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Update on the Nutrition Situation
Women and Nutrition
Malnutrition and Infection (part 1)
Targeted Food Subsidies

Update on the Nutrition Situation

Latest data from 33 countries show diverse trends.

One way to assess the realities of human conditions in the 80's is to track nutritional trends. Nutrition is central to human well-being, and responsive to environment in the most vulnerable people: young children in poor countries. What is happening to them? The answer - like much in the world - is that it depends on where you look. As illustrated on the front cover, there are countries where steady improvement seems to be taking root - Thailand for instance. In others, such as Madagascar, it looks like an underlying worsening trend may be setting in. In further countries, the effects of crises coming and going can be seen: in Ghana percentages of children underweight nearly doubled at the height of the economic crisis in 1983-4, coming down again as the situation was brought under control.

Data such as these bring a new focus. The broad global picture (see SCN News No 2) is of a tendency toward improvement in Asia, long-term deterioration in Africa, and stagnation or some worsening in Latin America. But countries and people are diverse, and averages can hide important differences. We need examples from within countries to get a balanced picture. Information from 33 countries was recently published in the SCN's "Update on the Nutrition Situation", and discussed at the SCN 15th Session, hosted by UNICEF New York in February 1989. The "Update" Report gives indicators of child nutrition, set alongside economic and food access indicators, prices, indications of indebtedness, as well as giving examples of seasonal effects and trends in certain localized areas.

Where is Nutrition Improving or Worsening?
Which countries have a high or low level of underweight children - as an indicator of malnutrition - and where the trend is rising (worsening) or falling? Some examples are shown in the box. Because the countries for which there is data are not a random sample, no firm conclusions can be drawn to apply to the developing world as a whole. Nonetheless, enough countries are represented to show the wide range of conditions and to begin to think about such questions as why some situations are better than others, and what these trends might mean for the future.

ACC/1989/PG/2 English Page 11 B. Update on the nutrition situation 34. Results, showing trends in the prevalence of underweight children, were summarized for the purposes of the meeting in the table below. Prevalence of underweight children
Recent trend	High (20% and over)	Moderate (10%-19%)	Low (under 10%)
Rising or static	Bangladesh, Benin, Ethiopia, Gambia, Madagascar, Mauritania, Niger, Philippines, Rwanda, Sudan	Jamaica, Nicaragua, Peru	Chile, Cuba, Venezuela
Falling	Botswana, Burkina Faso, Ghana, Guatemala, Indonesia, Sri Lanka, Thailand, Togo	Bolivia, China	Colombia, Costa Rica, Uruguay

The countries for which data were available are divided, first, into those estimated to have high, moderate or low prevalences of underweight children - this forms the columns in the box. (The classification is taken from data in the SCN's "Supplement on Methods and Statistics" to the First Report on the World Nutrition Situation). The countries with the highest prevalence are generally the poorest, measured in terms of per capita income, access to productive resources, services, etc. Added to this, it is known that countries in South Asia have a higher prevalence of underweight than would be expected from factors such as income, or child mortality; this is thought to be due to other effects of diet and perhaps disease, as well as an inter-generational carry-over such that low birth weight leads to small mothers having small babies. At the other end of the scale, those developing countries that have established a low rate of malnutrition, in some cases as low as that in industrialized countries, have a long record of sustained attention to health and social services. Chile, Costa Rica and Cuba are examples. It is worth noting in passing that some of the countries with the highest debt also have the best nutritional situation - for example, of the countries in Latin America listed, Costa Rica, Venezuela, Chile, and Uruguay have about twice the debt per caput of the others (Update Report, page 27).

The new information, though, concerns the recent trends, shown in the rows in the box. The period refers to around 1984 to 87. Countries were approximately classified, from data in the Update Report, into those with a rising or static trend in proportions of underweight children, and those where the best judgement was that it was falling. Factors associated with a deteriorating trend included economic stress, instability and internal conflict, and drought. But this was not the full story: a number of countries in the "falling" category had faced similar problems. A missing factor seems likely to be the priority given to the use of available resources to protect nutrition -that is to policies favourable to nutrition.

Where the nutrition situation is judged to be relatively bad and worsening (top left-hand cell in the box), often some of the factors are well known. Bangladesh is reckoned to have one of the highest levels of underweight children in the world, and indications are that this is not improving: economic difficulties (80% of the population are under the poverty line), the most crowded population density anywhere in the developing world with half the rural population landless, and extreme vulnerability to flooding, are at least some of the causes. In the Philippines, political upheavals coincided with a small but noticeable peak in child malnutrition. Most of the countries in Africa in this category have suffered from the vicious combination of economic recession and drought. In Madagascar, for instance, an already difficult situation worsened from 1985 on, with sharply rising prices, unrest, and drought: this is reflected in a jump in the underlying rate of malnutrition - seen superimposed on the marked seasonal pattern in the diagram on the front cover.

But in some situations, there are signs that the effects of drought and economic stress have been effectively contained. Ghana's struggle with debt and drought has been widely reported - now it looks like the nutrition situation itself, which dramatically deteriorated during the crisis of 1983-1984, has at least returned to the pre-crisis level (see front cover). In Botswana sustained programmes for employment and food distribution in drought-affected areas prevented malnutrition from rising much during the prolonged drought of 1982-1987, and the trend in prevalence may well now be downwards.

