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Interview with Dr A Horwitz, SCN Chair, 1986-1995
Behavioural Change and Nutrition Programmes
Poor Nutrition and Chronic Disease - Part I

Interview with Dr A Horwitz, SCN Chair, 1986-1995

Dr A Horwitz, Director Emeritus of the Pan American Health Organization, was elected SCN Chair in 1986, and recently retired from this position. During his tenure, SCN News (and a number of other publications) were launched and expanded in distribution. Peter Greaves and John Mason interviewed him for SCN News.

Dr Horwitz, you were Assistant Director of the National Health Service in Chile from August 1953 to February 1959 and then Director of PAHO from 1959 to 1975. Looking back over this long period during which you were involved with public health, could you give some perspective of the efforts and achievements you value most?

First, I would like to express my gratitude to Drs. Mason and Greaves for this interview for SCN News, a journal that, in my view, informs so well on the scientific bases of nutrition issues, particularly in the developing world. It has also contributed very effectively to present the real image of the UN Subcommittee on Nutrition to an increasing number of readers throughout the world.

Now, with reference to your question, it is certainly not simple to even try to synthesize 22 years of experience in health. Still let me point out that I was one of the organizers of the National Health Service of Chile (NHS). It integrated a number of dispersed and uncoordinated institutions of medical care and public health in one Service to progressively cover the whole population of the country. Actions for the protection of health and the prevention and treatment of diseases were developed, with particular attention to an information system to register, analyze and publish how health problems were evolving and the NHS was performing.

If I compare, 42 years later, the morbidity and mortality rates of Chile with the ones at the beginning of the NHS, when Chile was in an early period of demographic and epidemiological transition, the progress has been immense. As an example, infant mortality per 1000 live births was 126 in 1953. We were sure that there was gross under registration, so that the rate was higher. In 1994, infant mortality in Chile was 11.9 per 1000 live births. As a result, life expectancy has also increased very significantly. Total malnutrition of children under five is below 10%. Severe malnutrition has practically disappeared.

In a recent Forum in Santiago on “Health in the Process of Development of Chile”, I was asked to speak about the organization of the NHS. The Minister of Health who engineered the Law that created the Service was also a speaker. Former Directors of the NHS also referred to their experience. There was consensus that the “golden period” of health in Chile was the one when the NHS was in operation. This is certainly rewarding.

In its time the NHS was a model for other countries in the Americas that wanted to use more effectively available resources to prevent and treat priority health problems with an integrated approach.

With reference to the Pan American Health Organization, I would like to mention that in my time the doctrine that health has an intrinsic value for all human beings i.e. it is an end in itself, but it is also an essential means for human and economic development, was proposed. Funds for health are a reproductive investment, not an expenditure. Member Governments of PAHO became convinced of the soundness of this approach. The need for external capital was evident to speed up the prevention and treatment of disease. The InterAmerican Development Bank, first, the World Bank, later, the Agency for International Development of the USA, and other countries, started to invest in health infrastructure, water and sanitation, university education in health sciences and technology, food and nutrition, veterinary public health, and other programs. This approach was reflected in the morbidity and mortality indicators as well as the availability of human and material resources. “Health Conditions of the Americas”, published by PAHO every four years since 1953, registered the progress, or lack of it, in all countries of the Region.

Among the many programs developed by the Governments with the technical cooperation of PAHO it is worth mentioning that smallpox was eradicated from the Americas in April of 1971, long before all other Regions of the developing world.

When did you first become interested in nutrition and why?

At the NHS in Chile we gave high priority to nutrition because the malnutrition-infection complex contributed very significantly to infant and early childhood mortality. I referred already to the results.

In my time, PAHO strengthened and expanded the Institute of Nutrition of Central America and Panama (INCAP), created and supported with the Governments the Caribbean Food and Nutrition Institute (CFNI), and sponsored projects on nutrition in other countries of the Americas.

I have always believed that good nutrition is essential for the prevention of disease and the promotion of health and there is some evidence in this regard. Well nourished children with an effective immune system overcome more effectively different acute infections. In the classical study by Puffer and Serrano, “Patterns of Early Childhood Mortality”, sponsored by PAHO, it is shown that malnutrition was the underlying or associate cause of mortality in 57% of the more than 35,000 deaths of children under five that were analyzed.

Recent research by Pelletier et al¹ indicates that any degree of malnutrition increases the mortality risk, including the marginal and subclinical forms. Furthermore, nutrition is essential for human development and, therefore, for economic development. Besides increasing the risk of small children dying, malnutrition impairs school performance and also labour productivity in adults.

1. Pelletier, D. et al. (1994) The Relationship Between Child Anthropometry and Mortality in Developing Countries. Supplement to the Journal of Nutrition, 124(10S).

The Reports on the World Nutrition situation prepared and published by the SCN have effectively contributed to show the real prevalence of malnutrition and its importance. As a whole, about 2 billion people are affected by some form of malnutrition. Few, if any, social conditions could reach this magnitude of prevalence and risk. Progress has been rather slow. While the prevalence of protein-energy malnutrition among children under five was reduced from 42% in 1975 to 34% in 1990, the total number with PEM increased from 170 million to 184 million. The numbers of people affected by micronutrient deficiencies are staggering, despite the effective control technologies. Iodine deficiency disorders affect 500 million people; over 200 million preschool children are at risk of vitamin A deficiency; about 400 million women show signs of iron deficiency anaemia.

