCs improve agricultural
production, economic performance, and human potential, nutrition must be
included as a critical input as well as an essential output of
development programs. Most of USAID\'s development assistance either
affects health or food consumption or relies upon nutritional well-being
to achieve develop­ment objectives. For this reason, it is of greatest
importance to give increased atten­tion to opportunities for improving
the nutrition impact of sectoral policies, strategies, programs, and
projects.

This policy paper reviews the justifications for U.S. investment in
improving nutri­tion in LDCs and sets out some policy guidelines for
USAID programs. The objective of the nutrition policy is to maximize the
nutritional impact of USAID\'s economic assistance. The policy
recommendations are as follows:

· USAID places highest priority on alleviating
**undernutrition**-inadequate food consumption and biological
utilization of nutrients.

· USAID\'s policy is to improve nutrition through **sectoral programs**
in agriculture, health, food aid, population, and education as well as
through direct-nutrition pro­grams.

· This policy will be implemented through incorporating nutrition and
food con­sumption as factors in decision making in sectoral strategies,
programs and projects.

This can be effected through:

A. **identifying** projects based upon analysis of nutrition and food
consumption pro­blems; this is especially appropriate in formulating
country development strategies.

B. **including** nutrition as a factor in project design:

1\. in **agriculture**, through maximizing consumption effects of crop
and technology selection, research and extension, and appropriate
national policies.

2\. in **health**, through primary health care which emphasizes growth
monitoring of children, providing pre-and post-natal nutrition,
supporting environmental health measures, and promoting proper infant
feeding practices.

3\. in **food aid**, through targeting appropriate rations to at-risk
groups com­plemented by growth monitoring, health care, and nutrition
education.

4\. in **population** by complementing voluntary family planning
services with nutri­tion programs whenever feasible.

5\. in **education**, through promotion of basic education for women,
nutrition educa­tion in the schools, training community outreach workers
in nutrition, and advanc­ed training for professionals and policy makers
in LDCs in nutrition.

C. **targeting** sectoral projects to individuals or housholds at-risk
of developing nutrition problems;

D. **monitoring** and **evaluating** nutrition impacts of projects that
are likely to affect nutrition, food consumption, or food production.

E. **complementing** sectoral programs with nutrition projects to
enhance nutrition impacts;

F. **utilizing the private sector**, especially the food industry, in
food programs whenever feasible;

G. **encouraging** appropriate national agriculture, health, and
nutrition policies to address nutrition and food consumption problems;

H. **coordinating** with LDC governments and other donors to achieve
nutrition goals.

In seeking opportunities to integrate nutrition concerns throughout
USAID\'s development assistance program, USAID will focus on the factors
that affect food consumption, nutritional needs, and health of
nutritionally at-risk groups.

**Preface**

Since 1965, USAID has been a leader in international efforts to improve
nutritional status in LDCs. For instance, through USAID\'s pioneering
work in nutrition plan­ning and surveillance[^1], I the multisectoral
nature of the nutrition problem in LDCs has become increasingly clear.
USAID\'s nutrition strategy of 1973[^2] demonstrated keen foresight in
emphasizing protein-calorie malnutrition[^3] rather than the then­
popular \"protein-gap. \" USAID\'s nutrition strategy of 1977[^4]
introduced integrated preventive approaches to nutrition by focusing
attention on household purchasing power for food. This approach was
innovative not only in calling attention to the fact that all members of
a household may be at nutritional risk (not just the women and
children), but also in noting that nutrition problems involve more than
ag­gregate food supply. USAID has also been a major proponent of
nutrition planning in developing countries and has been a leader in
increasing the nutrition planning capacity of developing country policy
advisors, through workshops and training sessions at U.S. institutions.

In the last decade, significant strides in nutritional science have
caused USAID to reexamine its nutrition policies and strategies. Major
scientific and methodological findings have implications for nutrition
programs.

\- Measurement of children\'s growth in less developed countries (LDCs)
has shown that until they reach 5 years of age, children in nearly all
populations (excluding pygmies) have the potential to grow as tall as
U.S. children. This means that children in LDCs are short not because of
genetics but rather because of poor nutri­tion.

\- A number of studies have shown that adequate dietary energy
(calories) plays a central role in producing healthy, adequate birth
weight babies. Supplementing marginally nourished pregnant women\'s
energy intake improves pregnancy out­come significantly.

\- Nutritionists and psychologists have shown that poor nutrition
impairs cognitive and neurological development which in tum reduce
learning capacity, attention span, and school performance.

\- Studies on the effect of energy intake and iron status on energy
expenditure have proved that undernutrition and anemia reduce work
productivity. Improvement of nutritional status is matched by increased
worker output.

\- Investigators from many institutions have shown that most staple
grains provide sufficient amounts of protein for human needs. Only for
preschool-aged children fed entirely on staple grain and in some
populations for which roots and tubers com­prise nearly all of the
dietary calories, protein content of the diet may be insufficient. -
Medical studies have shown that poor nutritional status impairs the
body\'s im­mune system resulting in more frequent and longer bouts of
illness and higher susceptibility to life threatening disease.

\- Clinical nutrition studies have revealed previously unknown but
essential com­ponents of the diet; for instance fiber, trace minerals and
a balance of cholesterol and different fats have been found to be
essential.

\- The absence of a truly equivalent manufactured substitute for
breastmilk has highlighted the unique role of breastfeeding in infant
nutrition, even in the United States. In developing countries
breastfeeding is essential to infants in low income households because
breastmilk substitutes are often unhygienic because they are im­properly
prepared using unclean utensils and unsafe water.

USAID\'s policies in food and agriculture, health, population and food
assistance have also changed, necessitating restatement of USAID\'s
major policy objectives in nutrition to provide overall guidance for
improving programming to meet these ob­jectives.

**I. Introduction**

Sound nutrition policies are essential to the overall development
efforts of LDCs. One of the messages that the U.S. carried to the Cancun
Summit (in October 1981) was that \"increasing food produc­tion in
developing countries is critically impor­tant---for some, literally a
matter of life or death. It is also an indispensable basis for overall
development.\" Despite enormous strides in agricultural technology in
the last decade, however, people are still dying from starvation and
extreme malnutrition.[^5] Hundreds of millions are not getting enough to
eat---thus rendering them vulnerable to disease and disability, and
unable to work or learn to their full potential. If, as the U.S.
emphasized at the UN General Assembly in September, 1981, \"the
individual is the beginning, the key element, and the ultimate
beneficiary of the development process,\" then one of the first goals of
development efforts must be to overcome the obstacles that stand in the
way of in­dividual initiative and potential. This paper ex­amines a
variety of policy initiatives that the U.S., other donors, and LDCs
themselves can adopt to maximize the impact of development programs on
nutritional status of citizens of the developing world.

