WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOP. THE WESTERN PACIFIC BUREAU RtGIONAL DU PACIFIQUE OCCIDENTAL
•
ORGANISATION MONDIALE DE LA SANTE
REGIONAL COMMITTEE
WPR/R C35 jT echnica1 Discussions/ I 17 August 1984 ORIGINAL: ENGLISH
Thirty-fifth session Suva 5-1 J September !984
MALNUTRITION, GROWTH AND DEVELOPMENT
Technical Discussions
By its resolution WPR/RC34.R23, the Regional Committee decided that the subject of the Technical Discussions at its thirty-fifth session would be "Malnutrition, growth and development". The present document is being distributed to Member States as a background paper to the discussions. Part I of the paper provides an overview of nutritional status trends in the Region with particular reference to low birth weight, protein-energy malnutrition, nutritional deficiencies and infant and young child feeding. Part II examines inter alia the role and responsibilities of the health sector in developing programmes for the control of malnutrition, particularly among · vulnerable groups such as infants, pre-school-age children and pregnant and nursing mothers. Part IU presents suggestions for the development of a minimum programme and calls for a new strategy for the control of malnutrition by the health sector.
WPR /R C 35/T echnical Discussions/! page 2
CONTENTS
Page INTRODUCTION . . ••. . . . . •. •. ••. . . . . . . •. •. . . ••. . . •. . . . . . •. . . •. . . •. . . . 3 4
PART I- OVERVIEW OF REGIONAL NUTRITIONAL STATUS TRENDS • . • . . . . l.
INCIDENCE OF LOW BlRTH WEIGHT • • • • . • • • . . . . • • • • . . • . . . • • • . . . . . . PROTEIN-ENERGY MALNUTRITION (PEM) • • • • • . • • . . . . • • . . . • . . . . . . . SPECIFIC NUTRITIONAL DEFICIENCIES ••. . . . . . . . . . . . . . . . . . . . . . . . .
t;
2.
6
3.
8 8 8 I0 I0
3.1 3.2 3.3 4. 5.
Nutritional anaemia . . . • . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . Iodine deficiency diseases (IDD} • • • . . . • . • • • . . . . • . • . . . • . • . . . . . Vitamin A deficiency • • •.• • • • • .. • . . • . • . . . . . . • • . . . ... . . • • . . . . • . .•.•••••••• ·• . . . . • • • . . • • . • . . .
INFANT AND YOUNG CHILD FEEDING
PHYSICAL GROWTH AND PSYCHOSOCIAL DEVELOPMENT . . . . . . . . . . NUTRITIONAL PROBLEMS OF AFFLUENCE • • • . • • . . . . . . . • . . . . . . . . . .
I2
6.
14 I5 15
PART II- DEVELOPMENT OF NATIONAL NUTRITION PROGRAMMES . • . . . . .
l. 2. 3. 4.
INTRODUCTION • • . . • • • • • •.• • • • • .• • • • • • • • • • • • • • . • • • . . • . . • . . • • . . . . . . THE WIDER CONTEXT OF FOOD AND NUTRITION PLANNING • .. • · · • • DEFINING THE PROBLEM AT THE NATIONAL LEVEL .• • . · • · • · • · · • · · · DEFINING THE PROBLEM AT THE COMMUNITY LEVEL • • . • . . . . . . . . . . THE HEALTH SERVICES IN INTERSECTORAL FOOD AND NUTRITIO·N PLANNING •••.••. • •. • • • • · • • • • • • · • • · • · · • · • • • · · • • · · • · · · ORGANIZATION OF NUTRITION PROGRAMMES IN THE HEALTH SECTOR •••.••.••••••••.••••••••••••••....•. • . · • . • • · · • • · ROLE OF THE HEALTH SECTOR IN THE CONTROL OF NUTRITIONAL PROBLEMS .•••••.••••••••.••.••.•...•. · . • · • • • · · · · •
I5 16
17
5. 6. 7.
I8
19 20
7.1 7.2 8. 9. J0.
Control of specific deficiencies .•...•............ • . . . . . . . . . . Control of protein-energy malnutrition . . . . . . . . . • . . . . . . . . . . . . .
20 21 22 23 24 25 27
NUTRITION THROUGH THE HEALTH SECTOR AT THE COMMUNITY LEVEL •••••.•••••••.••...•••••••..•.••..•... • . · · · · . RESEARCH AND TRAINING .•••••••••••••••••• •................... ROLE OF INTERNATIONAL AGENCIES . • • • • • • • • • • • • . • . • . . . • . . . • . • . .
PART III- THE NEED FOR A MINIMUM PROGRAMME •••.•...... ; • . . . • • • • • R E F E R E N C E S •••. . . . . •••••. •••. . •. . •. •. ••••••. •. . . . . . . . . ••. . ••. .
WPR/RC35/Technica1 Discussions/ I page 3
INTRODUCTION
At its thirty-fourth session in 1983, the Regional Committee cho.se the subject of "Malnutrition, growth and development" for the Technical Discussions to be held in conjunction with its 1984 session. Nutrition has not been discussed in the past and this new interest echoes the resolutions of the World Health Assembly and the World Food Conference, which recommended that countries strengthen their programmes tor the control of nutritional deficiencies and establish policies that recognize food and nutrition as important aspects of socioeconomic development. It is not the scope of this paper to attempt a fuJJ discussion of aU the aspects of malnutrition, growth and development. There have been a number of expert committee reports and other reports on the various aspects of nutrition in the present context ( 1-4). This paper is chiefly concerned with defining the role · and responsibilities of the health sector in the development of programmes for the control of malnutrition, especially among the vulnerable groups. The term "malnutrition" covers a number of diseases, each with its own etiology relating to a specific nutrient or combination of nutrients. These diseasesare a result of a metabolic imbalance at the ceHular level between the supply of nutrients and energy and the body's need for them to ensure maintenance, function and growth. Malnutrition can be prevented by modifying or eliminating factors which interfere with the normal flow of nutrients and energy to the ceU at any of several stages, from food availability through absorption to final use by the body. It can also be cured by increasing the nutrient and energy supply (in deficiency states) or by reducing it (in cases of excess). Malnutrition can be produced experimentally in ahimaJ models and has clearly defined anthropometric, clinical and biochemical features. The body's first response to nutrient and energy imbalance is adaptation. In cases of severe or prolonged stress, however, adaptation faits. It is at this stage that malnutrition becomes a medical problem by itself as well as in conjunction with other closely related illnesses. Food availability is undeniably a major concern but malnutrition is not synonymous with, nor is it a consequence of, consumption of too little food alone. The main factor is the individual's ability to fully utilize the food that is consumed, whatever the amount. Infection and disease impair this process; when food is scarce; the increased need for energy aggravates the effects of malnutrition and the situation may deteriorate further with lack of appetite in the sick individual. The undernourished are most susceptible to infection and disease and thus a vicious circle is formed. The relationship between nutrition and mental development Is complex, and the role played by psychosocial and emotional stimuli at home is considerable. Although malnutrition due to excess is a serious threat to health and survival in the older age groups, the most severe and widespread forms of malnutrition in the world today are related to one or more nutrient deficiencies. WHO has given high priority within its overall programme of nutrition to supporting efforts by countries to reduce and eliminate such deficiencies.