Although in many countries the prevalence of chronic diseases associated with malnutrition is increasing, I believe that the most important problem with a direct impact on the nutritional status of the people is poverty. It has grown in many countries of the world as a direct result of the economic adjustment policies and the model of market economy in operation in them. Poverty breeds malnutrition and, in turn, malnutrition increases poverty, a vicious circle. Based on a limited experience in a few countries, resources should be targeted to the poor, particularly mothers, so that they can become self-supporting and self-sufficient. With greater income, women tend to invest more in food and health for their families.

Urban Jonsson has stated this approach very clearly: “Social research and experience show that poor people should be recognized as key actors in development rather than passive beneficiaries of commodities and transfers. Their survival and coping strategies are among the most appropriate and resource-relevant actions. With such a view, development work must become participatory, with the aim of empowering poor people, communities, and countries. With empowerment comes ownership and sustainability.”²

2. Jonsson, U. (1995) Towards an Improved Strategy for Nutrition Surveillance. Food and Nutrition Bulletin, 16(2), 102.

I was impressed by the decision of the governments during the World Food Conference in 1974 to create the SCN as an approach to coordinate the activities of all international agencies concerned with food and nutrition in the world. It included participation of the bilaterals. The rationale was that nutrition as an outcome required the inputs of different sectors of development and diverse disciplines within them. At the international level, agencies should coordinate their efforts in the formulation of policies, programs and specific nutrition interventions based on the scientific evidence available. At the national level, the same process should occur. The Advisory Group on Nutrition (AGN) was created to respond to requests from the SCN on up-to-date information as well as to suggest to the SCN nutrition issues for the consideration of the Sub Committee. I was elected a member of the AGN, and after two years became Chairman. Then a vacuum occurred in the chairmanship of the SCN because the elected official decided to take a position at the InterAmerican Development Bank, and I was asked to serve ad interim. Since then I have been re-elected to four consecutive two year terms, concluding in September 1995, when Dr Richard Jolly became the Chairman of the SCN.

I did not seek the position, but when it was offered to me I felt almost an obligation to accept, since I believed in the objectives of the SCN and thought I might be able to move things forward. I felt then, as I still do, that good nutrition is essential for human development and well-being and that available resources, better invested and managed, could reduce more significantly malnutrition in the world.

Within the work of the SCN, what achievements do you particularly value?

I think the single most important achievement has been the fact that since 1977, representatives of UN agencies and of bilateral governments have met every year to examine nutrition problems and interventions based on up-to-date information provided by the AGN and the Secretariat. Decisions have been taken usually by consensus. It is an effective system of coordination by information. Agencies could then transfer to governments, through technical cooperation, the best approach that science and experience recommend for the solution of specific nutrition problems.

There are a number of other achievements I would like to list, and in doing so I want to pay tribute to the Technical Secretary of the SCN, Dr John Mason, whose energy and expertise were responsible in large part for their success:

· The publication of the World Nutrition Reports based on data stemming from different agencies, collected and collated by the Secretariat. They have been widely quoted by governments, agencies and scientists.

· The reports on the flow of resources for nutrition showing that international investments per capita are way below need.

· The analysis of nutrition problems prevalent in the world e.g. on iron deficiency anaemia and vitamin A deficiency.

· The updating of nutrition problems and programmes covering more than 40 countries of the world. Some of this has arisen from the symposia which it has become traditional to hold immediately before the annual meetings of the SCN.

· The reports on the nutritional status of refugees, which are of great significance for governments and agencies concerned with the tragic situation of these human beings.

· SCN News, which as already mentioned has served the interests of health and nutrition professionals and non-professionals cooperating in reducing malnutrition rates in the world.

· Taken as a whole, the SCN publications are highly valued and are often quoted by the nutrition scientific community and national and international agencies.

· The SCN proposed the International Conference on Nutrition that was organized by WHO and FAO. The Declaration and Plan of Action stemming from the Conference have become important sources for nutrition policy formulation and program implementation in many countries of the world.

· The Advisory Group on Nutrition (AGN), since its inception, has been very important for the SCN, facilitating decisions based on sound information reflecting the knowledge and experience of its members.

· With a view to the future, the Secretariat has proposed to the SCN different alternatives to develop within or without the ACC.

Because poverty is increasing in the world, malnutrition will remain or even grow and become more difficult and costly to reduce and eventually to control. It is essential that governments and international agencies give priority to nutrition and invest accordingly. Health and nutrition should be placed at the centre of human and economic development in all countries, but particularly in those where the malnutrition-infection complex is the major cause of death and disease of children under five and of mothers.

It is encouraging to note that a number of countries with a low gross national product per capita have been able to improve significantly the nutritional status of the people, although the process has taken a few decades. It is also worth noticing the increased interest and funds available to reduce or virtually eliminate the major micronutrient deficiencies. The contributions of basic and operational research for better understanding the causes and consequences of malnutrition, and the bases for controlling it, have been crucial. However, if governments and international agencies do not ascribe priority to nutrition and do not invest what is needed, the situation will deteriorate further.

I believe that the SCN should continue its coordinating and information activities, after deciding on membership and functions as proposed by the Secretariat.

What advice to you have for us all?

Keep the faith that you are committed to a most noble cause, the well-being of people whom you do not know but whose needs you feel intensely. Redouble your efforts in whatever you do in nutrition while being hold and imaginative.