Investments pay off.

Long-term investment in health, nutrition, and other social services seems to be paying off in, for example, Indonesia and Thailand. In Thailand particularly underweight prevalences fell steadily from 1983 to 1987, as seen in the figure on the front cover. If this improvement, of about two percentage points prevalence per year, were maintained - and the current rapid increase in GNP is no doubt crucial - elimination of malnutrition could indeed be seen here in the 1990's. But the rate of improvement in Thailand is around the fastest seen anywhere.

A similar picture emerges among the countries only moderately affected by malnutrition. Economic and other crises have taken their toll, in Jamaica, Nicaragua and Peru. The situation in China is of particular significance: data indicate that malnutrition was nearly eliminated between the 1950's and 1980's in urban areas. For example, the average height of seven year old girls had increased from 115 cms in 1950 to 125 cms by 1975-1980 (125 cms is equivalent to international standards, so no further increase is likely).

Price Hikes predict Malnutrition.

One surprising spin-off of the study concerned a striking parallel between food price changes and malnutrition rates. This is illustrated in figure 1. Information on these two factors came from totally separate sources - prices from government statistics via the International Labour Organization (ILO), child underweight rates from Catholic Relief Services in Ghana. The graphs were printed one above the other in preparing the Update Report, as shown in the figure. This was almost certainly the first time that these have ever been viewed in this way. Not only was the parallel immediately striking, but a lag could even be seen: food price changes preceded malnutrition rate changes, by around three months. The implications for early warning were clear. Further analysis on data for Ghana and other countries has been done by SCN and ILO, and results are now being used to suggest some additional procedures in early warning systems.

Figure 1. Ghana: relative price of food (FPI/CPI) and prevalences of underweight children (from clinics), 1980-87, seasonal factors being removed. In the lower graph these are superimposed (--- is FPI/CPI), showing that food price changes appear to preceded malnutrition changes.

Patterns of change.

Three patterns of change in nutrition are happening, it was proposed at the SCN 15th Session. On a time scale viewed in decades, the trend in child nutrition seems of gradual improvement if undisturbed by crisis (political, economic or drought). In Africa per capita incomes and food production have declined in the last 20 years: although a slight improvement in nutrition was detected in the 1970's, this was reversed in the 1980's. Nutrition is deteriorating as a result. Elsewhere, long-term increases in income, education, food availability, and health services have improved welfare (except where interrupted by such factors as economic recession); and nutrition has improved. Long-term development, in the same way that it contributes to lowered infant and child deaths, can drive malnutrition downwards.

Taking a shorter perspective, of within-decade changes, the disrupting effect of crises can be seen in country after country. A severe crisis may affect levels of living and nutrition for several years. One can see retrospectively that crises pass and malnutrition may fall. Quicker and more effective measures are needed during crises to protect health and lives: to prevent peaks of malnutrition, no doubt associated with increased mortality, occurring. The response of malnutrition to drought, food shortage, price inflation, and the like appears to be rapid - possibly with a lag of a few months - and effects may linger.

Finally, the marked effect of season is brought out, Madagascar again (see front cover) providing a vivid example. Here, rates of child malnutrition climb rapidly during the pre-harvest time (harvest is April-May) and fall with the post-harvest recovery. The change is as much as ten percentage points of prevalence. This pattern, which is seen in most African countries where the data are available, directs attention to targeting nutrition interventions in time as well as by area: programmes that mitigate seasonal shortages of money and food, knocking off the peaks of malnutrition, could be important in bringing long-term improvement. Nonetheless, the seasonal effects-should be seen in relation to the high underlying prevalences. The ten percentage point seasonal increase adds to an already high underlying level of nearly 50% in the children attending clinics where the data came from.

Optimism and worrying trends.

A balanced view of the nutrition situation in developing countries is therefore, as expected, mixed. It is generally true that where conditions are improving, this leads to improved nutrition; relatively this optimistic picture is seen particularly in a number of African countries. Most worrying is the static situation in a number of countries, notably in Latin America, and the continuing decline in living standards, which we can see in malnutrition rates, in Africa. Information such as this serves to highlight the need for action, can help direct that action to people most in need, and can measure success.

The constant toll of malnutrition and disease is unquestionably a continuing tragedy. Child death rates in developing countries are around 15 million per year and numbers of malnourished children persistently rise - reaching about 150 million underweight children by our most recent estimates. In most countries, there is a race between population growth and development; in others, mainly in Latin America and Africa, even the proportion of the population malnourished is increasing. Nonetheless, we can see that progress is possible, even in difficult circumstances. The challenge is to improve the circumstances and learn the lessons.

- J.B.M.

Women and Nutrition

Multiplicity of tasks, conflicts and trade-offs women must face are part of the lifestyle in many poor countries.

The ACC/SCN's annual symposium, in February 1989 at UNICEF headquarters, New York, was on the topic of "Women and Nutrition". The proceedings are being published by the ACC/SCN: this article introduces the subject. The several background papers commissioned for the Symposium were carefully structured to deal with the kaleidoscopic nature of women's overlapping commitments. In particular, women's "invisible work" was given statistical and economic reality.