U.S. foreign aid is based on a commitment to broad based economic growth
in developing coun­tries through \"alleviation of the worst physical
manifestations of poverty among the world\'s poor majority\" including
\"starvation, hunger, and malnutrition\" (Foreign Assistance Act of
1961, Chapter 1, Sections 101 and 103). Improving nutrition is vital to
the overall goal of strengthen­ing the economies of developing countries.

Nutritional well-being is a necessary and crucial input in the
development process. Undernutri­tion-insufficient consumption,
absorption, and biological utilization of food-can result in starva­tion
and death in extreme circumstances, but is usually disguised as low
stature and weight, low worker productivity, poor school performance,
poor reproductive performance, or lethargy.

*Undernourished* *adults* have lower stamina, pro­ductivity, and
attentiveness. They are sick more often and more seriously than
well-nourished adults. *Undernourished women* give birth to smaller,
less robust babies than well-nourished women. Low birthweight babies are
at high risk of death before the age of one year. *Undernourished*
*infants* have low disease resistance which may cause them to die from
what would be minor diseases under better circumstances (measles case
mortality in Guatemala in 1976, for instance, was 268 times that in the
U.S.). Diarrhea and intestinal parasites (the most prevalent cause of
illness in LDCs) are exacerbated by and in turn aggravate poor
nutritional status of the child since the ability to absorb and
effectively utilize nutrients is sharp­ly reduced under these conditions.

*Undernourished children* have stunted mental and physical development
that may later compromise school performance, physical capacity, and
economic productivity. *Undernourished* *households* are less productive
because of disease, human energy shortage, time losses to sickness and
inefficiency, and loss of human life (high pregnancy losses and matemal
mortality, high in­fant and child mortality, low life expectancy)
*Undernourished individuals, communities, and* *societies* fall far
short of their creative, physical and economical potentials because of
losses to poor nutrition: health and education expenditures are wasted
because many of the recipients of these services never reach productive
age; human spirits are constrained by enervation; opportunities for
national development are foregone because of undeveloped human capital;
and internal security is fragile as a result of frustration or
dissatisfaction with the inadequacy of one of the basic necessitates of
life: food.

Better nutrition is also an essential *output* of economic development.
Unless health, life expec­tancy, and vitality are improved as a result of
economic growth, development has not achieved its true objectives. In
the long run, USAID\'s assistance to developing countries should be
reflected in improved nutritional status. This will not come about
automatically, however. It will re­quire a conscious effort to include
nutrition as a basis for resource allocation in strategies, pro­grams and
projects.

Approximately 600 million people in developing countries do not have
access to enough food to meet their nutritional needs. Only a small
portion of those people are clinically malnourished. The preponderance
of them are mildly to moderately undernourished. Others are poorly
nourished on a seasonal basis. Still more are at the margins of adequacy
such that major illness, increases in food prices, or decreases in real
income could force them into nutritional deficit. Although the largest
number of calorie-deficient people are found in Asia, it. is in Africa
where the largest proportion of the total population consumes
insufficient energy (see table).

**Number of people (millions) and share of population with**

**calorie intakes below 90% FAO/ WHO requirements**

**in selected countries by region, 1973**

Millions of As A Percent As A

People with of Regional Percent of Total

Calorie Population Calorie Deficient

Deficient Diets % %

LAC 92 37% 15%

Asia 448 49% 75%

NE 34 33% 6 %

Africa 25 53% 4 %

599 46%

SOURCE: Reutlinger and Alderman. **The Prevalence of Calorie-Deficient
Diets in Developing Countries.** World Development 8:406, 1980.

II\. **Objective of the nutrition policy and its accomplishment**

The objective of this policy is to maximize impact of USAID development
programs on nutritional well being of poor people in LDCs. This
objective will be accomplished in development sectors through including
nutrition and food consump­tion as factors in decision-making and
cost-benefit analysis concerning strategies, programs, and pro­jects. It
can be accomplished through any or all of the following mechanisms.

1\) identifying projects based on analysis of the nutrition problem;

2\) designing projects to overcome constraints to meeting nutritional
needs;

3\) targeting projects to nutritionally at-risk groups;

4\) monitoring and evaluating impacts of projects on nutrition and food
consumption;

5\) providing technically strong nutrition programs to (a) backstop
activities in all development sectors, (b) supplement sectoral efforts
to ensure effectiveness in meeting nutrition goals and (c) complement
sectoral programs with specific nutri­tion project activities to enhance
nutrition impact;

6\) increasing the indigenous capacity in LDCs to analyse and overcome
nutrition problems through promotion of multisectoral nutrition planning
and appropriate national policies.

III\. **Elements of the Nutrition Policy**

The nutrition policy of the Agency for Interna­tional Development is to
improve nutrition and food consumption through sectoral programs in
agriculture and health and through direct nutri­tion programs when they
are suited to achieving Agency objectives.

Nutrition policy concerns the factors that affect human food consumption
and nutritional re­quirements, focusing on the needs and resources of the
household, including health considerations, economic demand, and food
use. Reciprocally, agriculture policy pertains to the factors that
in­fluence the production of food and other crops and agricultural
employment generation. Food policy, which technically links consumption­
oriented nutrition concerns with production-oriented agriculture
perspectives, tends to focus on prices, imports and exports, aggregate
de­mand, and national food security, with relatively little attention to
questions of nutritional needs or food distribution at the household
level USAID\'s Food and Agriculture Development Assistance Paper[^6]
details the ways in which agriculture production, food supply, and
family incomes can be increased. The successful im­plementation of the
Food and Agriculture Policy will not solve all nutritional problems, nor
should it. Agricultural projects can positively affect nutri­tion through
the mechanisms detailed elsewhere in this paper. Those nutritional
problems which are not most effectively or appropriately dealt with
through agricultural development must be solved through health or other
sectors or through direct nutrition programs. This policy paper
articulates the Agency\'s nutrition policies and discusses the ways in
which activities in agriculture, health, and other development sectors
can positively affect nutrition in developing countries.