WPR/RC35/Technical Discussions/ 1 page4 ·
PART I OVERVIEW OF REGIONAL.NUTRITIONAL STATUS TRENDS
At the core, of malnutrition lies the· problem - in our Region especially - of pover,ty in developing. countries, more specifically among the ruraL poor• Low productivity and poor purchasing power are the principal causes of substandard food consumption. The problem is aggravated by inapprop.riate choice of foods as. well as unhealthy food habits. The wide preval.e nce of infectious diseases, especiaHy in childhood, poor environmental sanitation and Jack of knowledge of appropriate· feeding practices, aU contribute to complicate the-· picture of malAutritioR•- ThotJgh the·degree of malnutrition-in· the Region as a . whole: may not appear to be · so~ alarming. as in some other reg-ions .of WHO, a closer examination of the~ situation in individual cotmtries reveals that the· nutritional status of the population,. especially the vulnerable groups, is far from satisfactory• · This section provides an update on · sefected regional nutritional status. trends among women, infants and young childrem·. It must be borne in mind that the· data available are not always comparable betweeA" countries owing. to differences in the methodoiogy and sampling·:procedures used~-·
J. INCIDENCE OF LOW· BIRTH WEIGHT
Low birth weight is the most significant indicator: of the risk to survival and healthy growth and development, and is thus. an important guide to. the level of care needed by the individual infant;. Because birth· weight is conditioned by the health and nutritionalstatus of the mother, the -proportion of infants with low birth weight also serves as an index of the overall health · status of mothers and communities. In particular, it reflects the health and nutritional deficiencies of pregnant women, the too close spacing of births, excessive· work . load· during pregnancy; and inadequate prenatal care. Low birth weight is thus andndicator oi health status and quality of life that continues to merit particular attention; for example, where. action to reduce infant morbidity- and mortality is concerned. This is borne out by the Health Assembly's decision to include it among the indicators for monitoring progress towards health for all (2). . · The limitations of this indicator are obvious, especiaUy in the rural areas; where routine weighing is not always the practice· since, the - majority of births take· place outside· health institutions. The available data indicate that there is a wide variation between countries or areas in the Region with respect to low birth weight. It ranges from 0.4% to 25·% (see Table 1).
WPR/RC.35/Technica1 Discussions/! page 5 ·
Table 1. Low birth weight
Country or area
Percentage of low birth weight in infants (~ 2499 ~rams) Year Percentage
American Samoa Au.s tralia Brunei China Cook Islands
1982 1979 J982 1979 1982 1979 1981 1975 1979 1979
2.9
5.8
10.0 6.0 3.2 J 3. 9
Fiji Guam Hong Kong Japan Lao People's Democratic Republic Malaysia New Zealand Papua New Guinea Philippines Republic of Korea Samoa Singapore Tonga Tuvalu VietNam
8.7 8.1 5.1 J 8.0
1979 1982 J979 1981 1981 1982 1982 1982
9.0 5.8 25.0
18.1 9.2 1.5
8.0 0.4 4.0
19.82 1982
.8.0
Source: Western Pacific Region Data Bank on Socioeconomic and Health Indicators (Revised as of 26 March 1984).
WPR /R C 35 /Technical Discussions/!
page 6
As birth weight is a measure· of the outcome of the period of most rapid growth and development in the human life span, it is also the most significant indicator of an infant's chances of survival and healthy growth and development. Indirectly it is also an indicator of overall health and socioeconomic development. Possibilities for intervention to reduce the incidence of low birth weight are available to the health sector. The prevention and management of diseases during pregnancy and the promotion of appropriate dietary intake as a function of ·energy output, combined with a reduction in work load, are examples of such approaches. The primary health care approach offers the best opportunity for extending the necessary support to alleviate the problem of low birth weight.
2. PROTEIN-ENERGY MALNUTRITION (PEM)
The data available in the Western Pacific Region with respect to protein-energy malnutrition (PEM) are insufficient to clearly quantify the extent of the problem except in those countries where a national survey has been conducted. Most of the survey results pertain to small population groups selected at different periods of time by different workers and for this reason any comparison is limited. In spite of the deficiencies, it is possible to make a rough estimate of the extent .o f the problem in the developing countries of the Region. ·The majority of the surveys have used weight-for-age to determine the prevalence of protein-energy malnutrition because of its recurrent use in epidemiological surveys. There are very · few surveys whiCh have used weight-for-height (for thinness or wasting) or height-for-age (for shortness or stunting) as indicators .o f malnutrition. It is now recognized that weight-for.,..age is a composite of these two more specific indicators. Adequate growth as measured by weight-for-age is included in the short tist of indicators for global monitoring and evaluation of the global strategy for health for all by the year 2000 (~). Table 2 gives a measure of the extent of the problem in some of the developing countries or areas of the Region. In determining trends in malnutrition, it is essential, besides using the same indicator when comparing data, to -use the same criterion to distinguish malnourished from non-malnourished children. There are also considerable fluctuations in the percentage of malnourished children at different ages. Attempts by WHO to measure comparative trends in the prevalence of protein-energy malnutrition in children under 5 years using selected survey results indicate that the problem of malnutrition among children appears not to have worsened among developing countries in the Region when expressed in percentage terms based on weight-for-age. However, the growth in population during the last 20 years appears to have resulted in a slight increase in the absolute number of malnourished children under the age of 5 compared with the situation ten years ago. This obserVation apparently is relevant to the Western Pacific Region as well.
WPR/RC35/Technical Discussions/ 1 page 7
Table 2.
Current information on protein-energy malnutrition among children under 5 years in some developing countries or areas of the Western Pacific Region
Country or area
Percentage of children beJow 80%~/ 10 F- 30.8
SourceE/
Fiji
I£/
Lambert, J. & Johnson J. National Food and Nutrition Committee, 1980 DeJbecque & DeJbecque, 1982 Buswell, R., 1982 Kripps, R. (WHO), J 984 Nutrition Section, Ministry of Health, 1978 Florentino, R., 1982 1975
French Polynesia Kiribati Lao People's Democratic Republic Papua New Guinea Philippines Samoa
7
-
8
14.5 42 36 17.22./ 9.5 Urban 9.1 Rural 19.5 16.8
1975 Brazil, H., 1979 Weerasinghe, 1980 Malaita, R.A., Bellona, 1982 Maiolo and Borelli, 1982 Mar Min Hung, Ministry of Health, 1983 National Institute of Nutrition, 1983
Solomon Islands Tonga Vanuatu . .