Current measurements such as GNP give an unsatisfactory index of economic productivity, since "do it yourself" work has no market price. Women's "invisible work" is largely unreported, and earns no recognition in economic terms. If women's unpaid household labour were quantified and given economic value, it would add up to an additional one-third to one-half of the world's GNP. Gender disaggregated data on agricultural productivity reveal that women (who form up to 40% of the agricultural force, grow half the world's food, and own 1/100 of the world's land), produce non-tradeables (food for home consumption) for a low rate of return in comparison to males who receive a high rate of return for tradeables in the form of wage employment, and non-food crops.

Measurement of women's work output is crucial to the understanding of women's vulnerability to disease and death by virtue of gender. An analysis of women's time and energy expenditure is essential for any quantification of unpaid domestic and agricultural labour. An operations research catch phrase, "the zero sum game" is a mathematical "pie" which denominates the cancellations, adjustments and trade-offs of time and energy required for the production of food, water and fuel which comprise the primary work obligation of women. This concept of "zero sum game" - which provided the working title for the main background paper by J McGuire and B Popkin - is meant to encapsulate the conflicts and trade-offs most poor women cope with daily. And many barely cope: as the symposium heard, many women are on the edge of being burnt-out by the overburden of family care, productive work, and biological demands - often not helped by cultural expectations.

In the "zero sum game" equation, women's work output radically depletes her time and energy stores. Time is a fixed and limited dimension; while the energy required for the cultivation and processing of food, and the collection of water and fuel, is an elastic, transferrable, but finite resource. The result? Women must work more hours and expend more energy than men while performing their multiplicity of tasks. Food intake is not always commensurate with this demand, and women bear a disproportionate burden of calorie deficit in relation to energy expenditure. The synergism of gender, poverty, and negative nutritional status translate into the grim mathematics of maternal morbidity and mortality. Task selection and time allocation have a crucial bearing on family nutrition and on women's own nutritional status.

Women's simultaneously exercise roles in economic production, home production and reproduction. During forty percent (40%) of a woman's life on average, she is pregnant and/or breast feeding - time is pre-committed and many other activities precluded. Reproduction, for poorer women, is a social obligation with a built-in physiological disadvantage. Why? Inherent within women's roles, during child-bearing years but affecting the life span, are predictable conflicts in which biological, cultural, and economic forces intersect to drain women's energy and time. Take biology versus culture, for example. Cultural forces which demand repeated pregnancies conflict with common-sense reproductive biology (limit pregnancies, anaemias and maternal deaths). Take economics-versus culture: the social mythology which demands numerous children restricts women's ability to engage in paid work. Take biology versus economics: the physical energy needed for reproduction reduces energy available for other productive work. Food preparation may take two to three hours; fuel and water collection may take one to six hours. Time and energy allocations are strained by a heavy domestic and agricultural workload. The correlation between workload and failure to gain weight during pregnancy becomes obvious. Women's nutritional status and these roles are inseparable in terms of cause and effect. These factors converge to establish the patterns of systematic discrimination against females which lead to preventable morbidity, depletion and death. Statistics analyzed by sex effectively prove that gender is a significant determinant of nutritional status. A mapping of nutritional differentials between males and females according to socio-economic status, indicates that this nutritional deprivation is economically as well as culturally mediated, and the varying social and economic value ascribed to women may be a crucial factor in their access to food. Where females have high economic value, they receive larger shares of food and health resources; where their perceived value is lower, their consumption of food is substantially less.

If there were ways to circumvent women's legal and economic powerlessness, by providing better access to resources for poor women, would they work? Yes. As an example, the Grameen Bank in Bangladesh, initiated in 1976, has proved to be a successful combination of original interventions for the economic empowerment of women. Within the banking service, which provides credit to the landless poor, is a development component which is designed to improve the socio-economic status of women by providing credit services in the form of small loans for income earning activities (such as kitchen garden plots and crops). Women move from a negligible income status to a position where they contribute an extra one-third income to their households. They are taught a loan repayment discipline: weekly installments of two percent of the amount of the loan. It is no surprise to find that women form more than 70% of the bank's members and repay more than 90% of their loans on time. Income generation support of this sort provides an original and workable solution which enables women to market a portion of their food resources and control a measure of income.

Women's coping strategies to produce adequate nutrition for themselves and their families, therefore, can be bolstered by empowerment - across the board. Access to credit facilities and income generation techniques translates into women's economic self-respect. Access to public services such as piped water, fuel, and convenience foods converts into a time and energy bonus for women. Access to female-oriented agricultural extension programmes designed to teach women cultivation techniques and food cycle technologies, reduces weeding time, increases crop yields and protects against losses to insects and rodents.

Child care burdens can be eased by mobile creches or co-ops which improve children's nutrition and reduce the mother's workload. Educating women to overcome their cultural norms of self denial and to stand up for their health rights, independently of their husband's or mother-in-law's "permission" to use health services, pays dividends in a reduction in maternal mortality figures. Access to health clinics improves women's nutrition directly, by food supplementation, control of anaemia and dietary deficiencies and, indirectly, via immunization programmes and the prevention of her children's sickness.

Taking an inventory of the work which poor women perform as their duty gives visibility to a situation where the occupation "mother" is synonymous with "dangerous to your health". This synonym should be eliminated by identifying radical interventions and creative innovations to be incorporated in future development strategies.