Behavioural Change and Nutrition Programmes

A Symposium on the above topic was held during, the 21st Session of the ACC/SCN. Issues raised during the discussions are summarized here.

Source: Elena Hurtado, INCAP

Parents want to care for their children as well as they can. They want to adopt practices best for their children to thrive. They will change their practices when convinced that they can be improved, and when they have the wherewithal to do so. Behaviour is at the heart of nutrition and health. Traditional behaviours may become known to be detrimental to nutrition, and their adaptation may be the key to better nutrition and health. And in societies undergoing rapid changes, the behavioural responses to that change are crucial. Often beneficial practices need to be protected - for example in the care of children by extended families when moving to urban areas, or continuing useful traditions such as fermenting food to reduce bacterial contamination.

The effective application of scientific advances in health and nutrition usually involves changes in behaviour of families and, particularly, mothers. Few would disagree that it is an obligation to ensure that children are immunized against the dangerous diseases of childhood, measles being a prime example. But to help mothers to bring their children for immunization, they need to be made aware of the benefits, informed of how to get access to them, and persuaded that this is worth the time and expense often involved. That immunization rates have reached levels of 80 or 90% in many poor countries over the last decade testifies to the extent to which mothers will adopt new practices when it is so clear that they are beneficial for their children. The widespread adoption of oral rehydration therapy in the home is a similar such example.

Behaviours beneficial to micronutrient malnutrition may require other types of awareness and motivation. In iodine-deficient areas a more complex linkage of awareness of goitre and cretinism with the possibility of prevention through purchase of iodine-fortified salt, assuring the availability and quality of that salt through persuasion and legislation, and embedding a behaviour that is clearly of benefit to the individual and community, is crucial but not easy. Perhaps more complicated still concerns preventing iron-deficiency anaemia in women, where the deficiency itself is less obvious, and the available interventions are less easy and less widely effective - such as ensuring daily (or possibly weekly) access to iron tablets, and sustaining the intake through pregnancy. Other examples apply to vitamin A deficiency which persists in many societies even though there is plentiful potential vitamin A in the food supply.

While behaviour is central, only part of this is determined by understanding and information. In many cases other resources enabling change are lacking, and need to be addressed at the same time. A major constraint in poor societies is the time available, particularly to women, to care for children and look after their families. Indeed, the practices adopted are to a great extent dictated by necessity and the availability of resources. Technology can help - more efficient cooking stoves, for instance, can reduce the time necessary for collecting fire wood; piped water frees up major amounts of time otherwise spent fetching water. Nonetheless, changes in practice that involve greater demands on women’s time are unlikely to be adopted. Similarly, a lot of behaviours at community and family level require access to resources from outside: obvious examples are supplies of vaccines, iodized salt, etc. Other resources do not need outside access, breastfeeding being a prime example; but breastfeeding practices are in reality dictated by economic needs for many working women. Promoting breastfeeding without taking account of the necessary changes in, for example, working conditions, may not be very effective. Finally, topical information can be crucial as an enabling factor. For instance, immunization rates can be greatly improved if information is provided as to which clinics provide immunization on what days. Similarly, ensuring that people know where to get iodized salt, and what price they should pay, is needed for sustained success of iodization programmes.

Despite wide agreement that changes in some specific behaviours could bring about major improvements in nutrition, only relatively minor parts of the resources in nutrition programmes are aimed at this. Moreover, modern thinking on how to foster beneficial change is not systematically applied where programme components do exist. Such considerations led the SCN to organize a Symposium on Behavioural Change and Nutrition Programmes held at UNICEF Headquarters, New York, on Monday 7 and Tuesday 8 March 1994, during the 21st Session of the SCN. The Session was opened by the late James Grant, Executive Director of UNICEF, and the Symposium was chaired by Urban Jonsson, then Chief of the UNICEF Nutrition Section. The Symposium was organized into three parts. The first, “What Behaviours?” was introduced by Elena Hurtado (INCAP, Guatemala). “Means of Changing Behaviours” were then discussed in papers by William Smith (Academy for Educational Development, Washington, D.C.), Marcia Griffiths (Manoff International, Washington, D.C.), Bjorn Ljungqvist (UNICEF, then working in Uganda and now representative in Cambodia), and Jane Vella (Jubilee Popular Education Center, N. Carolina). Finally, a panel of invited discussants considered the third topic “Experiences in Behavioural Change and Implications for Agency Policy”, introduced by Reynaldo Martorell (Chairman, AGN, Emory University, Atlanta).

What Behaviours?

What kind of behaviours might be targeted for change as part of programmes to improve nutrition? Infant and child feeding behaviours provide a clear example of where there exist sound scientifically-based guidelines on practices that could improve nutrition - for example, there should be no pre-lacteal feeds, the newborn should be fed within the first hour after birth, the infant should be breastfed exclusively for 4-6 months after birth, and so on. This provided the focus for the first presentation by Elena Hurtado and was a subject repeatedly referred to throughout the Symposium. “Infant feeding behaviours refer to both maternal and child behaviours associated with food intake by the child and can include the following - food preparation... feeding/eating per se... and helping behaviours” explained Dr Hurtado.