20 4.8 23 43.~/
VietNam
~/Below 80% of reference standards (weight/age)
P.l Many of the sources are unpublished; S.IF = Fijian; I = Indian
compiled from reports
2.1 Moderate to severe degrees, fl./ Harvard standards
using Philippine standards
WPR/RC35/Technical Discussions/ 1 page 8
In the future, more accurate estimates of trends that shed more light on types of malnutrition should b~ possible through the increased use of more specific indicators such as weight-for-height and height-for-age, which wiU provide a reasonably clear picture of the gravity of the situation and enable progress to be made in the prevention and control of malnutrition.
3. SPECIFIC NUTRITIONAL DEFICIENCIES
At global level, although there are signs that the situation is improving in relative terms, the absolute numbers suffering from nutritional anaemia, especially iron deficiency anaemia, endemic goitre and vitamin A deficiency strongly suggest the need for effective preventive and curative efforts. Although progress in dealing with ·iron deficiency anaemia is more difficult, a relatively low-cost technology has already been developed for the control of goitre and vitamin A deficiency. 3.1 Nutri tidnal·anaemia
Although nu,ritional anaemi~ affects all age groups and both sexes, the problem is most acute among women where it contributes significantly to maternal morbidity and mort;:tlity. Nutritional anaernta is estimated to affect nearly two-thirds of pregnant and one-half of non-,pregnant women in developing countries <z>. The available ~nformation on the prev~lence of anaemia in women in. developing countries lJp to 1978 was report~d in the World · Health Statistics Quarterly, Vol. 35, No. 2, 1982, arid the extracts from this report covering countries in this Region are given in Table 3. The trend in the Western Pacific Region is almost identical with the global trend. Progress in the control of iron deficiency anaemia has been hampered by a number of factors, including: the low rate of absorption of iron and the inadequacy of the tools developed so far to deal with the problem; the difficulty in reaching vulnerable groups and obtaining their cooperation in prevention programmes in view of the long duration of treatment; and the frequency of side effects. Recent field trials in iron fortification of food, especially in the Philippines where riee was fortified with iron, appear to point the way to an effective alternative approach to iron supplementation. Consideration has also been given to overcoming the effects of iron losses due to parasites and frequent pregnancies. A considerable amount of research and development will still be necessary if iron supplementation and other initiatives are to have appreciable effects. 3.2 Iodine deficiency diseases (IDD)
It i~ generaUy accepted now that we should not confine our attention to endemic goitre alone but should also consider epidemiologically associated cretinism, deaf-mutism and mental deficiency. The prevalence and severity of goitre among women are of particular concern because of the danger of cretinism in infants.
WPR/RC35/Tectmical Discussions/! page 9
Table 3.
Population at risk: number and estimated percentage of women aged 15 to 49 years with haemoglobin concentration below the norm
Country or area
Pregnant women Number Percentage (in thousands) with HB below the norm
Non-pre'gnant women Number Percentage (in thousands) with HB below the norm
EASTERN SOUTH ASIA Lao People's Democratic Republic 120 371 1 501
62 77
651
IMalaysia Philippines Singapore VietNam OCEANIA Fiji Papua New Guinea Other
2 366 8 182 467 8 430 44 37
47 26 50
33 1 448
13
68 55
135
72
110 17
490 239 70
70
Source: World Health Statistics Quarterly, No. 2, 1982
WPR /R C 3 5/Tee hnical Discussions I 1 page 10
Endemic goitre is still a severe and w.idespr·e ad problem in some countries of the Region owing to the large number of population who are at risk to iodine deficiency diseases. Considerable efforts need;' to be made f·o r the control of this problem. Estimates made in a few countries of the Region are shown in Table 4. These estimates indicate that more than 200 mil: l ion people in six countries of the Region are at risk as a r-esult of iodine deficiency diseases. In addition; pockets of endemic iodine deficiency d'iseases-can be seen in a. few countries of the Region such as Fiji and Papua . New Guinea. Proven techniques, both simple and cheap, are av ailable to control iodine deficiency. These do not involve sophisticated technology and can be used anywhere. in the world. The successf.ul implementation of control programmes is o.niy in part a medical· problem. The main issue is the· need f:or political will to o.vercome various geographic, economic and .administrative obstacles associated with iodine supplementation. 3.3 Vitamin A deficiency
Xerophthalmia:, the eye disease that is due to vitamin A deficiency, can lead in its severe form to nutritional blindness and to destruction of the eye (keratomalacia). Even mild cases of xerophthalmia contribute to increased morbidity and mortality in young children. The problem is seen in Fiji, Democratic Kampuchea, Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam as a serious public health problem. As in goitre control, a relatively inexpensive technology exists to control vitamin A deficiency, in. particular through periodic massive dose administration or by fortification of certain foods. The long-term preventive programme would necessarily consist in improvement. of the diet through availabiJity of vitamin A,-rich foods. For some reason;. there has not been any extensive programme providing wide coverage in the Region although there have been eHorts in some countries to distribute large doses of vitamin A as a therapeutic measure. The tria-ls conducted in the Philipppines to test the feasibility of fortifying monosodium glutamate with retinol in order to provide an additional readily available source of vitamin A in the household diet have proved to be a success.
4. INFANT AND Y:OUNG CHILD FEEDING
Since the 1979 WHO/UNICEF Meeting on Infant and Young Child Feeding, there has been increased public awareness of the importance of appropriate nutrition during pregnancy and lactation, breast~feeding and appropriate weaning. The few surveys held in the Region had pointed to an alarming decline in breast-feeding in developing countries. In some major urban areas, the proportion of breast-feeding mothers had dropped to 20-30%.