- Rosemary Kevany

Malnutrition and Infection (part 1)

Operational implications of current knowledge: diarrhoea and malnutrition; measles, vitamin A and protein-energy malnutrition.

Each year about 13 million infants and children die in the developing countries⁽¹⁾. The majority of these deaths are due to infections and parasitic diseases, and many if not most of the children die malnourished. The precise contribution of malnutrition as an immediate cause of death is not known, nor would it be the only relevant figure, for in poor countries children from birth or soon after are caught in a cycle of malnutrition and infection, which many do not survive⁽²⁾. In Africa, for example, more than 20% - on average - do not reach their fifth birthday⁽³⁾. The "malnutrition-infection" complex remains the most prevalent public health problem in the world today. Nutrition and health are closely linked, but advances in nutritional knowledge remain to be applied to the same extent as those in the field of health.

In the more than twenty years since the landmark publication by Scrimshaw et al (1968)⁽⁴⁾ on "Interactions of Nutrition and Infection", knowledge of this subject has become well-established. The mechanisms of many of these interactions have been elucidated, and the relative importance of such interactions in different circumstances has been clarified. The same period has seen enormous advances in methods for preventing and managing infections. Immunization coverage for major childhood diseases has now reached over 65% of children. Improvements in environmental sanitation, education and literacy which help to improve child rearing and health practices, and a whole range of new and increasingly affordable antibiotics and anthelminthics are having effects not imagined 20 years' ago.

THE SILENT KILLERS
Illness
Vaccine-Preventable diseases (Polio, Tetanus, Measles, Diphtheria, Pertussis, Tuberculosis)	46 million not fully immunized, annually (infants) 2.8 million die annually (Children) 3 million disabled annually (Children)
Diarrheal diseases	At least 750 million [episodes] annually (Children) 4 million die annually (Children)
Acute Respiratory Infections	4 million die annually (Children)
Tuberculosis	1.6 billion carry the bacteria 10 million new cases annually 3 million die annually
Sexually-Transmitted Diseases	1 out of 20 teens and young adults contract annually 5-10 million infected with AIDS virus
Malaria	100 million cases annually Almost half of the world's population live in malarious areas
Schistosomiasis	200 million cases
Source: Report on World Health, WHO Features, Sept. 1989, No. 136

On the other hand, although understanding of protein-energy and micronutrient deficiencies is now well advanced, preventing these deficiencies appears still to be problematic. Protein-energy malnutrition is related to poverty and long-term progress is linked to development, although in the interim effective programmes can be undertaken. Micronutrient deficiencies are more susceptible to direct control, and wider application of effective programmes is feasible. Although globally the proportion of people undernourished fell somewhat during the 70's, probably less so during the 80's - and actually increased in Africa -the total numbers of people undernourished continue to rise with population growth⁽⁵⁾. Along with this, the total numbers of children underweight - due to malnutrition and infection - are still increasing⁽⁶⁾.

That nutrition influences infection and the causes and outcomes of episodes of disease is becoming part of conventional wisdom. Protein-energy malnutrition is known to have a depressing effect on the immune system; moreover effects on different elements of the immune system can be distinguished. Hence, growth failure is associated with lowered immunity. Indeed, it seems that even mild degrees of malnutrition begin to adversely affect immunocompetence, hence morbidity and mortality, which shifts attention to mild-moderate as well as severe protein-energy malnutrition.

Looked at the other way round, the mechanisms whereby infections lead to growth failure and clinical malnutrition are becoming better understood. They operate through anorexia, changes in metabolism, malabsorption, as well as behavioural changes affecting feeding practices; and lead to malnutrition in the context of limited nutritional reserves.

The interactions of nutrition and infection with regard to individual infections and defined nutrients are now better known. For example, we know that PEM increases the duration of episodes of diarrhoea. The importance of interactions between vitamin A deficiency and a number of infectious diseases (notably, but not confined to, measles) are now becoming clear. For instance, vitamin A deficiency affects epithelial membranes, and thus relates to respiratory tract infections and diarrhoea. Deficiencies of other micro-nutrients, even when clinical signs are not present, exert an influence through such routes as immunocompetence and integrity of epithelial tissues. One effect of iron deficiency is through depressing immunity, but the implications of this can be complicated by, for example, iron stimulating pathogen growth, as discussed in part II, in the next issue of SCN News. Zinc, it is emerging, may have a general effect on infectious disease, again at least partly through the immune system. Much of the attention to iodine deficiency disorders has related to effects of the deficiency itself, such as on brain development, but this deficiency may also have some effect on immunity. However, research on iodine deficiency in relation to infectious disease is limited, and it was felt that insufficient data were available to include this topic in the review.