Source: Elena Hurtado, INCAP

When such clear recommendations exist, how then is it possible to translate them into behavioural practice? Much of how it is done depends on the type of programme and behaviour change that is sought, and the prevailing environment and behaviour of the targeted population. Dr William Smith presented an overview of the available approaches for behaviour change, giving examples mainly from work on AIDS prevention programmes, and providing the reassuring message in his introduction that “behaviour does change - it changes in positive directions - it changes despite serious obstacles.” Five ways of influencing human behaviour, drawing on the theoretical models developed by behavioural scientists were described: “one of them is power. You can pass a law, you can pass a regulation, you can create a sanction. You can use logic. You can give people certain facts... Emotional appeals are also very important. Incentives - providing someone with a reward for doing something - and facilitation strategies, making it easier to remove the obstacle that is preventing them from changing their behaviour... Designing products to offer advantages people want is another way of influencing behaviour. Some pioneering work in the nutrition area was to develop new kinds of food products (involving mothers in the process) that offer advantages that those mothers really want.”

How do we decide on the method, or combination of methods that should be used in any particular situation? A good start is to carry out formative, qualitative research, working with the community and potential program participants, including health or agriculture extension workers, and school teachers. “This kind of research helps ensure that the programme strategy is based on programme participants’ articulation of problems and needs and how to fulfill them” explained Marcia Griffiths in her presentation on “Social Marketing” which she defined as “the application of marketing principles to social program design and management”. This kind of preliminary research, she explained, can reveal concepts that require clarification, such as “goiter is not God-given; iron pills will cause dark stools, but this is not a sign of illness; and young children do need some oil in their food...” The type of motivation required can be identified: “take breastfeeding - we have learned that mothers are not always swayed by being told about the antigens of breastmilk, but rather by ideas such as convenience - breastfeeding is the most convenient way to feed a baby...” she said. External factors needing change can also be revealed since there may be “misinformation from local health or agricultural extension workers; a policy that does not allow access to particular goods, such as iron pills that can only be obtained from the health center; and the unacceptability of pills when compared to syrups/tonics.”

Participation and Feedback

The technique familiarly known as the “Triple A Cycle” was described by Bjorn Ljundqvist in his presentation on “Participatory Approaches to Behavioural Change”. The three “A”s of the cycle are Assessment, Analysis, and Action. How does it work? Taking infant feeding behaviour as an example, a mother may decide that she wants to breastfeed her child because she believes that this will be best for her baby’s health, or because she has been motivated to do it for some other reason. She will then ANALYSE how she could achieve this. Depending on the strength of the behavioural intention, the mother may discover that what she has to do - the ways she has to change her behaviour in order to breastfeed - are justified (or not) by the perceived rewards. On the basis of her analysis, the mother would then put into ACTION (or not) the breastfeeding behaviour. This would then be followed by an ASSESSMENT of how well the ACTION produced the perceived rewards of the original behavioural intention. The mother may well then re - ANALYSE the situation and either farther modify her behaviour to achieve the perceived goals, or change the behavioural intention in a “I tried my best, but wasn’t able to get what I wanted, so I will give up” kind of way, and so the cycle would continue. Inputs at all stages of the cycle might help in achieving the desired action: increasing the strength of the behavioural intention, so that the mother will be willing to go to greater lengths to ensure that she can breastfeed; removing obstacles that cause her to decide it is not feasible at the “analysis” stage; providing continuing support at the “action” stage; and providing reinforcement of the behavioural intention, positive support, and feedback at the “assessment” stage.

The Triple A Cycle: ASSESSMENT - ANALYSIS - ACTION

Source: Bjorn Ljungqvist, UNICEF

“Adopting the Triple-A Cycle principles in programming by necessity puts the ‘actors’ (in the example above, the woman who wants to breastfeed) in focus, and the understanding of why actions do or do not take place becomes the basis for formulating programmes. In the case of nutrition programmes, the actors are usually poor people and not only understanding but also respect for their capabilities to cope with extremely difficult circumstances is a sine qua non in any efforts to promote change in their nutrition-related behaviours” said Dr Ljundqvist. Examining the role of external nutrition programmers in the process, he explained “I think it is irrelevant to ask if people or communities are participating in ‘our’ programmes. The question is rather if we are allowed to participate in their efforts to cope and shape a better future for themselves and their children. Will they really accept us as partners? In practice, of course, there is never an issue of us as external programmers participating as direct partners to poor people in the communities. Instead the issue is to what extent we, within our programmes, have been able to identify change agents or animators and provide them with skills and tools useful for the persons and the communities where actions have to take place. Have we been able to establish an effective facilitating system that is able to respond to the ideas and the needs articulated by the communities? And have we been able to facilitate for groups of people to come together and participate with one another in order to take action on issues of joint concern?”

Animate, Don’t Dominate

In a presentation on “Nonformal Adult Education”, Jane Vella took up the issue of identifying change agents or animators, and providing them with skills and tools for working with individuals and communities to help them successfully achieve beneficial changes in behaviour: “what and how can we teach teachers of village health workers, physicians, nurses, managers of programs to achieve the sustainable learning and behavioural change needed?” she asked. Traditional teaching methods, characterized by teacher domination, are not appropriate or effective, she argued; rather the goal should be animation - a method of teaching which could then be passed on to the village health workers. “Since we teach the way we were taught, we have to ask ourselves how we begin to change the educational process and corollary theories and assumptions about learning in order to invite village health workers to animate rather than dominate”, she explained. “We all have had the experience of learning content we did not fully understand or believe in, skills we saw no use for, and attitudes incongruent to those of our own hearts. Nonformal adult education developed in the late fifties and early sixties as an alternative approach to teaching village men and women, working in rural communities and urban areas, using an approach that involved listening to the experience of adults and drawing out their response to new concepts and skills... when adult education is animation, people respond. When it is traditional teacher domination, people disappear.”