WPR/RC35/Tec hnlcat Discussions/ I page 11
Table 4. Extent of iodine deficiency disorders (IDD) (in millions)
Total
Country
population
Estimated population at risk for IDD
Estimated goitrous population
Estimated population (0-15yrs) with IDD
China Democratic Kampuchea Lao People's Democratic Republic Malaysia Philippines Viet Nam
1000.0 6.1
200.0 1.8 1.1 1.2
78.;0 0.7 0.4
16.00 0.14
3.7
0. 09 O.l 0
13.4 51.6 56.6
0.4
I I
15.3 17.0
6.0 6.6
1. 20 1.36
I
Sources: Compiled from a report based on: Hetzel, B.S. Iodine deficiency disorders (IDD) and their eradication. Lancet, November 12, pp. 1126-29 ( 1983) Stanbury, J.B., Hetzel, B.S. Endemic goitre and endemic cretinism, New York, Wiley, 1980, pp. 101-121 Panday, C.S., Kochupillai, N. Endemic goitre and endemic cretinism in South-East Asia. Paper presented at the Fifth Meeting, PAHO/WHO Technical Group on Endemic Goitre and Cretinism Control, Lima, Peru, J 983
WPR/RC35/Technical Discussions/ 1 page 12
Numerous resolutions on infant and young child feeding adopted by the World Hea lth Assembly and the Regional Committee since 1979, .a s well as the wide range of discussions that have taken place in recertt Regional Committee sessions, are indicative of the level of national and international awareness of the importance and relationship of breast-feeding and malnutrition. There have been ~ncouraging efJorts jn most. countrie s of the Region to promote breast-feeding for a minimum period of 4-6 months. In most of the Membef" States, the health authorities have provided guidance to their healt h personnel and caJJed attention to their responsibilities, in particular with respect to t he protection and promotion of breast-feeding. The International Code of Marketing ot Breast-milk Substitutes has received almost universal acceptance. National workshops, intersectora1 meetings and consultations, primarily to revie w the trends in .breast-feeding and the impact of breast-milk substitutes, have been held in a number of countries or areas during tne last Jew years, notably in China, Fiji, Kiribati, the PhiHppines, the Republic of Korea, Samoa, Tonga, Vanuatu, and Viet Nam. WHO has a lso supported research activities on the di-ffe:r~nt aspects of infant and young cniJd feeding in several countries, including China, Fiji, Papua New Guinea, the Philippines, the Republic of Korea, and Viet Nam. National codes or legislative measures for the appropriate marketing a nrJ distribution of breast-milk substitutes are now available in Australia, Malaysia, New Zealand, Papua New Guinea and Singapore. National codes are also being fina lized in Fij i and the Philippines. It is encouraging to note that countries that manufacture and export br east-milk substitutes, particularly Australia and New Zealand, have also indicated their wiHingne ss to comply with the spirit of the International Code. In other countries such as China, Lao People's Democratic Republic and Viet Nam, the threat to breast-feeding by breast-milk substitutes and their marketing is minimal and distribution of breast-milk substitutes is subject to state control. The continuous flow of information from almost aH countries of the Region on action taken to encourage br~ast-f:eeding, as well as on the International Code of Marketing of B-reast-milk Substitutes, is .e vidence of the growing national commitment to appropriate infant and young child nutrition. Nonetheless further e fforts a re st ill necessary, especially to encourage breast-feeding among vulnerable population groups such as urban working mothers, to promote the nutritional status of m.o thers and to ensure appropriate supplementation from the .age of 4 to 6 months.
5. PHYSICAL GROWTH AND PSYCHOSOCIAL DEVELOPMENT
Under proper circumstances, a child's growth in height foJJows an extraordina rily regular pattern, so much so that the rate of growth is one of the best indices of a child's general health; yet we are in total ignorance as to how this normal rate is regulated or controJJed. We do not know what causes the growth velocity to diminish as the child gets older or by what means the child knows how large he "ought" to be at any given age.
W PR/R C35/Tec hnical Discussions/ I page I 1
Failure to grow may be due to any number of causes: malnutrition, hypothyroidism, growth hormone deficiency, coeliac or bowel disease, renal diseases, cortisol excess, chromosomal disorders, to name just a few. The mechanisms responsible for slowing down growth - about most of which we are again ignorant - evidently differ from one disorder to another. But though the causes of growth failure may vary, the response when failure is repaired is the same. If thyroid hormone is given in hypothyroidism, growth hormone in growth hormone deficiency, or food in malnutrition, the Child resumes growing but at a rate usually well above the rate to be expected for his age. This phase of recovery has been cailed "catch-up growth"(~). Most of our knowledge about the association between nutrients and height c omes from animal experiments, studies in developing countries and indirect observations ot the changes of trends in height and weight during periods of war in developed countries ('!_). Overt deficiency in nutritional intake affects the growth of children and the abilit y of children to catch up in height diminishes if deficient intake is prolonged. There is no universal rule by which a set proportion of growth is determined by genes and another fixed proportion by environment. Growth of children wiJi depend on tl')e genetic and environmental variability in each country and these are changing over time. The relationship between nutrition and mental development is complex and the role played by psychosocial and emotional stimuli at home is considerable. The studies currently being carried out on the delivery of specific health, nutrition and informal education services (for example: the "mental feeding" programme in the Philippines) have shown promising results with respect to the emotional and physical development of preschool age children. It is only recently that both physical growth and psychosocial development have been widely recognized as sensitive indices of the health and nutritional status of the population, but the main difficulty is the development of appropriate indicators for psychosocial development. Development of psychosocial indicators must take into account both cultural diversity and universality. Indicators .need to be developed in full understanding of the relationship between growth, psychosocial development and other factors such as breast-feeding, malnutrition, infection, maternal educational level , family structure, urbanization and poverty. A second stumbling block in the development of psychosocial indicators is the neecJ to make them sensitive enough to detect the remedial conditions as opposed to monitoring of the health status alone. Though knowledge of suitable indicators has recently been daimed in developed countries, further research is needed before .a universally applicable approach to their adaptation in different settings can be put forward. A. considerable amount of work has already been done in developing indicators for physical growth. Simple and sound scientific techniques have been produced to monitor the growth of an individual or group through, for example, the use of growth charts in many countries. This stage has not been reached with respect to psychosocial indicators. One of the first efforts of WHO in this context was to hold a consultation rneeting on health indicators based on psychosocial development in 1983 (!. .Q). Much work still remains to be done to make simple universally applicable psychosocial indicators available at the field level, which will take into consideration all aspects, including nutritional and environ mental ones.
WPR/RC35/Technka1 Discussions/! page II+
Very few studies on psychosocial development in relation to malnutrition have been conducted in, this-RegiGn except, lor example, the study of the mental feeding prograrnrne in the Philippines in which emotional stimuli facilitate both physical and· mental development in malnourished children~
6.. NUTRITIONAL PROBLEMS , O F AFFLUENCE
Problems associated with dietary factors .which are of concern to. the developed or industrialized countries, have already started to have an imp.act in the developing countries, especic:Uly among affluent and urban societies. These include obesity associated with excess of sugar, fat, animal fat or calories; cardiovascular diseases associated with dietary factors; diabetes mellitus and specific forms of undernutrition affecting specia l groups (nutritional anaemia:,. dental caries, endemic. goitre, mild deficiencies of vitamins, problems with alcoholics~ the elderly and migrant workers). Of special concern is the very high prevalence of diabetes and obesity- in the countries of the South Pacific. WHO is focusing increasing attention on these problems.