These interactions are cyclic, and closely linked, and it is relevant to talk about a malnutrition-infection complex. A diagram is shown in Figure 1. This summarizes the principles underlying malnutrition and infection, as follows. Inadequate dietary intake can cause weight loss or failure of growth in children, and leads to low nutritional reserves. This is associated with a lowering of immunity, probably with almost all nutrient deficiencies. Particularly in protein-energy and vitamin A deficiencies there may be progressive damage to mucosa, lowering resistance to colonization and invasion by pathogens. Lowered immunity and mucosal damage are the major mechanisms by which defences are compromised. Under these circumstances, diseases will be of potentially increased incidence, severity, and duration; the relative importance of these three factors is not fully worked out in all cases. The disease processes itself exacerbates loss of nutrients, both by the host's metabolic response, and by physical loss, from the intestine. These factors themselves exacerbate the malnutrition, leading to further possible damage to defence mechanisms. At the same time, many diseases are associated with a loss of appetite, and other possible disabilities, cycling back to further lower the dietary intake. While other relationships play a part, this cycle summarizes many of the most important, and accounts for much of the high morbidity and mortality under circumstances of high exposure to infectious disease and inadequate diet, charracterizing many poor communities.

Figure 1 Malnutrition/Infection Cycle

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OPERATIONAL IMPLICATIONS

Diarrhoea and Malnutrition

Diarrhoea associated with malnutrition is probably the commonest cause of death in young children worldwide. For example, in an urban community in the Gambia over 35% of deaths in children aged 0-3 years were found to be caused by diarrhoea coupled with malnutrition. The importance of the distinction between acute diarrhoea and persistent diarrhoea (episodes of more than 14 days duration) has recently been recognized. Studies from different countries have shown that up to one half of deaths related to diarrhoea were linked to persistent diarrhoea. One study showed considerably higher mortality per episode from persistent than from acute diarrhoea⁽⁷⁾. Such figures may vary by area, season, and environment, but their importance is clear.

Diarrhoea (especially persistent diarrhoea) often causes deterioration of nutritional status, and poor nutritional status has been shown to increase the duration of diarrhoeal illness. Effects of nutritional status on incidence of diarrhoeal episodes, which are more determined by environment and personal hygiene, are more varied; the same applies to severity⁽⁸⁾. Effective management of diarrhoea also helps to prevent future illness, probably including diarrhoea, since maintenance of nutritional status helps to maintain immunocompetence. Thus there are important nutritional implications for both prevention and management of diarrhoea in children. But because nutritional needs change with age and because persistent diarrhoea carries a greater nutritional risk than acute diarrhoea, nutritional recommendations are specific to age and duration of diarrhoeal episode. In general, rehydration is of priority for management of acute diarrhoea, with nutrition becoming increasingly important as the duration increases towards persistent diarrhoea.

Exclusive breastfeeding is recommended for the first 4-6 months of life. This helps to prevent diarrhoea by minimizing the infant's exposure to diarrhoeal pathogens, which are common in other foods and in water. For the management of diarrhoea in children of this age, continued exclusive breast feeding (with increased frequency and duration of feeds if possible) is the most important nutritional aspect of management. Exclusively breast-fed infants (less than 4-6 months) with diarrhoea should be breast-fed with increased frequency, which should often prevent dehydration. If such infants nonetheless become dehydrated, rehydration therapy may be required. WHO guidelines recommend breast feeding after the first 4 hours of rehydration, or earlier if rehydration is complete, and continued breast feeding thereafter in addition to continuing oral rehydration⁽⁹⁾. Ensuring adequate maternal hydration through encouraging adequate fluid intakes by the mother may be important. This is particularly important in acute diarrhoea, but breast feeding should be maintained in persistent diarrhoea also. When breast feeding is maintained during diarrhoea, the growth faltering commonly associated with diarrhoea is rarely seen, and the risk of death is minimized.

Although breast milk alone is not sufficient for continued growth after 4-6 months of age, it is recommended that breast feeding continue into the second year of life with increasing intakes of suitable weaning foods. The frequency and duration of feeds should be maintained during diarrhoeal illness. For this age group, continued non-exclusive breast feeding is not the only nutritional recommendation, but is nonetheless of great value in the prevention and management of diarrhoea through its effects on exposure to pathogens and maintenance of nutritional status.

Breast feeding is essential for prevention and management of disease in young children.

Food hygiene during the weaning period is crucial to diarrhoea prevention. The use of fermented foods in weaning diets should be considered. Although an increase in exposure to diarrhoeal pathogens is inevitable during weaning, the extent of the increase can be minimized by striving to ensure that foods and utensils do not become contaminated, thus helping to prevent diarrhoeal attacks. The inclusion of fermented foods (which often constitute part of the traditional diet) may also contribute to the prevention of diarrhoea, since recent research indicates that levels of pathogenic bacteria are considerably lower in fermented foods than in non-fermented equivalents. This characteristic of fermented foods also makes them suitable for supplementation of the diet in management of diarrhoea.

For management of diarrhoea in children of weaning age it is most important that breast feeding continues to be supplemented with suitable foods, ideally to at least the level of the healthy child. This is especially true in persistent diarrhoea, which is relatively common in children of this age and carries a high risk of growth faltering and subsequent re-infection. During recovery from diarrhoea, extra food above the normal intake should be provided to restore nutritional status (a target of 125% of normal intake, with nutrient-dense foods, has been suggested)⁽¹⁰⁾.

In children of weaning age or older, ORT is recommended primarily for prevention and treatment of life-threatening dehydration during diarrhoea, which is more common in acute than persistent diarrhoea. It may also play a role in nutritional management: since dehydration is thought to contribute to the anorexia that can accompany diarrhoea, ORT may help to maintain appetite and thereby nutritional status during bouts of diarrhoea.