Why Isn’t Behaviour Change Included More in Programmes?

If we know of effective methods and techniques for promoting behaviour change, and if behaviour change is so important, why isn’t it used more widely in nutrition programmes in developing countries? As Dr Horwitz (SCN Chairman) commented “behaviour change is really at the heart of all health and nutrition programmes”.

Might part of the problem be that programme planners and decision-makers are failing to change the way they do things themselves? “We have a behaviour change problem in the community that we represent” commented G de Cunha. “There is something that is preventing us from doing what we know needs to be done, using the resources that are there” A solution to this problem may lie in the way the goals and objectives of programmes are conceived of. Currently they are expressed in terms of coverage, of prevalence, and of supplies. “Our goals and objectives are not sufficiently expressed as proportions of people who will do this or that” he suggested. The experience of the UNICEF-supported breastfeeding programme in Brazil illustrated this point. “The goals and objectives of the programme were expressed in behavioural terms. Formative research was conducted, and on the basis of that, a strategy was drawn up... the strategy was not to speak to the mother, and insist that she breastfeed her child, thus making her feel responsible and guilty if she was unable, but to show that the mother already had a desire to breastfeed her child six months and more, but what came between her child’s lips and her nipple was all of society” he said.

“You cannot, in behaviour change programmes, say I am doing this and I am doing that, and I am doing the other, but we don’t really have the money for this fifth thing. If you say that, you end up believing that a cask can hold water without one strip of wood. That was the message of the breastfeeding programme, that you have to tackle all the factors or you don’t have a programme. But don’t link too many objectives together. Again, for example, the breastfeeding programme worked marvelously over two and a half, three years. Breastfeeding duration doubled, prevalence, which was around 80% went up to nearly 90% in the main towns, in the slums, bang on our target group, but then after three years of success, the programme was disactivated by the government, who did the wrong thing for the right reason, making the point that breastfeeding surely was not all that was involved in the health and nutrition of the infant. Surely there were other things, like ORS, surely there were other things like ARI, surely there were other things like growth monitoring. Of course, we being UNICEF, this was throwing the bible at the vicar. So we said, of course. The result was that from a single point story which we were telling about breastfeeding, we suddenly were telling five stories. There was that one breastfeeding horse that was far in front, and instead of saying all right, these horses pulling this chariot will try and catch up with that horse, that horse was dragged back and harnessed with the other four horses that were beginning and as a result the programme suffered and the figures began to prove that we were right, because the breastfeeding prevalence and durations began to decline.” G de Cunha, India.

There may be another reason for the lack of behavioural change components in nutrition programmes. “Why are there so few experts?”, Dr Martorell asked. “In planning the symposium, I was struck by how difficult it was to identify speakers... at one time I commented that behaviour change experts seemed to be rarer than, particle physicists!” One response to this question was that perhaps this is because the study of behaviour seemed as complicated as particle physics. But this is not so, argued William Smith “behaviour change specialists really are not so rare, you just need to know where to look”.

“Dr Smith was very clear, he told us don’t try to be experts in communications. Call us. Perfect. But I understood from Dr Ljundqvist that perhaps the nutrition programmer could become, at the same time, the nutrition communicator or the nutrition educator or vice versa. What are we going to tell governments? How to go about this? If this is essential, as apparently it is becoming more and more so, it must be implemented throughout the world, not only the developing world incidentally, the developed world also. Who is going to do this? Who is going then to train whatever quality of staff is needed? How? I think this has to become clear in the discussion.” Dr A Horwitz, Chairman, SCN.

Resources Enabling Change

In many situations resources provided from outside are required to enable the behavioural change to take place. If they are not there, or if people do not perceive them to be there, change cannot happen. One example given was that of a UNICEF IDD Programme in Tanzania, where nutrition education was not at first accompanied by provision of iodized salt. As F Kavishe explained “at one time we actually had to stop advocating that people should take iodized salt”.

In another example, also from the IDD programme, this time involving the provision of iodized oil capsules, the resources were there, but people did not believe that the capsules contained iodinized oil and would not take them. The reason? The iodized oil capsules were being distributed in a car marked “family planning” - it was thought that they were anti-fertility drugs.

Another important enabling resource for behavioural change is time. For example, the effect a programme has on women’s time is a significant enhancer or inhibitor of whether the behavioural change component is effective. An example given by Eileen Kennedy (USDA) was that of a World Bank funded and run credit scheme in Ghana targeted to women, in conjunction with a nutrition education component and a growth monitoring component. The philosophy was that by increasing women’s income through credit, in addition to providing education to mothers, an income constraint would be relieved as well as a knowledge constraint, which would lead to both better household food security, and improved nutrition of women and children. It was discovered that the way this targeted credit with education programme operated throughout the country varied dramatically - some of the credit schemes increased the time constraint on women, others did not. The most effective of these strategies, however, was where credit with education not only increased women’s income, but it did so in a way that decreased women’s time constraints. The message is: promoting behavioural change success often requires removing other constraints, such as time.