**USAID\'s policy emphasizes coordination among** **sectors and between
the field and Washington to** **maximize achievement of nutrition
goals.**

Because most project officers are not nutritionists, it is essential
that missions make best use of out­side technical experts and improve
their inherent field capacity through training and enhancing field staff
with nutritional expertise.

Integration of nutrition concerns throughout USAID\'s program is best
institutionalized in the context of project, program and CDSS reviews
and by providing technical input to sectoral strategies. More
particularly, if a project is likely to affect the food system, health,
or household labor and time, then the potential for nutritional impacts
should be given careful consideration. Special attention will be given
to such projects in missions which identify food production and
malnutrition as major problems in the host country.

A. **Problem Identification**

**USAID\'s nutrition policy places highest priority on alleviating
undernutrition-that is, inadequate consumption of food.**

*Undernutrition* can be traced to *insufficient food supply, inadequate
access to food, insufficient purchasing power, inappropriate demand
patterns* (due to taste, tradition, perceptions), *inequitable*
*distribution* of food within countries, *inequitable* *allocation* to
individuals within families, and/or *poor utilization of food.*

Part of the problem is inadequate food supply---of the 36 lowest income
countries in the world (those with GNP less than U.S. \$370 per capita
per an­num) in 1977, eleven had a food supply that pro­vided less than 90%
of the estimated aggregate human energy requirements; nineteen other
coun­tries had between 90% and 100% of food energy needs available.[^7]
In subsaharan Africa, average per capita food supplies have actually
been decreasing over the last decade, although elsewhere in the world
per capita food supply has increased slightly. Therefore programs in
agriculture and population are essential to solving the nutrition
problem in the long term.

The imbalance between growth in food supply and population increase may
explain undernutri­tion on a macro or national level, but many coun­tries
with apparently adequate aggregate food supplies have high incidence of
undernutrition. Some countries which are net food exporters still have
serious nutrition problems.

On the regional, household, and individual level, the nutrition problem
relates to many factors in addition to food supply. *Physical access*­
markets, roads, transportation, production for auto-consumption-often
limits the availability of food within and between regions,of a country.
Futhermore, *economic access and purchasing* power are usually limiting
factors for the rural and urban poor. High consumer prices, low income,
low producer prices, and unreliable employment may limit economic access
to food. In many cases *food availability has a seasonal component* as
well-preharvest hunger is common in subsistence economies. For this
reason, improved productivi­ty, on-farm grain storage, food preservation,
local food security and seasonal employment can affect nutritional
status.

*Intrahousehold distribution* of food is another determinant of
nutritional status. Frequently women and young children receive less or
lower quality food while the men and economically active children are
given significantly more and bet­ter food. In many cases this is due to
economic pragmatism: if the wage earners are hungry, they cannot work as
hard, they will not earn as much money and the family will be worse
off.[^8] This pro­blem can be addressed through culturally ap­propriate
nutrition education and through direct nutrition programs (e.g., home
gardens).

In that women\'s income seems to be spent preferentially on food, USAID
might also take ad­vantage of such existing household allocation
behaviors to address nutrition problems by specifically including women
in income producing projects. The ways in which household resources are
allocated, who makes the decisions, and how these processes change over
time are just now be­ing studied[^9] so that guidance in using such
pro­cesses to improve nutrition will be generated from the field.

Undernutrition is also related to high food needs or excessive
nutritional losses. Human food needs are above average in developing
countries because of higher energy expenditures in work, and high
proportions of growing children and pregnant and lactating women.
Excessive losses are due to infec­tious disease, intestinal parasites,
and diarrhea.

**Addressing protein inadequacy and micronutrient** **deficiencies is
also important.**

Dietary protein, Vitamin A, iron, iodine, and some B Vitamins are
lacking in some areas of the world and for certain population groups.
Technollogicai solutions to these problems are available, although
actual delivery of the technology has proven administratively difficult
in some cases. Deficiencies may be inherent in the local diet or may
result from agricultural or economic changes. In some parts of the
world, the staple diet is often too bulky to satisfy the nutri­tional
needs of small children simply because their small stomachs will not
hold enough food. For these individuals increasing the nutrients per
gram of food- \"nutrient density\"- is of high priority.

A \"modern\" diet can rapidly replace a traditional one, sometimes with
deleterious short-term nutritional consequences. With increasing income,
for I­instance, some poor families buy higher status less nutritious
foods: polished rice instead of brown rice, sweets and snacks instead of
staple grains.

B. **Designing programs to address nutrition problems**

**USAID\'s policy is to include nutrition as a factor in program and
project design.**

1\. **Agriculture and rural development**

Agricultural and multisectoral rural development programs comprise the
bulk of USAID\'s development assistance budget both because agriculture
is a major source of national income and because most people in LDCs
live in rural areas. Through agricultural and rural development
projects, USAID is simultaneously helping to improve the food supply,
economic base, and employment in those countries. In order to assure
that agricultural goals are achieved and that the benefits of
development reach the poor, however, the nutritional needs of the rural
population and the nutritional impacts of development programs must be
taken into account.

To address nutrition concerns within USAID\'s agricultural program, it
is necessary to know how *the food produced reaches the ultimate
consumer* *and* *how the income generated is ultimately spent* *on food*
and other commodities. Increased food production or higher income does
not **automatically** mean better nutritional status especially in the
short term. Problems of food distribution and storage, income
distribution, intra-household control over resources, and alter­native
(nonfood) claims on financial resources all affect the
production/nutrition equation.

Rural households which are nutritionally at-risk are often those with
few productive resources---land, water, labor, or capital. They produce
only an occasional marketable surplus and pursue limited economic
activities. They may also be least able or willing to take risks, either
because they are physically inaccessible or because they have the lowest
margin for absorbing setbacks. Hence, their market returns may be low,
and the technology they use different from that designed for and
relevant to commercially-oriented farmers. To improve the productive
capacity and hence the nutritional well-being of farmers who are not
currently market oriented will require a strong emphasis on development
of appropriate institutions as well as agricultural research and
technology that is responsive to their needs and risk situtation.
Improving the productive capacity of more resource-rich and
commercially-oriented farmers is also important for nutrition since
these farmers are likely to be the primary producers of urban food
supplies.[^10]

Incorporation of nutrition concerns into agriculture programs
necessitates a balanced allocation of resources among short-term
production-oriented investment, investments in long-term human resource
development, and medium-term investments designed to ensure ac­cess to
factors of production and markets, par­ticularly for those rural and
agricultural households which are nutritionally at-risk. There are trade
offs and complementarities; between meeting production/ employment goals
and meeting nutritional goals which should be taken into account by the
mission staff when making program decisions.