In order to implement these recommendations for prevention and management, programmes to combat diarrhoeal morbidity will need to concentrate on influencing the behaviour of those responsible for day-to-day care and feeding of infants and young children. In some cases this will simply mean conservation and support of traditional practices, e.g., breast feeding, fermented food technologies. Appropriate dietary regimes using local food should be developed for nutritional management of diarrhoeas. As dietary bulk is such a problem in many traditional cereals, the use of amylase-rich flour to hydrolyse starches should be considered.

Measles, Vitamin A and Protein-Energy Malnutrition

Measles is estimated to kill 2,000,000 children a year, almost all in developing countries. Measles is known to interact particularly with deficiencies of protein-energy and of vitamin A. It is a common precipitating cause of potentially blinding eye lesions (especially due to xerophthalmia) in young children, and of severe growth faltering and protein-energy malnutrition. Measles occurring in poor environments is thus associated with growth faltering, vitamin A deficiency and immune suppression. The immune suppression can persist for up to four months after infection, and goes some way to explaining both the particular risk of respiratory and diarrhoeal complications of measles, and the relatively greater severity of the disease, in poor communities. The increased risk of other infections contributes to the cycle of further malnutrition and further infection. Post-measles diarrhoea is particularly difficult to treat and has a very high mortality risk. Prevention of measles, through immunization, is thus an important means of reducing severe protein-energy malnutrition and vitamin A deficiency.

Preventive nutritional measures for reducing the severity of measles and its consequences relate to both vitamin A deficiency, and to protein-energy malnutrition. The provision of vitamin A supplements to populations at high risk from measles is recommended in all communities where vitamin A deficiency exists. In this context, distribution of vitamin A capsules with immunization programmes is particularly relevant, and is beginning in a number of countries. Protein-energy malnutrition is an established risk factor in measles, thus programmes that improve nutrition in general can also be expected to contribute to reducing the severity of measles.

Renewed emphasis on nutritional management during and after measles is of high priority, to prevent the severe growth faltering and high mortality often associated with measles. This again refers to deficiencies of both vitamin A and protein-energy.

Measles causes vitamin A deficiency, and measles is more severe in vitamin A deficient children. In all communities exposed to vitamin A deficiency, morbidity and mortality from measles would probably be reduced, not only by regular vitamin A supplementation for that population, but by ensuring that all children with measles receive vitamin A. In particular, when the case fatality rate for measles exceeds 1% in communities where vitamin A deficiency exists, all children with measles should without fail get vitamin A capsules⁽¹¹⁾. Studies in Tanzania have shown reduced case fatality rates from measles when children were given vitamin A during the disease. Measles infection substantially increases vitamin A utilization, thus vitamin A administration during the disease helps prevent deficiency when body stores are marginal prior to infection, in turn providing protection against xerophthalmia and probably immune suppression.

Ensuring adequate intakes of protein and energy during the management of measles, and, especially important, during the immediate post-measles period, requires fresh emphasis. As for diarrhoea, this is particularly important for young children after the age of exclusive breast feeding. Continued feeding with suitable weaning foods can help to counter the anorexia, malabsorption, and increased protein breakdown that adversely affects the nutritional status of children with measles. Practices in some cultures of withholding food during measles in young children is particularly to be discouraged. At the same time, continued breastfeeding at all ages of children who are breastfed should be supported.

Maintenance of adequate vitamin A nutrition may also reduce non-measles morbidity and mortality. There is some evidence that vitamin A deficiency increases the risk of respiratory infection and possibly diarrhoea, perhaps through its effects on cellular and non-specific immunity. In addition, mortality from these and other causes may be elevated in vitamin A deficient children.

* * *

The operational implications of nutrition and infection interactions apply to health programmes specifically, and to the fact that interventions to improve nutrition will often be an effective way of preventing ill health. Some of the latter may be outside the health sector itself.

Nutrition interventions as part of health programmes will help prevent infection, and are an important feature of effective management of disease. In general whenever malnutrition is a problem, for example as marked by growth faltering in children, nutritional support (e.g. supplementary feeding, micronutrient distribution, nutrition education) through the health services should be seriously considered. Some circumstances likely to be particularly important for breaking out of the cycle of malnutrition and infection have been highlighted. Adequate protein-energy status seems particularly important in prevention and management of many diseases - notably diarrhoea (especially persistent diarrhoea), measles and respiratory tract infections (see next issue). Adequate vitamin A status also protects against many diseases, measles being the best known. Attention to iron status is always important, and will be stressed in relation to malaria and intestinal parasites.

Measures that improve the nutritional status of the population will thus have important beneficial effects on health. This means that meeting the objective of improving health requires actions to alleviate poverty and to bring an adequate diet within the reach of everyone; the health sector must advocate such actions, some of which are the direct responsibilities of others⁽¹²⁾. Nutrition programmes, whether or not operated through health services, will benefit health. Similarly, access to adequate health services improves nutrition. For example, measles immunization reduces severe protein-energy and vitamin A deficiencies. The recognition that malnutrition is inextricably bound up with infection means health interventions are essential to preventing and treating malnutrition.