Behavioural Change versus Capacity for Change

What do the words “behavioural change” imply? To some, they suggest an unreasonable level of control from outside influences - “this whole concept of behavioural change has a bit of a paternalistic connotation, it implies that it is us who think that somebody else should change their behaviour, and very often in a specified way: is that really true?” asked one participant. Similarly, others commented: “I worry when hearing you talking about your communication behaviour - who decides the messages? There is a philosophical question here about control... I think that behaviour change might be necessary, but rather than setting up objectives for behavioural change, we should be improving people’s capacity to decide on actions or behaviours themselves”.

Quoting the words of President Nyrere, Dr Kavishe said “ ‘the one thing all history teaches us is that people have to act for themselves and in their own interests. People know their own needs, once convinced that this can be overcome by their own efforts, they will make these efforts. Development brings people freedom provided it is development of people. People cannot be developed, they can only develop themselves. For a while it is possible for an outsider to build a man’s house, but an outsider cannot give the man pride and self-confidence in himself as a human being. Those things a man has to create himself by his own actions. He develops himself by what he does, by making his own decisions, by increasing his understanding of what he is doing and why, by his own fall participation’. I think that is the kind of behavioural change that we are looking for” added Dr Kavishe.

Whatever the capacity of people to decide for themselves, however, the knowledge about what they should be aiming to achieve often lies in the hands of others, whose responsibility it is to judge when that knowledge should be passed on. There exist many examples where messages provided in the past have been judged later to have been incorrect, for example earlier emphasis on protein - but on the other hand, is it right to withhold knowledge believed at the time to potentially save lives? In reality, though, in nutrition programmes, as G de Cunha said “when we talk about behaviour change we are talking about nutrition interventions that have already been decided... so what the behaviourist in a nutrition programme is attempting to do is to function like a good driver in a vehicle that is there already, with the destination already determined, in a car with a given capacity.”

Changes in the ways that children are nurtured - as the main example considered - can clearly be beneficial for their health, development, and nutrition. Promoting such behavioural change, when modern knowledge suggests clear benefit for the child, is not in principle an imposition, but an obligation similar to, for example, providing immunization. At the same time, the capacity should be enhanced among communities, families, and individuals to assess their needs, analyze potential behavioural changes, and to decide on the appropriate action.

What Next?

Promoting behavioural change is an important responsibility of those concerned with nutrition programmes. Well-established methods exist for promoting behavioural change, and for determining what precise approaches to use. Formative research, participatory assessments, and other tools developed from social marketing, from modern methods of adult education, and from community experiences, can be much more widely applied.

Probably the main message is that behavioural change is of central importance in improving health and nutrition; and there is no technical reason why this should not assume much greater importance in nutrition programmes. In turn, this will require careful planning, development of human resources, and the backing of agencies and governments to achieve this. Barriers in terms of lack of knowledge and absence of methods are minimal. The next step should be widespread adoption of these within many or most programmes aimed at improving nutrition and health.

V.E./J.M.

Poor Nutrition and Chronic Disease - Part I

The first of a two part report of the proceedings of the ACC/SCN Symposium on Nutrition in the Epidemiology and Prevention of Cardiovascular Disease, Diabetes Mellitus, and Obesity in Developing Countries.

The Symposium began with an overview of the topic by Dr J Jervell, member of the AGN and President of the International Diabetes Federation. Presentations then followed on “The Emergence of Chronic Diseases in Developing Countries” by Dr T Byers of the University of Colorado; “The Role of Foetal and Infant Growth and Nutrition in Causality of Cardiovascular Disease and Diabetes in Later Life” by Dr J Hoet, Professor Emeritus at Louvain University, Belgium; “The Contribution of Urbanization and Lifestyle Changes to Cardiovascular Disease, Diabetes Mellitus and Obesity in Developing Countries” by Dr A Wielgosz, Division of Cardiology, University of Ottawa; and “Prevention and the Role of Nutrition” by Dr G Beaton, Department of Nutritional Sciences, University of Toronto.

In Part I of this report of the Symposium proceedings, the introductory presentation by Dr J Jervell, and papers by Dr T Byers and Dr A Wielgosz on the epidemiology and causes of non-communicable diseases in adulthood, are reproduced. Part II, to be published in the next issue of SCN News, will cover the role of foetal and infant malnutrition in increasing the risk of cardiovascular disease and diabetes in later life.

INTRODUCTION: OVERVIEW AND IMPLICATIONS FOR THE FUTURE

by Dr J. Jervell, President, International Diabetes Federation

Non-communicable diseases are emerging not only with the same strength as they have done in the industrial world, but perhaps even more strongly, in the developing countries - especially those which are developing fast.

What are the diseases we are speaking of? We have a group of diseases which we call sometimes the “metabolic syndrome” in the western world, and this is because if you have one of them, you are more likely to have one of the others (see figure 1). If you have diabetes, you are more likely to have hypertension, you are more likely to get coronary heart disease and stroke, and your blood lipids are more likely to be deranged.

Figure 1. The Metabolic Syndrome or Syndrome X Coronary artery disease angina pectoris myocardial infarction sudden death Stroke Diabetes mellitus type II and impaired glucose tolerance Hypertension Dyslipidemia Central Obesity

These diseases apparently have a common causation. In western medicine, today we talk about insulin resistance or hyper-insulinaemia, which may provide a link. Perhaps they may also be joined together as a consequence of earlier under-nutrition, and as a consequence of changing lifestyles.