**Agricultural projects should anticipate changes in food consumption
which accompany changes in cropping patterns.**

When the cropping pattern, labor or resource allocation, seasonality of
harvests or income is changed by an agricultural project, alterations
are usually made within the household to ac­commodate them. Many of these
changes are benign---but where food habits are changed there is a
potential for negative nutritional impact. At the very least, projects
affecting these factors should monitor nutritional status or food
con­sumption of the target population.

Additional labor requirements for a new or im­proved crop may cause a
farmer to plant less labor intensive and less nutritious household food
crops (for example, cassava is planted instead of yams because the
former requires less labor and is less sensitive to timing of
cultivation and harvesting).[^11] By providing off-season employ­ment or
interharvest crops such labor/ food supply conflicts could be avoided or
minimized.

When cash crops are harvested once per year, householders may be cash
short in the non-harvest season and unless they have planted a food
crop, they may not be able to buy sufficient food for their needs.
Moreover, when a large number of farmers in a region convert acreage
from food crops to cash crops, local food supplies may be limited and
increase.in price unless local transpor­tation and marketing mechanisms
are improved. Lower income farmers are particularly vulnerable to
seasonal variations in food supply and income because a larger
proportion of their income is spent on food and because they are most
likely to have smaller food reserves. Therefore, attention should be
paid to the institutions on which the household food systems depend.

The new cash crop farmer may not be able to pur­chase the foods in his
traditional diet in the quan­titites which used to be consumed from
sub­sistence production. In order to fill stomachs, therefore, he may
have to purchase less expensive and less nutritious foods. Also, when
cash income replaces food income, there is a higher likelihood that
non-food items will claim a portion of the household budget.[^12] In
commercial agricultural production projects, positive nutrition impacts
can be enhanced through complementary nutri­tion components like
nutrition education and home gardens.

Recently, attention has been directed at farming systems, particularly
to the physical and temporal constraints to increasing productivity by
smallholders. Because farming systems programs are inherently
multi-sectoral in focus, they offer a good vehicle for adding nutrition
activities where needed and appropriate.

**Agricultural projects should anticipate nutritional impacts of labor
requirements.**

Human energy and time are frequently the scarcest resources in farm
families, especially in subsistence and female-headed households. Even
on commercial farms, labor is frequently---scarce for peak cultivation
and harvest activities. Some agricultural improvements are more labor
inten­sive than traditional methods. For instance, new rice varieties
require more time and energy to cultivate than traditional varieties.
Where unemployment is high, such innovations can have positive effects
on income and food con­sumption. On farms which cannot hire labor,
energy - and time-saving technology in the form of low cost innovations
which are also capital­ saving e.g., hand pumps, small-scale grain mills)
can be vital elements of a strategy to improve nutritional status.[^13]

Current USAID policy emphasizes the impor­tance of employment generation
as a component of agricultural and rural development. For max­imum
nutrition impact, employment oppor­tunities should be directed to high
nutritional risk groups and spread evenly throughout the year, to assure
steady income to meet food needs and discourage labor migration, or
properly timed with seasonal food shortages (usually in the preharvest
period) to raise income at a time that food deficits must be made up
through pur­chases. At a minimum, wages should be com­mensurate with
energy costs of the work. In cae Latin American country it was found
that the in­troduction of sisal into local agriculture pushed farmers
into caloric deficit because their energy expenditures in sisal
processing exceeded the amount of food energy they could buy with their
wages. The new technology, in short, introduced an extra nutrition
Cost.[^14]

**On- and Off-farm employment can strengthen intrahousehold resource
allocation patterns which improve nutrition.**

When women\'s employment is encouraged, ef­forts should be taken to
facilitate good child care and nutritional practices, including the
encour­agement of proper infant feeding practices. Fre­quently when rural
women are employed outside the home, infants are cared for by siblings
(often not much older than themselves) or elderly fami­ly members. The
quality of care and food pro­vided to the child may be inadequate under
such conditions and the caretaker, often a young girl, may be missing
out on educational opportunities because her services are needed at
home. By pro­viding work close to home, allowing infants to be brought to
work, provision of child care facilities or services, and training
caretakers in proper child care practices, potential negative ef­fects
could be minimized.

Evidence has been accumulating to indicate that who earns the income is
almost as important as *how much* is earned. The adult male usually
decides how his income will be spent and gives a portion to the female
head-of-household for household necessities (mostly food) but the
pro­portion of his income spent on food is usual1v lower than that of
women\'s income. In address­ing nutrition problems through employment
generation, project designers should understand and take into account
the wavs in which different household members use tneir income. (See
foot­note 9).

**Agricultural research should address food consumption patterns of
at-risk groups and recognize their technological and capital
constraints.**

Increasing the nutritional content of crops through genetic manipulation
is but a small part of the potential nutritional impact of agricultural
research. Far greater nutritional improvements are likely to result from
research improving productivity, reliability, and food processing
characteristics of basic food crops which are grown and/or consumed by
nutritionally at-risk groups and by incorporating certain techno­logical
and resource assumptions into plant breeding. Research on basic food
crops like cassava and millet can have major implications for nutrition.
Recent research on cassava, for in­stance, has focused on breeding a
plant which can survive with very few leaves. Because cassava leaves are
a major source of nutrients in the preharvest period in some cultures,
the in­troduction of this new plant will enable farmers to eat both the
leaves and the roots. Crops which require large amounts of fertilizer
and water, those for which there are economies of scale, and those that
require mechanization for cultivation, harvesting, or processing will
not be weil-suited to those farmers who cannot get credit and who have
few available capital resources. Those are the same farmers who are
probably poorly nourished and have the greatest nutritional need.

2\. **Health**

**Promotion of good health is essential to meeting** **the nutritional
objectives of the Agency.**

The interaction between nutrition and infection is well-known.[^15] A
poorly nourished individual has an impaired immune system which means
not only that he is more susceptible to disease, but also that treatment
may not be as effective. In addition, certain infections raise
nutritional requirements, reduce nutrient absorption, or decrease
appetite---all of which lower nutritional status. For these reasons,
nutritional well-being is both a precursor and a product of good health.