NOTES

This article is based on "Malnutrition and Infection"; ACC/SCN State-of-the-Art series, Nutrition Policy Discussion Paper No. 5, 1989, by A. Tomkins and F. Watson; ACC/SCN, Geneva.

(1) Data from "Supplement on Methods and Statistics to the First Report on the World Nutrition Situation", ACC/SCN (1988), Table AIII; total number of infant deaths per year (1980-85) for 94 developing countries covered =9.3 million; total number of child deaths (1984) = 3.9 million.

(2) See, for example, recent reviews by J. Rivera and R. Martorell: "Nutrition, Infection, and Growth". Part I: Effects of Infection on Growth. Clinical Nutrition (1988), 1 (4) 156-162. "Part II: Effects of Malnutrition and Infection and General Conclusions", ibid 163-167. The study still widely quoted ascribing causes of death to malnutrition is: Puffer R. P & Serrano C.V. Patterns of Mortality in Childhood. Scientific Publication No 262 PAHO (1973).

(3) Calculated from ACC/SCN (1988) op. cit. Table AIII: Average IMR for Africa (1980-85) equals 121.5 deaths per thousand live births; CDR equals 23.1 deaths per thousand child population per year; (0.1215 + (4 X 0.0231) = 0.21, or 21%).

(4) Scrimshaw N. S., Taylor C. E., and Gordon J. E. Interactions of Nutrition and Infection. Geneva: World Health Organization (1968).

(5) See FAO 5th World Food Survey, Table 3.1. Data also shown in First Report on the World Nutrition Situation, and Supplement on Methods and Statistics Table AIII.

(6) From ACC/SCN (1988) op. cit.: estimates of numbers of underweight children for the 94 countries are: 1974-76, 149.3 million; 1983-5, 152.5 million; 1984, 157.9 million.

(7) Results from the Gambia communicated by A Tomkins. For information on persistent diarrhoea, see "Update Persistent Diarrhoea" WHO/CDD, No 4. March 1989.

(8) See Tomkins & Watson (1989-cited above) Section 4.2, table 3.

(9) WHO/CDD "A Manual for the Treatment of Acute Diarrhoea". WHO/CDD/SER/80.2 REV. 1 (1984). WHO, Geneva.

(10) National Research Council (1985).p.30. Nutritional Management of Acute Diarrhoea in Infants and Children. National Academy Press, Washington DC. This document also gives details in an Appendix of energy needs for recovery from the effects of diarrhoea.

(11) Joint WHO/UNICEF Statement on Vitamin A and Measles. Weekly Epi Record (1987) 62 133 - 134. WHO, Geneva.

(12) See: "Intersectoral Action for Health", World Health Organization, Geneva (1986); and WHO Technical Report Series, No 667 (1981). "The role of the health sector in food and nutrition". Report of a WHO Expert Committee, WHO, Geneva.

- J.B.M.

Targeted Food Subsidies

Results from trial in the Philippines.

One of the strategies used by governments to augment the nutritional status and real incomes of their populations are consumer food subsidies. Food costs account for nearly 80 percent of the total expenditures for the poorest households in developing countries. As a means of correcting income distribution and as protection from adverse impacts of structural adjustments, the provision of food subsidies has therefore had a strong attraction for policy makers. But food price subsidies, even if effective in achieving their direct objectives, may be very costly. Evidence from countries like Egypt and Sri Lanka has shown the high fiscal cost of food price subsidy programs, and that once introduced, their termination may be politically difficult. The cost effectiveness of food subsidy schemes could be improved by targeting them to those segments of the population most in need; and since cost effectiveness depends on the precise design and implementation of such schemes, small-scale pilot studies are useful in assessing the validity of a particular plan.

To test the effectiveness of a targeted food price subsidy scheme in the Philippines, a pilot scheme was implemented in a research collaboration between the International Food Policy Research Institute and the Philippines National Nutrition Council/Ministry of Agriculture. Using a geographic targeting procedure, the experiment was conducted in three provinces (Abra, Antique and South Cotabato), involving 14 villages, half of which received the subsidy, the other half providing a comparison.

The pilot scheme, implemented for one year beginning in mid-1983, consisted of price discounts on two calorie-rich foods, rice and cooking oil, and a nutrition education component in the form of classes for mothers. Rice was selected because it is the major staple in the Philippines and cooking oil because its caloric density makes it a good choice for boosting the energy consumption of children, who may not be able to consume enough calories from a high-bulk food such as rice. Results of detailed analysis, published recently (Ref. see source below) are summarized here.

The study provides strong evidence that the targeted subsidy scheme was successful in increasing calorie consumption, mostly as a result of increases in purchasing power resulting from the price subsidies from rice and cooking oil. In the experiment, each household within the geographically targeted area (a village in this case) was issued a ration card that guaranteed a monthly quota of rice and cooking oil at a subsidized price. The quotas were filled by private village stores (known as sari-sari stores in the Philippines), who in turn purchased rice and cooking oil from public or private wholesalers and received reimbursement for the subsidy from a special account established in a local bank. The assessment from the viewpoint of administrative and technical feasibility concludes that there is a real advantage in the use of an existing infrastructure of extension workers and an existing delivery system such as village variety stores.