WPR/RC35/Technical Discussions/ l page 15
PART II DEVELOPMENT OF NATIONAL NUTRITION PROGRAMMES J. INTRODUCTION
Countries are beginning to realize that proper nutrition and provision of sufficient food are fundamental aspects of development planning. In the 1960s, development was seen and measured mainly through aggregate values of national wealth, i.e. the gross national product, the increase in which does not necessarily reflect an improvement in the socioeconomic condition of the masses. In the 1970s, development was considered to be inseparable from a more just and equitable distribution of income, combined with an increase in national wealth and a growing emphasis on improvement of the patterns of consumption among the economicaHy more disadvantaged countries. Better nutrition will not only be a result of such a pattern of development but also a cause that will contribute to socioeconomic progress through better health. However, the purely economic effects of better nutrition should not be emphasized over the humanitarian, health and social grounds for advocating a reduction in malnutrition. In other words, nutritional improvement must be seen as an objective of socioeconomic development in its own right and must come before purely economic considerations. Bringing about nutritional improvement is undoubtedly a complex challenge and wili need the total commitment of at Jeast the sectors responsible for agriculture, rural development, education, social welfare and health. F AO has pioneered the muJtisectoral approach to the promotion of national food and nutrition policies (NFNP), with WHO's sustained support. National food and nutrition policies are aimed more at the deep-rooted causes of malnutrition and of inadequate food availability than at treating the consequences. It is necessary to look at the wider context of food and nutrition planning and the sectoral responsibility of the health services if appropriate programmes are to be developed in the health services. The rote of the health sector, in particular with regard to problems of malnutrition, needs to be very clearly defined in order to develop specific nutrition programmes within the health sector.
2. THE WIDER CONTEXT OF FOOD AND NUTRITION PLANNING
Primarily, health sector planning of nutrition should be seen within the context of and integrated with overall multisectoral food and nutrition planning. Previous approaches to food and nutrition planning have taken second place to economic development planning. Such an approach has failed to contain the problem of malnutrition in many countries and has even aggravated it in spite of strategies to maximize economic growth. Most applied nutrition programmes cannot
WPR/RC35/Technkal Discussions/! page 16
have more than a marginal impact on the problem of rnaldistribution of food; hence no amount of food supply can ensure an adequate diet for those people who have insufficient means for their own subsistence. In placing emphasis on food and nutrition, therefore, consideration needs to be centred on overall development planning. The basic issues to be considered are, first, that malnutrition is seldom present alone; and second, that malnutrition is usually one aspect of syndrome of ill health which also includes other disease conditions. Thus, improved nutrition alone will not restore or sustain health nor can health be restored and sustained without adequate nutrition. Third, the personal disease syndrome is only one aspect of a more complex social syndrome. Thus, nutrition and health services alone cannot produce a healthy social environment nor is a healthy social environment possible without adequate provision of nutrition and health services.
a
3. DEFINING THE PROBLEM AT THE NATIONAL LEVEL
Most of the statements about national nutrition problems are less helpful than they might be, mainly because they fail to use available evidence to define the problem in a way which will be most useful for policy and programme formulation. These include: per capita availability of calories and nutrients, estimates of numbers affected by specific nutrient deficiencies, and broad definition of affected groups. Such observations could be misleading, and yet pertinent and timely information may be available. Estimates of food and nutrient availability are invariably based on food balance sheets derived from food supply /utilization figures, estimates of food availability in countries at a given time, and the available nutrient per capita. These estimates have shown that in most countries there is enough overall to meet everybody's requirements but in practice the consumption surveys fail to show that everybody's protein, calories and essential nutrient needs are met. In the past, food intake and dietary surveys have supplied estimates on the prevalence of specific nutrient deficiencies and given rise to estimates of the percentage of the population having intakes which are below the recommended allowances of any nutrient. With further estimates of average deficiency, it has been possible to calculate the quantity of food needed to supplement deficient intakes. Now, however, it is clear that these do not ensure the elimination of malnutrition. The basic objective is to ensure that food is avaiJable to the people who need it. Epidemiological and clinical experiences show that it is the vulnerable groups like infants, children, pregnant and nursing mothers who have malnutrition. Our knowledge of nutrient requirements per unit of body weight is that these are greater among such categories of population. The problem is also serious among low-income families in certain specific regions. It can also be seen that some households have a low food intake and that malnourished mothers and chiidren are found in such households. The concept of the family at risk would be more useful and within these families spec-ial attention could be given to vulnerable individuals.
WPR/RC35/Technical Discussions/!· page 17
Statements of national nutrition problems can only present an overall view and can be seen as summaries of a more detailed analysis of the national problem.
4. DEFINING THE PROBLEM AT THE COMMUNITY LEVEL
Malnutrition problems go through a pre-pathogenic stage in which several factors combine to predispose to the emergence of the disease. Determination of food availability, dietary and other related surveys are parameters of this stage. Once the disease has started (pathogenic stage), there is a period of physiological and metabolic change before symptoms become evident (pre-clinical stage). Biochemical methods are useful for pre-clinical diagnosis; during the clinical stage, anthropometric, clinical and morbidity data are important tools. Categorization of the nutritionaHy deficient population based on ecological, socioeconomic and demographic characteristics would be most useful for planning purposes. Casual observation can provide useful information regarding nutritional status in the community. Data on height and weight related to age, morbidity data and other observations like environmental sanitation, quality of drinking water, access to health care, the extent of. poverty, etc. are sources of valuable information. Systematic inquiries on indexes like food intake data, anthropometric and clinical surveys, health service records, demographic data, etc. present both advantages and limitations but are complementary to one another. ·
In a community, it is important to know who is short of what and why, and also to specify when, since malnutrition may not be continuous. Malnutrition, however, is not necessarily limited to the poorest families. Grouping of individuals in appropriate socioeconomic, demographic and other categories facilitates the design of measures to meet their particular conditions. The following types of measure, for example, suggest different approaches to classification: universal measures like sa1t iodization, fluoridation, etc.; services for groups such as iron for pregnant women, vitamin A tor small children, advice on infant feeding for poor urban families, food storage advice for poor rural families, etc.; relief services such as assistance in drought or flood and supplementary feeding programmes for specific socioeconomic arid demographic groups. An effective diagnosis of community nutrition problems should, therefore, aim at providing the following: (a) (b) evidence of existence of malnutrition, including manifest disease syndrome but also subclinical forms; definition of the presentation of the condition, etiology and epidemiology;
WPR/RC35/Technica1 Discussions/! page 18
(c)
identification of the characteristics and categories of people affected; extent of the numbers involved; prognosis of these nutrition-related problems.