We talk about diseases and we talk about risk factors. Diabetes, in addition to being a disease in itself, is also a risk factor for coronary heart disease. If you have diabetes you are three to four times as likely to get coronary heart disease and myocardial infarction, angina, and sudden death. If you have hypertension you get more stroke and more coronary heart disease. If you have dyslipidemia?, it’s the same way.

But diabetes in itself is also a disease with symptoms and with specific complications. I was asked earlier today why do you talk so much about diabetes, is a little high blood glucose really dangerous? I repeat, it causes specific complications. Diabetes is the most common cause of blindness in adults in America; it’s also the most common cause of amputations. In Japan it’s the most common cause of renal failure in adults. So it’s not only causing coronary artery disease and stroke, but specific complications as well.

These diseases may have a common preventive aspect, but once they have developed, you need very specific management plans to control their impact. So sometimes we say the primary prevention of these diseases is probably much the same, but the management, once they appear, is very costly and very different.

There are two main types of diabetes. One is insulin-dependent diabetes, an auto-immune disease which destroys the beta cells in the pancreas, the cells which produce insulin. It’s called insulin-dependent because without insulin the patient dies. It is also known as type I diabetes.

As far as we know today, it is probably not particularly common in developing countries. This may be in part because it is undiagnosed - we do know that there is a lot of type I diabetes which is not diagnosed in developing countries. But this is not the main type of diabetes that we are talking about today. That is the non-insulin dependent diabetes, due to an insulin resistance and a reduced capacity to produce extra insulin to overcome this resistance. Sometimes this is called type II diabetes.

A pre-diabetic stage is called impaired glucose tolerance. WHO has decided that you have diabetes if 2 hours after having drunk a solution with 75 grams of glucose, you have a blood glucose of more than 200 milligrams per deciliter. If it is below around 140 mg/dl you are normal, but if it is in between 140-200 mg/dl you have impaired glucose tolerance, unpaired glucose tolerance is a risk factor for developing diabetes, and also increases the risk of getting a myocardial infarction.

Now there is also malnutrition related diabetes which occurs in some developing countries. There are two types of this. One is due to a pancreatitis, perhaps - it has been suggested due to inadequately processed cassava. The other is related to severe undernutrition throughout childhood and adolescence, and Joseph Hoet will talk more about this later today (see part II).

How common is diabetes in the world? I am talking about diabetes because we have good criteria for making the diagnosis, and a lot of good surveys have been done. It is much harder to get good data on causes of death from myocardial infarction in developing countries. Results of a study on the prevalence of diabetes in adults, by standardized criteria and age corrected are shown in figure 2. There is a wide range of prevalences. In the Pima Indians in Arizona, about 50% of the adults are diabetic, at the survey time: at the age of 40, 50% of Pima Indians have diabetes. They were described about a century ago as a population where diabetes was not seen; then they were poor agricultural people, now they live in the reservation and are very obese. What is striking in figure 2 is that high diabetes prevalence is either in developing countries or in under-privileged groups in developed countries, such as the Hispanics or the Indian populations in the U.S. Diabetes is extremely high in people who go directly from a hunter-gatherer existence, and skip the agricultural part of our development going directly into an urbanized life-style.

Some recent examples come from Pakistan. Surveys in Karachi have shown a prevalence in the adult population, about 25 years of age, of 16.5% diabetes. In my own country, which is Norway, the prevalence in a similar population would be 3%, and I can tell you we are fatter than the Pakistanis that we studied! Impaired glucose tolerance - the pre-diabetic state - in Pakistan was 10.4%, adding up to more than a quarter of the adult population having some form of glucose intolerance. This leads to increased risk of coronary heart disease, and indeed when we talked to cardiologists in Pakistan, they said that myocardial infarction in young men around 30-40 years was much more common than seen in the western world.

In Shikapur, up to one quarter of the population has glucose intolerance; in rural Baluchistan (a tribal area) the prevalence is 17%. So even there they have more glucose intolerance than in urbanized northern Europe.

Why are these non-communicable diseases, including diabetes, becoming so high? Is it due to genetics? Obviously, if you go on an individual basis, and ask a person who has non-insulin dependent diabetes or coronary heart disease or hypertension, or obesity, these conditions are commoner in their relatives, in their parents and grandparents. It is not just due to family life-style, there are definite genetic factors. But are the genetic factors responsible for the differences between ethnic groups? Probably some. Pima Indians are probably genetically disposed to get diabetes to a higher degree than most other populations of the world. But from all other continents and all other ethnic groups there are subgroups of populations who have diabetes incidences like these. For example, the Chinese at present have a prevalence of 2% of diabetes in their adult population; the Chinese in Mauritius have 13%. So they are not protected, they have just not become urbanized yet. The north Hong Kong Chinese population has a prevalence of diabetes of 5%, so it’s developing there, and is higher than in Europe, for example.

Figure 2. Prevalence (%) of total glucose intolerance (diabetes and IGT) in selected populations in the age range of 30-64 yr.

(Source: (1993). Diabetes Care, 16(1), 170)

Obesity is a risk factor. Obesity minus physical activity is more dangerous than obesity with physical activity. There are many good studies showing this, both for coronary heart disease, diabetes, and hypertension. So obesity is the risk factor but physical inactivity is equally risky. When I go to cities such as Karachi, or Accra in Ghana, I wonder how are people going to have physical activity programmes there - especially in Karachi, which is a city of 11 million inhabitants.