**Nutrition objectives should be addressed in the health sector through
primary health care.**

One of the main emphases of USAID health policy is primary health care
delivery and the nutritional aspects of good health are stressed.
Preventive health care---immunization programs, environmental
sanitation, parasite con­trol, health and nutrition education, growth
monitoring, prenatal care, and well-baby clinics, etc. - is the focus of
USAID\'s health policy and an important element in its nutrition policy
as well. It is extremely important, for example, to reach pregnant women
and preschool children in order to avoid the permanent damage which can
result from malnutrition in early life. Health care is necessary,
although not sufficient, for good nutrition. Improving prenatal maternal
nutrition can be an effective way of reducing infant mor­tality through
increasing birthweights of infants and increasing maternal nutrient
stores.

**Growth monitoring is a low cost preventive** **health care measure
with major nutritional** **significance.**

Growth monitoring involves the periodic weighing of preschool children
and using that information to target health care, health or nutrition
education, family planning, or supple­mentary feeding programs to mothers
of children whose growth is faltering.

Growth monitoring of preschool children carried out by community workers
is an ideal way to break the downward spiral in health caused by
repeated incidents of infection and malnutrition. It has been found that
mothers usually do not know that their children are not growing prop­erly
until they exhibit the physical manifestations of clinical
malnutrition.[^16] Growth monitoring alerts the mother early that her
child\'s health is deteriorating and enables the family to treat the
problem while the solution is still within its means. In many countries,
growth monitoring has proved to be effective and inexpensive. Because it
depends on and tends to generate sustained community effort, growth
monitoring can be a vehicle for institution-building and increas­ing
utilization of primary health care and other basic services in the
community. Proper timing of inoculations, preventive health care, proper
weaning practices, home-based treatment of diarrhea (oral rehydration
therapy), and family planning can all be encouraged through growth
monitoring.

**It is the policy of USAID to support breastfeeding and proper infant
feeding practices.**

Traditionally infants were breastfed for two or more years but now
\"modern\" women bottlefeed their infants, often without knowing enough
about the nutritional needs of infants. Babies fed barley water,
cornstarch gruels, and diluted infant formulas, often prepared with
unsafe water and contaminated utensils, may die before their mothers
find out how to feed them proper­ly. The more serious problem in rural
areas is late introduction of complementary foods to breastfed infants.
Proper complementary feeding of the weaning child is often a problem of
dietary practices, home food preparation and preserva­tion constraints,
and other demands on women\'s time. A more multifaceted approach, going
beyond breastfeeding promotion and food availability is therefore often
required. Nutrition education, including encouragement of breastfeeding,
improved child feeding practices, food fortification, and strong
national nutrition policies, can avert these negative nutritional
impacts.

**Environmental health measures are another** **means of averting
nutrition problems.**

Other nutrition enhancing health activities are inoculations for common
diseases (BCG, measles) and health education aimed at changing behavior
or conditions that expose children to parasites and intestinal disease.
Malaria, schistosomiasis, tuberculosis, and cholera are endemic public
health problems which heavily affect nutritional status in many parts of
the world. Controlling these diseases will also rein­force the
nutritional impacts of improved food supply and consumption.

**Provision of community water supply and in**­**stallation of latrines
should be encouraged as a** **part of the general development strategy
in** **health project areas.**

Parasites and gastrointestinal disease could be substantially reduced
through improved hygiene. The preschool child\'s feces can be a major
source of infections in the household unless the mother takes adequate
precautions. Where water is not readily available, however, hygiene
education may be less important than water supply. Therefore provision
of an adequate water supply can be part of incorporating nutrition into
health projects.[^17]

3\. **Food Assistance**

The Agricultural Trade Development and Assistance. Act of 1954 (PL 480)
provides for con­cessional sales of U.S. agricultural commodities to LDC
governments (Titles I and III) and pro­vides food donations for famine
relief, combat­ting malnutrition, and promoting economic and community
development (Title II).

As a major resource transfer (Titles I and III), PL 480 can be used to
support and encourage good development policies. (This is discussed in
detail in the Food and Development Discussion Paper.[^18] ) In the area
of nutrition, such policy reforms could include a functional national
nutrition policy, nutrition monitoring systems, and manageable,
well-targeted subsidized con­sumption system for the lowest income
groups, or nutrition-responsive agricultural policies. The foods
themselves can have nutritional impact if carefully programmed and
targeted. If food aid had a disincentive effect on local agriculture it
could adversely affect nutrition, so attention must be paid to this
aspect of food aid. Further­more, the food commodities can change tastes
and cause shifts in demand for local and imported foodstuffs.

Nutrition improvement has been one of the ma­jor objectives of Title II
in the past. To achieve this objective, significant changes in USAID\'s
programs are called for, including better targeting, specifically to
reach malnourished preschool children and pregnant and lactating women,
appropriate ration sizes, and inclusion of nutrition education along
with the supple­mental food.

Title II, as emergency relief, has obvious nutri­tional and humanitarian
importance, and it can also be used to overcome short-term household
food supply shortages.

In some settings, Title II may be useful for household feeding or as a
resource for health, education, family planning, and income generating
activities. Title II is also one of the few means available to USAID for
overcoming urban malnutrition, a growing problem through­out the
developing world. The Bureau of Food for Peace and Voluntary Assistance
is currently reviewing the objectives and guidelines for more effective
programs of Title II And will shortly be issuing guidance to the field
on this issue.

4\. **Population**

**Nutrition both affects and is affected by fertility levels.**

High rates of population growth tend to limit per capita development
gains and overload the physical and economic infrastructure of LDCs. The
direct impact of high birth rates, however, is most visible at the
household level---in high ratios of non-productive to productive
household members, and in the biological, physical, and temporal
stresses on women caused by frequent childbearing. Infant mortali­ty
(often due to poor prenatal nutrition of the mother and postnatal
nutrition of the infant) is considerably higher when birth intervals are
short.

Programs which join provision of voluntary family planning with efforts
to combat under­nutrition can be cost-effective and culturally
ac­ceptable. In one Asian country, for instance, a growth monitoring and
primary health care pro­gram has been added to the national voluntary
family planning program, in large part because it is clear that further
reductions in fertility may come only when parents believe that each
child born will survive to adulthood.