(d) (e)
5. THE HEALTH SERVICES IN INTERSECTORAL FOOD AND NUTRITION PLANNING
The participation of the health services in intersectoral planning of food and nutrition should principally be in relation to: (a) (b) the diagnosis and surveiHance of the nutrition status; sectoral programmes that need intersectoral coordination.
The health sector should be able to provide sufficient detailed data that are necessary for food and nutrition planning, which should specify the rnagnitude and nature of the different nutritional disorders, those who are affected by nutritional problems, and where those who are affected by malnutrition may be found. ln addition, the health sector should provide information on health-related conditions that are linked to nutritional disorders. To complete the nutrition situation analysis, it is necessary to have knowledge of the availability of food and food consumption patterns. Hea1th sectors should be able to provide on a regular and systematic basis data of the type mentioned above, which, when analysed in conjunction with information from other areas (crop conditions, employment, weather forecast, price indexes, etc.), will provide a sound basis for the planning or implementation of measures directed at preventing a deterioration or obtaining an improvement in the nutritional condition of the population. The size .of the family at the micro level and the number of people at the macro level are obvious determinants of food demand. The control of population growth and the extent of the family planning effort wiU depend on the national priority given to this .important area. As the health sector is usually responsible for family planning, it will have an important intersectoral influence in achieving a balance between population growth and food supply. The important problems of food hygiene and food control, in which the heal ttl sector traditionally plays a leading role, have implications for other sectors like agriculture, animal husbandry, food industry and commerce. Food control measures are of great importance in time of shortages. Special mention should be made o1 food contamination, where food acts as a vehicle for disease. The health sector should be able to provide the necessary technical expertise to other sectors, especially as regards nutritional requirements and al!owances, food composition and nutritional diseases. An important area which is still difficult to assess is the effect that an adequate levef of health can have on food production through the increased capacity of the agricultural work force to perform its heavy tasks.
WPR/RC35(fechnicaJ Discussions/ J page 19
6. ORGANIZATION OF NUTRITION PROGRAMMES IN THE HEALTH SECTOR
Nutrition in the health sector is viewed today more as a component of progranimes and as an integral part of the health of the family. For this purpose, there is an obvious need for a nutrition unit at the central level within the health structure, 'Which is capable of providing the necessary technical inputs• The central level functions of the nutrition unit are intended mainly to supply health planners with sufficiently detailed information or to organize its collection through nutrition surveys or an internal surveiLJance system. In sectoral planning, nutrition indicators based on such information will be useful for project formulation, monitoring and evaluation. Information on nutrition is also very important to intersectoral planning of food and nutrition. The participation of the nutrition unit in the formulation of projects will enable health planners to include nutrition-oriented activities as part of the strategy when necessary. The nutrition unit, in consultation with the division implementing a programme, has a primary responsibility for drafting norms relating to nutrition activities within a given programme. The unit should have appropriate links with agencies that supply food aid or technical cooperation. Control and surveiHance of food labelling and commercial food promotion, especiaHy promotion of infant foods, should be under the continuous surveillance of the nutrition unit. The unit should provide the methodology, criteria and expertise to monitor and evaluate programmes in which objectives and targets have been defined through nutrition indicators. The unit should have the technical expertise to advise the authorities on the need and justification for, and feasibility of, programmes to control specific deficiencies through fortification or supplementation. Last but not least, the nutrition unit has an important role to play in the participation of health in the intersectoral planning needed to formulate a national food and nutrition policy. Nutrition activities at an intermediate level reflect those of the central level, but on a smaller scale, the principal responsibility being the adaptation of centrally designed norms toexisting local conditions. At the local level, nutrition should form part of a package of services aimed principaliy at the mother and her child. The main constraint at the local level is the shortage of adequately trained personnel capable of performing the relatively simple tasks required in nutrition. The training of primary health care workers to perforrn this simple task and provision .of supervision or support with appropriate referral services should be the principal function of nutr'ition at the local level. Participation of the community in nutrition activities through the training of multipurpose or voluntary workers, who in turn would form a link between the health services and the community, would in the long run bring about changes in behaviour and attitudes towards nutritional problems of the community.
WPR/RC35/Technical Discussions/! page 20
7. ROLE OF THE HEALTH SECTOR IN THE CO NTR OL OF NUTRITIONAL PROBLEMS
Nutri tiona! problems of public health significance are: nutritional anaemia endemic goitre xerophthalmia protein-energy malnutrition( PEM).
Evidence from national food balance sheets and food consumption sur ve ys indicates that important sectors of the population fail to attain recommended levels o1 protein and energy intake. The more evident protein-energy malnutrition in infa nts and preschool children - which attracts the major part of our attent ion - c oexists with the ill-defined forms of malnutrition of the rest of the family . 7.1 7. 1.1 Control of specific deficiencies Nutritional anaemias
Nutritional anaemia is extremely common in many countries of the world and affects not only the vulnerable groups but also the adult man. The c ombined effec t s of poor bioavailability of dietary iron and parasitism of the intestinal tracts explai n the wide prevalance found. Not much is known of the health implications of the milder degrees of nutri tiona l anaemias in children from six months to two years and women in t he reproductive age. Severe anaemia in pregnant women involves a higher risk for the mot her and t he foetus, and increasing evidence indicates a link between iron deficiency and the abilit y of the individual to resist infection. The main approaches to nut ritional a naemias a re iron supplementation schemes and fortification of foodstuffs with iron. Supplement s in the form of combined iron folate tablets can feasibly be provided to pre gnant women as a routine measure in antenatal care. Various attempts have been made t o fortify foodstuffs with iron and the recent trial in the Philippines at tempted iron fortification of rice. 7.1.2 Endemic goitre
Presently caHed "iodine deficiency disorders'', endemic goitre results from a low iodine intake and is an important problem in several countries of t he Region (Table 4). There is a growing awareness that goitre is the least significant of the health effects of iodine deficiency and that far more serious health consequences are occurring in iodine-deficient populations. In addition to endemic cretinism, which is characterized by deaf-mutism, defects of stance and gait, and irreversible mental deficiency, iodine deficiency leads to a greatly increased risk of still birt h a nd neonatal mortality, developmental handicap, neonatal hypothyroidism and related developmental brain defects among newborns. Effec tive c ontrol of e nde mic goitre has been achieved through iodization of salt or iodinat ed oil. Successf ul iod ization programmes should be a ble to cover almost all the sa lt availa ble for human consumption. Proper surveiUance and monitoringof salt utilization are not di ff ic ul t to conduct with modest clinic al and laboratory me ans.•