The procurement and selling performance of the accredited sari-sari stores varied according to several factors, such as: size of population served; frequency of purchase; size of revolving store capital and supply of credit; credit to consumers; location of the stores; and the character and acceptance of retailers in the community. Of these, among the most significant was the location of the shop. When central, the use was greater; similarly, farmers living in the countryside some distance from the shop were not able to make as much use of the subsidy, and benefitted less.

Each household was guaranteed a monthly quota based on household size - 5 kilos of rice and 400 grams of cooking oil per family member. The price subsidy on these was 30 percent of the price of rice and 50 percent of the price of cooking oil. The value of subsidy was equivalent to roughly 9 percent of the average household incomes in the project areas, or an equivalent of about US$9.50 per person per annum. Close to 84 percent of the cost of the scheme was the subsidy itself. Administrative costs accounted for only 9 percent and an incentive payment to retailers was about 7 percent.

Impact on Food Consumption and Nutrition

The food price subsidy scheme increased net incomes by more than 9 percent, according to the results of the study. Econometric analysis indicates that food (calorie) consumption increased significantly for households receiving the subsidy. Each additional peso of purchasing power (at the time $1 = about Peso 12) obtained from food subsidies would expand calorie acquisition by 230 calories per adult equivalent unit (AEU) whereas each additional peso of income from a source other than the subsidy is estimated to expand calorie acquisition by 150 calories per AEU. These findings therefore indicate that the extra incomes transferred in the form of food subsidies are likely to increase calories more than incomes from other sources. During the year that the pilot scheme was being tested, economic conditions deteriorated in general, for example inflation caused the market price of rice to increase some 40-50%. The households receiving subsidy did not in fact show a significant increase in calorie consumption (although it did not fall) but on the other hand consumption in the control households - those not receiving the subsidy - declined sharply. Thus, comparing the subsidized and control households, the subsidy was estimated to have resulted in significantly greater calorie consumption of about 10 percent above what it would have been otherwise.

Furthermore, as a result of the subsidy, pre-school children showed an improvement in their weight-forage of 4% to 7% (measured as a mean of standards), equivalent to a reduction of around 12 percentage points in the proportion underweight.

Cost Effectiveness

The fiscal cost of transferring each US$1.00 of real incomes to households in the project areas is estimated at US$1.20. However, if only the transfers received by households with malnourished preschool children are considered as benefit, whereas the transfers received by other in the project areas are considered as leakages, the cost increases to US$3.60. If only households consuming less than 80 percent of estimated energy requirements are considered as the target, the cost would be US$1.65. These figures are summarized in table 1.

Table 1 - Cost-Effectiveness Indicators Philippine Pilot Food Subsidy

	Not targeted	Targeted to households with <80% RDA	Targeted to households with children <75% WA
Fiscal cost of transferring $1.00	1.20	1.65	3.60
Annual fiscal cost of a net increase in food acquisition of 100 calories per AEU per day	6.75	7.40	13.60
Annual fiscal cost per preschooler of a net increase of 100 calories per individual preschool child per day	26.00	45.10	74.40
Annual fiscal cost of total subsidy	9.50	13.00	28.75

In estimating cost-effectiveness, the study considers one other factor. If rice and cooking oil are subsidized, households are likely to buy less food than usual from other sources. This would lower the net increase of food consumption due to the subsidy, because of substitution. Allowing for this, it could be calculated that assuring a net increase in daily calorie consumption of 100 calories/person/day for one year would cost roughly $6.75 per person/year.

There are clear policy implications from the responses of households to the food subsidy experiment. If the sole goals of the food subsidy scheme were to reach malnourished pre-schoolers, a second step could be added to the geographical targeting procedure (i.e. selecting villages). After villages with a high degree of malnourishment are selected, the subsidy could be limited to households with malnourished preschoolers, which in this case would reduce the cost of providing benefits to this group to about one-third the cost of providing the subsidy to the entire village (since for example one-third of households had underweight children).

The experiment also found strong relationship between malnutrition and low incomes. Families of landless farm workers, hired fishermen, and tenant farmers, for example, are much more likely to be malnourished than their neighbours in other occupations. Efforts to improve nutritional status of preschoolers in these groups through nutrition education are unlikely to be successful unless low income households' purchasing power is augmented. Efforts to reallocate the inadequate amount of food among household members so that preschoolers receive a larger share could reduce the energy intakes of adult wage earners to the point of impairing capacity to work, thus limiting the households' incomes even more. Nutrition education was nonetheless found to be effective in assuring that a larger share of the additional income is spent on food for the most vulnerable members of the households.

- Marito Garcia, IFPRI

(Further details in: The Pilot Food Price Subsidy Scheme in the Philippines: Its Impact on Income, Food Consumption and Nutritional Status, Garcia, Marito and Per Pinstrup-Andersen. Research Report 61, International Food Policy Research Institute, 1776 Massachusetts Ave. NW, Washington DC, 20036 USA, August 1987. A copy of the research report can be obtained at this address.)

CORRECTION:

We regret that in our last issue of SCN News, the figure 1 of the feature article on "Does Cash Cropping Affect Nutrition?", which appeared on page 6, was unfortunately mislabelled. We therefore reproduce the corrected figure 1 below:

Effects of doubling income on nutrition. Illustration of data from project in the Philippines: dilution of income effects, through food consumption, on child growth.