**Nutrition and family planning programs should be linked wherever
possible.**

Growth monitoring can be an important tool in linking nutrition and
family planning programs, because the faltering growth rate of the
infant indicates the need for introduction of weaning foods and the
return of fertility in postpartum women. Breastfeeding reduces fertility
the most when the infant is fully breastfed. Providing voluntary family
planning services at a health clinic or food distribution program site
will save time for the mother who seeks these services and encourage her
to associate good health, nutri­tious food, and the conscious choice
about fami­ly size. Coincidence of services can also be cost­effective by
economizing on building, training and management costs, but care must be
taken not to overload community workers who deliver these services.

5\. **Education and Training**

**Promotion of basic education wiU contribute to improved nutrition.**

Although education is not considered to be a nutrition intervention per
se, good nutritional status in children is frequently associated with
literacy and educational attainment of the parents, particularly of the
mother. In the long run, extension of basic education, particularly to
females, will have positive impacts on nutrition in the household.

**Nutrition education in schools can promote better food consumption in
the family.**

In the short term, schools can be an important avenue for improving
nutrition, not only through nutrition education (e.g., home economics)
but also through allied school activities (e.g., school gardens).
Particular emphasis should be given to the nutritional value of local
foods, purchasing foods to maximize nutritional value, storing,
processing and prepar­ing food to maintain nutritional value and hygiene
education. At a minimum, schools must have basic sanitary facilities and
water, since most of the content of nutrition and hygiene education
involves food handling and personal and community sanitary practices.
Efforts should be made to extend nutrition education to the rest of the
family through nonformal educa­tion, mass media, and community.
demonstra­tions.

**Training programs for community outreach workers should include basic
nutrition.**

In some countries, government and community outreach workers make
periodic visits to the households of nutritionally at-risk groups. In
set­ting up training programs for agricultural exten­sion workers, social
workers, medical personnel, and community volunteers, attention should
be directed to how malnutrition affects the households they visit and
how their activities can influence nutrition. Nutritional \"first aid\"
and referral (e.g., in the case of oral rehydration) could also be
taught. Although nutrition would be a small component of their training,
its inclu­sion would greatly increase public consciousness of nutrition
problems and improve informal nutrition monitoring of the community.

**Advanced training in nutrition is needed in many LDCs.**

Higher level training in nutrition is also needed. Development planners,
economists, agriculturalists, educators, physicians and nurses, must be
cognizant of the community\'s nutrition problems and of the possible
nutri­tional implications of their work. There is a serious lack of
nutrition planners in LDCs. If A.M.\'s efforts in nutrition are to
become self­sustaining, the countries must have a local capacity to
assume responsibility for problem analysis and program implementation.

C. **Targeting based on nutrition**

**USAID policy is to target sectoral projects whenever feasible to
households and individuals at-risk of developing nutritional problems.**

Nutritional risk is the probability that someone will develop a
nutritional problem. Women of childbearing age, infants, and preschool
children have traditionally been called \"vulnerable groups\" because
they are at high nutritional risk due to their increased physical needs.
In addi­tion, certain *households* are more likely to have malnourished
members than others, and these can be identified through a system of
\"functional classification,\" for instance by income groups,
landholding, crop production system, or house­hold composition. High
nutritional risk has been associated with geographic isolation, small
lan­dholding, occupation (fishermen, landless workers), low or scheduled
caste, household composition (polygynous and female-headed households),
low income, and low socio­economic status (illiteracy, unemployment). The
classification itself varies from country to coun­try.

The method used for targeting development pro­grams depends in large part
on the type of pro­ject proposed. Primary health care programs, for
instance, deal with individuals or groups of in­dividuaIs; hence it makes
sense to give particular attention to those individuals at highest
nutri­tional risk. Agricultural programs on the other hand, tend to focus
directly or indirectly on households, communities, or regions, and
therefore can use functional classification of these units as the basis
for targeting.

To determine nutritional risk, it is necessary to link nutrition status
or consumption data to in­dividual or household characteristics.
Frequently such data do not exist in a usable form for such analysis.
Low cost small-scale surveys and com­plementary computer software can
be,used to determine nutritional risk rapidly and inexpen­sively for
small areas. Pre-existing national data can frequently be manipulated to
yield useful in­formation for targeting also.[^19] Consumer price
indexes, for example, are frequently based on household consumption and
expenditure surveys.

An example of the uses of functional classifica­tion is the Integrated
Agricultural Development Project in Palawan, Philippines. Secondary data
supplemented by a small in-depth nutrition study in the project area
identified highland slash-and ­burn farmers and fishermen as
high-nutritional ­risk groups. Subsequently, the project gave particular
attention to those groups and emphasized food production for the upland
farmers. Deci­sions about provision of roads and water were based partly
on consideration of these at-risk groups, and specific nutrition
components were added onto the general agricultural and rural
development efforts to enhance their nutritional impact.

D. **Evaluating Nutrition Impacts**

**It is the policy of the Agency to monitor and evaluate nutrition
impacts of projects that are likely to affect health, food production or
food consumption.**

Most agricultural and health project officers are sensitive to
nutritional considerations and iden­tify alleviation of malnutrition as a
legitimate project goal. Nutritional impacts are not always measured
however.

Nutrition effects can be anticipated by system­atically reviewing the
ways in which a project might affect nutritional status and by
instituting monitoring systems for those variables most like­ly to be
directly affected. Some obvious factors affecting nutritional status
include:

\- food and nutrient availability at the individ­ual, household, and
community level, especially in the preharvest period;

\- response of food purchases to price and in­come changes;

\- allocation of food among family members;

\- household nutritional needs;

\- food preparation, processing, procurement and storage;

\- food security at the household level;

\- resources necessary for food utilization (fuelwood, water, time,
human energy)li - cultural food practices and beliefs;

\- environmental health and parasitism;

\- purchasing power of high-risk households and cost of an adequate
diet.

**A cost effective way to measure nutritional impact is to carry out
small cross sectional surveys of food consumption of groups or nutrition
status (usually height and weight of children) of individuals or
households\'**

Nutrition status surveys of a statistical sample of children can
indicate changes in nutrition over the life of project. Measures of food
consumption of groups, if carefully done by experienced scien­tists, will
also measure impacts of projects on target households. In one African
country, monthly information on food production, land, labor use, and
income of smallholders has been linked to intermittent surveys of
nutritional status of preschool children to monitor nutri­tional trends.
In an Asian country the communi­ty infant weighing program has enabled
monitor­ing of project impacts in some areas USAID is currently
supporting efforts in twelve countries to set up nutritional monitoring
systems which can be used to assess project impacts.