WPR/RC35/Technical Discussions/ 1 page 21
7.1.3
Xerophthalmia
Vitamin A deficiency is an important public health problem in some countries of the Region. Xerophthalmia is rarely a pure deficiency, but is usually associated with protein-energy malnutrition and often its advanced form , keratomalacia, is precipitated by an infectious episode. The advanced form, which leads to blindness, is rarefy found in schootchitdren and adutts. Measures · to control xerophthatmia include: education, administration of preventive doses of vitamin A, food fortification and curative steps. Education on the usefulness of feeding chitdren dark green Jeafy vegetables, massive preventive oral doses and fortification of foods have proved successful in many countries. Health workers should know about the seriousness and rapidity with which a child may lose his sight by keratomalacia and the need for prompt treatment to prevent the irreparable stage. 7.2 Control of protein-energy malnutrition
Protein-energy malnutrition is viewed today in a wide ecological context and as a deficiency disease, and strategies for its definite control should be part of the national socioeconomic development plan. The total energy intake, equatable with the quantity of food eaten, plays a decisive role in the production of protein-energy malnutrition. It is now clearly understood that the limiting factor in the diet of children suffering from protein-energy malnutrition is the total energy intake and only occasionally or marginally its protein content. · Infections and ari insufficient diet are inextricably linked to the causation of protein-energy malnutrition. The resistance of the malnourished child to infectious a,gents is generalJy diminished by a poor humoral or cellular defence. At the same time, infectious diseases produce a decreased appetite and a wastage of nutrients, especialJy through a higher rate of tissue breakdown. In the environment in which malnutrition occurs, infect_ions and infestations succeed one another and a large number of children suffer from acute or chronic infections during a considerable part of their first five years of life. Programmes designed to increase food availability without reducing the exposure to infectious agents or without attending to the host's capacity to resist an infectious disease, through immunization and prompt treatment, will fail to produce the expected result of reducing protein-energy malnutrition. Many studies show that the number of deaths in which malnutrition is an important factor is maximal during the first and second years of life. Hence, health planners need to direct nutrition-oriented programmes to this particular age group. The principal strategy lies in improving and increasing nutrition activities through the primary health care services. The effectiveness of these actJv1t1es through the health sector will depend on the strength of the services and the coverage offered. The objectives of health in relation to the control of protein-energy malnutrition are necessarily limited to:
WPR/RC35/Technica1 Discussions/ 1 page 22
(1)
protecting the nutritional status of children aged 0-5 years, e spec ially 0-3 years; reducing the malnutrition;, number of moderate cases that progress to se vere
(2) (3)
protecting the nutritional status of pregnant women and nursing mo thers; providing preferential treatment to those children that suffer fro m the more advanced forms of malnutrition, especially in conjunction with diseases known to cause high mortality when associated wit h ma lnutrit ion, such as diarrhoea/dehydration, measles, respiratory infections, etc.
(4)
Thus, the main programme activities should fall under the f ollowing: (a) (b) (c)
education and promotion o f appropriate nutri tion educat ion m essages; surveiHance of the nutritional status by weighing with the use of weight charts where these are feasible; programmes directed to mothers, mainly on nutritional educat ion, supplementary feeding and family planning; protection and promotion of breast-feeding up to the a ge o f four t o six months, and appropriate supplementation; curative and rehabilitation services f or treatment of c hildren suffering from advanced forms of protein-energy malnutrit ion at he a lt h centres, village health units, hospitals, nutrition rehabilitatio n and mothercraft centres; supplementary feeding programmes in very depressed com munities through the health sectors as well as utilization of supplementary food f or weaning purposes (More attention might well be given to the develop ment of recipes for the preparation of nutritious mixtures suitable for in fa nts and children).
(d) (e)
(f)
8. NUTRITION THROUGH THE HEALTH SECTOR AT THE COMMUNITY L EVEL
Availability of sufficient food at national and l ocal levels and a substant ia l increase in family income do not by themselves eliminate nutrition problems. A number of cultural factors are strong determining factors of malnutrition such as: erroneous feeding habits, inappropriate practices and beliefs re lated to health and disease, inadequate child-rearing practices, and reproductive behaviour. The healt h sector has a definite responsibility for carrying out extended programmes of nu t rition education and health education in order to eliminate these causative facto rs. At the same time, the synergistic action of malnutrition and infection stresses t he key role o f the health sector not only in the diagnosis and treatment of malnutritio n but also i n the control of the determinant factors.
WPR/RC35/Technica1Discussions/ J page 23
The first task of the health workers in the community is to obtain a rough assessment of the existing health and nutrition problems and available resources at local level. An excellent practice is weighing children under 5 years using simple weighing scales. Similarly, monitoring the weight gain during pregnancy can provide adequate information on maternal nutritional status. Like the growth chart, by similar means, the preliminary diagnosis of other common nutritional disorders such as goitre, anaemia and xerophthalmia can be placed within the capacity of the health worker. Together with the traditional maternal and child health services as well as health education and family planning, food and nutrition activities should be an integral part of the health services at the local level. Support should be given to mothers, to prepare themselves for breast-feeding and appropriate infant feeding in the weaning period. Thus, the health care worker at the local level should have a special concern for the diet and nutrition of the pregnant woman and the newborn. ldentification of families at risk on the basis of the presence of children with second or third degree malnutrition, and of other adverse circumstances, will give the health worker a good frame of reference for the selection of beneficiaries in supplementary feeding programmes. Distribution of iron tablets, vitamin A, etc. will also contribute to the control of food factors responsible for malnutrition. Very frequently, the main determinant factors of malnutrition are not the lack of food at the family level or its inappropriate distribution within the family, but rather the insanitary environment, including overcrowding and absence of adequate water supply and waste disposal, Jack of personal hygiene, lack of periodic health care, and failure to vaccinate. Traditional activities through the maternal and child health services will control these non-food factors. These include the monitoring of health, growth and development, early diagnosis and treatment of diseases, immunization programmes, prevention and control of diarrhoeal diseases, oral rehydration, deworming, family planning activities, health education, environmental sanitation programmes, and the appropriate referral of cases to higher levels of health care.
9. RESEARCH AND TRAINING
In the past, much of the effort in training and research was confined to areas of mostly academic interest, not necessarily related to the realities of nutrition delivery through the· health services. It is today evident that resources should be focused on the constraints on training and knowledge that limit the implementation of nutrition activities; in other words, training and research should be linked to the needs of programmes delivered through the health services. The requirements for training and research in nutrition should spring mainly from an analysis of the .manpower needs and the gaps in knowledge of a given problem or more generaHy from the nationai health plan.