**To estimate nutritional impacts of projects, it may not be necessary
to measure changes in nutritional status directly or comprehensively,
although that is preferable.**

Nutritional impact can be roughly estimated us­ing non-nutrition data.
For instance, monitoring local prices of major basic. foods (e,g.,
cassava or paddy rice) can provide a relatively sensitive measure of how
low-income consumers are likely to be affected by supply changes, in
areas where agricultural prices are not fixed. Supplies of foods in
local markets and granaries. infant mor­tality rates (using a base
population of at least 10,000), local wages, and incomes of at-risk
households can also provide evidence of prob­able outcomes if the
linkages between indicators and causes of undernutrition are
well-understood and if the indicators are of reasonable quality.

These techniques need to be supplemented by knowledge of intrahousehold
economic activities including production of commodities for home
consumption. Understanding the social, cultural and institutional
context in which projects are implemented can help a project designer
avoid potentially negative impacts and maximize positive effects of
development activities. In one area, a livestock management program was
designed to encourage cattle owners to sell the animals at two years of
age. The project origi­nally ignored the fact that women milked the older
cows, thus providing an important nutri­tional supplement to their
children\'s diet. Modification in the project design made it possi­ble to
avoid what would have been an extremely harmful secondary impact of this
income genera­tioh project.

E. **Complementing sectoral programs with nutrition projects**

**Nutrition projects should complement sectorial programs to enhance
nutritional impact when they are suited to meeting Agency goals.**

Nutritional projects play an essential role in extending and refining
USAID\'s efforts at alleviating malnutrition. Food fortification,
nutrition education including non-formal educa­tion through mass media,
food technology development, nutrition planning, and promotion of proper
infant feeding practices, have formed the backbone of technical
nutrition support in the past and should continue both to address
nutrition problems directly and to complement more indirect projects.
For instance, where agricultural programs are focused on raising
household income, a nutrition education compo­nent should assure that the
household has in­formation on the nutritional implications of alternative
uses of the new income and changes in the traditional diet.

F. **Utilizing the private sector**

In many cases, private sector initiatives can enhance public investments
particularly in the areas of agribusiness, food processing, and
for­tification. The private sector may also hold the key to solving
problems of urban malnutrition when they are due to inadequate food
marketing and distribution systems. Where possible, private sector
efforts should be encouraged. The recent effort by USAID to provide
technical assistance to food industries in developing coun­tries through
private sector representatives is il­lustrative of the types of
collaboration USAID seeks.

G. **Improving Policies**

**USAID supports inclusion of nutrition considerations in national
policies.**

USAID continues to endorse multisectoral nutrition policies in host
countries. National agricultural planners and policy makers should
consider the effects of food and agricultural policies on regional and
local food supplies, pro­ducer price stability, and food consumption,
especially by nutritionally at-risk groups.[^20] They should also be
encouraged to set up nutrition monitoring systems to facilitate such
analysis. Health policy should focus on preventive health care and
inclusion of nutrition components in primary health care. Education and
population policies should take into account the nutrition factor as an
input to and product of successful sectoral strategies.

H. **Coordination**

Many bilateral and multilateral donors have pro­grams designed to improve
nutrition USAID ac­tively seeks opportunities for coordination of
nutrition activities within countries. Cofinancing different components
of nutrition-related pro­grams and complementarity among programs by
different donors are strongly supported. USAID encourages host country
policies which effec­tively utilize all available private, public and
voluntary organizations to meet overall develop­ment goals.

**Conclusions**

A number of conclusions emerge from this review of USAID\'s nutrition
policy and object­fives. First, nutritional well-being is not only a
necessary input in the development process; it is also an essential
output. Hence, efforts to alleviate undernutrition are an integral
element of USAID\'s overall development assistance program.

Second, the greatest lasting improvements in nutrition in LDCs are
likely to result from changes which incorporate nutritional
considera­tions in the design of programs in other economic
sectors-especially agriculture, rural develop­ment and health. Hence,
this paper has devoted a great deal of attention to policy issues in the
design and implementation of agriculture, health, education, family
planning and other development activities. Direct nutrition projects are
an important complement to such activities.

Third, the United States has a key role to play in helping developing
countries overcome their nutrition problems---through its multisectoral
approach to economic development, its commit­ment to improving food
security in the Third World, its strong research and development
capacity in the biomedical and operations

research areas, as well as its commitment to ex­perimentation in search
of more cost-effective approaches to improvements in basic services in
LDCs. Furthermore, the U.S. food industry has much to share with LDCs in
Promoting a safe, nutritious, and reliable food supply.

Finally. in order to maximize the impact of USAID\'s development
programs on the nutri­tional well-being of the citizens of developing
countries, USAID will give increasingattention, through research,
analysis, experimental pro­jects, and programs to improve host country
and Agency ability to:

\- identify nutrition problems;

\- utilize the private sector whenever feasible to implement the policy;

\- design projects to overcome or minimize con­straints to meeting
nutritional needs of the at-risk population

\- target projects to at-risk groups;

\- monitor the impacts of development projects on food consumption and
nutrition;

\- add nutrition components or programs to enhance nutrition impact; and

\- strengthen the capacity of indigenous organizations to analyze and
overcome nutrition problems.

**Selected Bibliography**

**Intrahousehold Allocation of Food and other Resources and Impact of
Women\'s Work on the Household**

Nieves, I. A Balancing Act: Strategies to Cope with Work and Motherhood
in Developing Countries. Paper presented at International Center for
Research on Women Roundtable, 1981.

Protein Advisory Group of the United Nations. Women in Food Production,
Food Handling and Nutrition, 1977.

Safilios-Rothschild, C. The Role of the Family: A Neglected Aspect of
Poverty. World Bank, 1980.

U.S. Department of Agriculture: Consumer Economics Group. Intrafamily
Food Distribu­tion, Review of the Literature and Policy Im­plications,
1982.

**Functional Classification of Malnutrition**

USAID, Office of Nutrition. Nutrition Surveillance: Review of Progress.
1981 F.A.0. Introducing Nutrition in Agricultural and Rural Development,
Case Studies. 1982.