WPR/RC35/Technical Discussions/ 1 page 24 ·
There is an urgent need to extend the coverage of health services, and a realistic strategy would be to incorporate members of the village communities in the health services. The major challenge for training and research lies in determining what these village workers should do; what they should know; what skills they should possess; and how they will be taught. There is also an urgent need to train public health nutritionists at the national level and at the intermediate level of health administration. · There are reasonably adequate facilities in the Region to train middle and upper level public health nutritionists and more efforts are necessary to train trainers of community health workers. There is also a need to review the curriculum of all types of health workers to ensure that the nutrition component of their training is appropriate.. A review of the nutrition training of primary health care workers is available h1 the report of the WHO Expert Committee on the role of the health sector in food and nutrition (~). The guidelines prepared · by WHO for the training of community health workers in nutrition were tested in two countries in this Region and ·found to be adequate. These guidelines have been revised very .recently (_!!). In developing countries, research in nutrition needs to be considerably service-oriented because there is generally more knowledge about the nature of the problems than on how services should be organized to solve them. A regional working group in 1980 made a review of research needs and identified the main areas for research as well as specific. topics under each ( 12).
10. ROLE OF INTERNATIONAL AGENCIES
Cooperation .In food and nutrition is provided by . the United Nations and its specialized agencies, especially FAO, WHO, WFP, UNICEF, UNDP and more recently IBRD. Several countries in the Region also receive aid through bilateral agencies. There is a great need for coordination in this field of assistance among the various international and bilateral agencies involved. There is a further need for coordination between the various ministries of governments and . the international agencies. Considerable scope also exists for bilateral assistance between countries of the Region, especially in the areas of training and research. It is understood that each government should accept responsibility for its own nutrition/health problems and for defining its own objectives and values. The role of the international agencies is to provide collaboration in the specialized areas for which they exist, when countries request such collaboration. ·
WPR/R CJ 5 fT echnical Discussion sf 1 page 25 ·
PART Ill THE NEED FOR A MINIMUM PROGRAMME
If nutrition activities in health are to be effective, two chailenges must be faced: to reach the priority groups at greatest risk, and to develop the technology appropriate · to local conditions. It is to these two challenges that the reader's attention is now drawn.
By common usage, nutritionally vulnerable groups comprise infants, pre-school-age, children, and pregnant and nursing. mothers. Sometimes these age/physiological groups are referred to as priority groups for action. The concept of vulnerability also involves the idea, not always stated explicity but still of paramount interest in health planning, that the returns in terms of decreasing morbidity or mortality will be greater if resources are directed to the "vulnerable" groups. Although malnutrition may affect aJJ members of the underprivileged groups of a population, it is always the young rapidly growing children who are at greatest risk and among whom the consequences are more serious. In most populations where malnutrition is prevalent; children frequently have low birth weights as a consequence of maternal malnutrition. Many of them die in early life. Those who manage to survive are usuaUy breastfed and thus receive an adequate diet and are protected from many of the factors responsible for malnutrition during their first months of iife. Infants are particularly vulnerable to nutritional disease because the rapid rate of growth poses strict demands with respect to both the amount and quality of the food intake and because they are dependent on others for any food they get. . Breast milk plays a key role in the successful nutrition of the infant, but becornes progressively Insufficient for body maintenance and growth beyond the age of six months. Mothers commonly fail to see this, however, and do not supplement breast milk with enough food or the right type of food. The child is stiJJ entirely dependent , but is not protected by the supply of breast milk, which is declining in relation to the needs. Moreover, in the second year of life, aU too commonly a newborn sibling will compete for the attention of the mother. An insufficient food intake and a high susceptibility to infections make the first two to three years of life the most critical period during which by far the highest number of deaths oc·c ur of which the nutritional status is a direct or associated cause. These children are often not given other foods in the amount and of the quality required, and it is from ·this point until ·about the age of three years that malnutrition occurs in its most severe form. ' .
,
The period of weaning is therefore a critical one; and there ls a greater likelihood that the child wiU have a pdor diet and suffer from frequent infections, particularly diarrhoeal diseases• The amount of food that children of this age need, however, is not great and in most instances, especiaUy in rurai areas, they are deprived as a result of cultural rather than economic considerations. Appropriate nutrition education is therefore very important to ensure dietary improvement during this period arid could ·have a major impact on the reduction of protein-energy malnutrition. This is corroborated by present knowledge about protein and energy requirements and by experiences suggesting that these requirements can be met tflrough a variety and combination of foods regularly consumed by older children and adults in most areas where the problem exists.
WPR/RC35/Technical Discussions/ J page 26
The nutrition programme should give first priority to self-reliance in child feeding, and in particular to the following aspects: (J)
the needs and problems of children from birth to about three years of age in the setting of the family and community; the causes and prevention of inadequate food intake, both in quantity and quality; the maximum use of local resources, particularly of available and acceptable foods.
(2)
(3)
Encouragement and support of breast-feeding wilt take care of the needs of the child from birth to 6 months. The supplementary feeding required for the child frorn 6 months to 24 months can invariably be met with locally available foods. In focusing attention on this age group, it is not implied that the mother and older children are not vulnerable. However, if a choice is to be made, priority attention should be given to the child aged from 6 months to 3 years or at least up to 2 years. Ideally the other services provided to the mother and child should ensure the success of these efforts. There is increasing evidence that the concept of se!f-reliance in child feeding will be feasible only with the active participation of the community, which in turn will ensure universal coverage. To achieve this, there should be a very clearly defined nutrition component in primary health care. On the basis of all these considerations, a new strategy needs to be evolved providing for a major effort by the health sector in controlling malnutrition.
WPR/RC35/Technical Discussions/1 page 27
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FAO/NORAD. Food and nutrition policy and planning for Asia and the Far East. Report on a seminar held in New Delhi, February 1974. WHO Technical Report Series, No. 584, 1976 (Food and nutrition strategies in national development: ninth report of the Joint F AO/W HO Expert Committee on Nutrition) .. WHO Technical Report Series, No. 59 3, 1976 (Methodology of nutrition surveillance: report of joint FAO/UNICEF /WHO Expert Committee). WHO Technical Report Series, No. 667, 1981 (The role of the health sector in food and nutrition: report of a WHO Expert Committee). Development of indicators for monitoring progress towards health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for AU" Series, No. 4). Global strategy for health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for All" Series No. 3). WHO Technical Report Series, No. 503, J 972, (Nutritional anaemias: report of a WHO Group of Experts). Tanner, J.M., Catch-up growth in man. British Medical Bulletin, Vol. 37, No. 3, pp. 233-238 (J 981). Rona, R.J., Genetic and environmental factors in the control of growth in childhood. British Medical Bulletin, Vol. 37, No. 3; pp. 265-272 ( 1981). · Report of an informal consultation on health indicators based on psychosocial development. Ge.neva~ World Health Organization, 1983 {Document FHE/MNH/83.1) •. Guidelines for training community health workers in nutrition. Geneva, World Health Organization, ·1981 (WHO Offset Publication, No. 59). Report of the Working Group on Action-oriented Research, Development and Training Programme in Nutrit~on. Manila, World Health Organization, 1980.
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