Omawale. Nutrition Problem Identification and Development Policy
Implications, Ecology of Food and Nutrition 9:113-122, 1980. Effect of
Agricultural Development on Nutrition Eide, W.B. and F.C. Steady.
Individual and Social Energy Flows in Jerome, N. F., R. F. Kandel and
G.H. Pelto (Eds.) Nutrition An­thropology: Contemporary Approaches to
Diet and Culture. Pleasantville, N.Y.: Redgrave Press, 1980.

Fleuret, P. and A. Fleuret. Nutrition, Consump­tion, and Agricultural
Change. Human Organization 39 (3): 250-260, 1980.

Pinstrup-Anderson, Per. Nutritional Conse­quences of Agricultural
Projects; Conceptual Relationships and Assessment Approaches.
Washington: World Bank, 1981. World Bank Staff Working Paper 456.

Savane, M.A. Implications for women and their work of introducing
nutritional considera­tions into agricultural and rural development
projects. Food and Nutrition Bulletin 3 (3): 1­5, 1981.

[^1]:     ^?^Nutrition surveillance involves collection and analysis of
    data on food consumption and nutritional status on a regular basis.
    The current work being carried out at Cornell University through the
    Office of Nutrition is a good example of pioneering efforts in
    tracking nutrition surveillance efforts and promoting the functional
    classification of malnutrition.

[^2]:     ^?^**The USAID Nutrition Program Strategy**, U.S. Agency for
    International Development, June, 1973.

[^3]:     ^?^Lack of protein **and** calories is sometimes called
    protein calorie malnutrition (PCM).

[^4]:     ^?^\"USAID\'s Responsibilities in Nutrition,\" AIDTO Circular
    A-98, April 1977.

[^5]:     ^?^Throughout this paper \"malnutrition\" is used to describe
    a spectrum of nutrition problems including underconsumption, and
    nutrient imbalances. \"Undernutrition\" is specifically inadequate
    consumption and biological utilization of food.

[^6]:     ^?^USAID Food and Agricultural Development Assistance, March,
    1982.

[^7]:     ^?^If all people consumed as much energy as they needed (and
    no more than they needed), then a food supply equal to 100% of
    caloric requirements would be needed nationally. When some people
    consume more than they need and others consume less, however,
    estimates of required food supply must be inflated to conpensate for
    skewed overconsumption. In developing countries it is estimated that
    110% of dietary energy requirements is needed in the food supply to
    compensate for that nutritent wastage by overconsumers. In cases
    where distribution is very skewed, even 110% of energy requirements
    may be too low.

[^8]:     ^?^Recent review of the literature have shown that inequitable
    distribution of food within the household is ubiquitous. But uneven
    intra-household food allocation is not the only problem. Other
    research has shown that even if many low income families did
    distribute food according to relative requirements of each household
    member, no one would get enough to eat.

[^9]:     ^?^Evidence is just beginning to emerge on this point. Some
    studies have indicated that children of working women are less
    likely to be malnourished than children of non-working women. In
    Kerala, for instance, it was found that women\'s income was twice as
    important in determining children\'s nutrition status as men\'s
    income. In the Philippines women\'s labor force participation was
    positively associated with caloric adequacy among children in the
    lowest income group although consumption of Vitamin A was reduced.
    Women\'s working is not always best for children, however, most poor
    women in LDCs do participate in some form of work outside of the
    home. The positive association of women\'s income and nutritional
    status of their children is mediated by various aspects of the
    compatibility of women\'s productive and nurturing roles (e.g., the
    availability of childcare, homemaking services, and labor saving
    devices).

[^10]:     ^?^Innovations which keep costs of production down, no matter
    what the size of farm, will help to assure that the food supply is
    available at a reasonable costs, and will enhance overall purchasing
    power.

[^11]:     ^?^This phenomenon happend in West Africa where the
    introduction of cocoa induced a change from yams to cassava becuase
    the women has less time to spend harvesting their subsistence crops.

[^12]:     ^?^The impact of cash cropping on nutrition is a complex
    issue. Although increased income is the \"long term\" solution to
    the nutrition problem of most at-risk households, the improvement in
    nutrition is not automatic in the short term. Studies have shown
    that some income generating agricultural activities fail to improve
    nutrition. Frequently the benefits of additional income are
    undermined by time constraints of the mother, insufficient
    complementary health services, inadequate education of the mother
    resulting in poor food pruchasing habits, contaminated water
    supplies, and seasonal or erratic receipts of income which cause
    money management problems in the household. Nevertheless, families
    frequently find it difficult to return to food crops once they have
    cultivated cash crops.

[^13]:     ^?^Pooer households must use a larger proportion of their
    labor supply, (i.e., number of work days per family is higher than
    wealthier households) to satisfy their food needs. Women and
    children in particular have been shown to have significantly higher
    work loads in poor families.

[^14]:     ^?^Gross, D.R., and B.A. Underwood. Technological Change and
    Caloric Costs: Sisal Agriculture in Northeastern Brazil. Am. Anthro.
    73:725-740, 1971.

[^15]:     ^?^Chandra, R.K. Immunodeficiency in undernutrition and
    overnutrition. Nutrition Rev. 39:225, 1981. Scrimshaw, N.S. **et.
    al. Interactions of Nutrition and Infection**. Geneva: WHO, 1968
    (Monograph Series No. 57).

[^16]:     ^?^Griffiths, M. Growth Monitoring, Washington: Am. Pub. Hth.
    Assoc., 1981.

[^17]:     ^?^Intestinal parasites may consume up to 25% of dietary
    intake. Therefore eliminating parasites and infectious disease is a
    necessary element in solving nutrition problems. Unsanitary and
    inaccessible water supply has been shown to affect nutrition
    adversely in several countries. See USAID/PPC. Domestic Water and
    Sanitation Policy Paper, 1982.

[^18]:     ^?^USAID/PPC, **Food Aid and Development: A Policy Discussion
    Paper**, Washington, D.C.: August 1981. Other papers and reports are
    being or will prepared by the USAID Bureaus for Programs and Policy
    Coordination and Food for Peace and Voluntary Assistance.

[^19]:     ^?^To date functional classification has been used to
    identify nutrition problems in Costa Rica, El Salvador, Philippines,
    Zamba, Sri Lanka, Kenya, and Haiti.

[^20]:     ^?^USAID, in conjunction with the Nutrition Economics Group
    at U.S.D.A., has supported and will continue to support research and
    technical assistance to missions in this area.