Humanity developed as hunter-gatherers, probably a couple of hundred thousand years before we discovered agriculture. Then there was another 10,000 to 5,000 years before we became urbanized, but we are supposed to be hunter-gathers. Kierin O’Dea, in Australia, has collaborated with a group of Aborigines who had become extremely urbanized and then taken them out to the hunter gatherer existence for short periods.

The 10 Aborigines were diabetic, living in an urban environment, but had had a childhood in the outback and had lived the traditional existence as hunter-gatherers. There were 5 men and 5 women - all had diabetes, and they spent 7 weeks together in the hunter-gatherer existence. They had a marked weight reduction, their body mass index went down and their diabetes improved. Their fasting blood glucose and 2 hour glucose after 75 grams (which is a glucose tolerance test) went down and their fasting insulin levels went down so they became more insulin sensitive. They also lowered their cholesterol, their triglycerides which are all risk factors for coronary heart disease, their blood pressure and the bleeding time went up which means that their blood was not so likely to coagulate. They were less likely to get thrombosis.

There are three survival factors if you are a hunter-gatherer, according to O’Dea. You should have a strong preference for energy dense food, honey and fats - but there is little honey available and wild animals have much less fat than domesticated animals, so these are scarce, but you survive better if you like these foods because you then store them as fat. You should have a great capacity to gorge, because when food is there you should get as much as you can inside yourself, to store it for later use, and then you should minimize physical activity as much as possible, only be physically active when it is necessary. I asked Dr O’Dea how much time these hunter-gatherers spend actually hunting and gathering and preparing food and she said about 4-5 hours per day. It’s not natural to work as much as 8 hours a day for humanity, but still we do it. These beneficial tendencies for hunter-gatherers to gorge - to prefer energy-dense food and to be physically inactive when it is not necessary to be physically active - are not a good life-style in our society. It is too easy to be a hunter-gatherer in Washington.

Figure 3a. Correlation between mortality from diseases (total) 1964-67, in men aged 40 to 69 years (standardised rates/100,000 population) and infant mortality rates 1896-1925.

Figure 3b. Correlation between mortality from arteriosclerotic heart disease, 1964-67, in men aged 40 to 69 years (standardised rates/100,000 population) and infant mortality rates 1896-1925.

Figure 3c. Correlation between mortality from arteriosclerotic heart disease, 1964-67, in women aged 40 to 69 years (standardised rates/100,000 population) and infant mortality rates 1896-1925.

(Source: (1977). British Journal of Preventive and Social Medicine, 31, 92.)

Now are there other factors? A friend of mine Anders Forsdahl suggested in 1977 that perhaps if you were poor in childhood you were more likely to get coronary heart disease and premature death from arterial sclerosis in later life. He said this because he grew up in a very poor community in the 1930’s in northern Norway, where his father was the district physician, and he later came back as a district physician himself and saw that there was an awful lot of myocardial infarction and high cholesterol levels. He then did a very simple study. He compared the infant mortality between 1895 and 1925 with later total death and death from coronary heart disease. You can see that there is a pretty good correlation, in figure 3.

This could be a nouveau-riche phenomenon, that you are poor in childhood, you just eat more of the wrong things, but it could also be some sort of programming going on and this is what Joseph Hoet is going to talk about later today, and which Barker and Hales have suggested. They have done studies of the birth weights and the 1-year-old weights of children in a county in England, and found that the lower the birthweight, and the 1-year-old weight, the higher the coronary mortality later in life. A low birth weight and for some reason high placenta weight, leads to higher blood pressure later. You get more diabetes in those who have low birth weights, and low weights at one year. The hypothesis that early under-nutrition is so important for developing the non-communicable diseases of the metabolic syndrome later in life is based on studies done in developed countries, and no good studies have yet been done in a similar fashion in developing countries.

If, however, this is true, we can expect an epidemic once development occurs, and perhaps that is what we are seeing in Pakistan. The prevalence of low birth weight in 1990 was more than 30% in South Asia, and it is between 10 and 20% in very many areas of the world.

Of course, there are other changes which cause higher prevalences of these diseases, not the least one being the demographic changes that are occurring. The World Bank’s World Development Report (1993, p.32) compares the median age of death in various areas of the world: up to 1950, half the population died before they reached 20 years; in many countries this median had risen to around 40 or more by 1990, and the expectation is that this will continue. A totally different population pyramid will result, and we will therefore get a marked increase in the non-communicable diseases. So the success in preventing childhood mortality and morbidity leads to problems later, even though it is also a measure of success.

What we can wonder is perhaps whether the epidemic that we are seeing in the industrialized countries will come with even more force in the developing countries. Perhaps if the early undernutrition hypothesis is right, it may be a temporary phenomenon - hopefully - but not in our lifetime I think.

The expectation is that the communicable diseases will dominate the picture in the future. This is going to put a major strain on the resources of the health care system. In the developing countries today, meetings are being held by physicians and public health officials on how to actually manage these diseases when they occur. The primary prevention is, of course, the great challenge and should be high priority. I think we do know some of the lessons, although we need more research. Implementing these measures is difficult, but we have to start now.

THE EMERGENCE OF CHRONIC DISEASES IN DEVELOPING COUNTRIES

by T. Byers, M.D., M.P.H. and Julie A. Marshall, Ph.D., University of Colorado School of Medicine, Denver, Colorado.

Figure 1. Changing Age at Death in Developing Countries

WORLD BANK, WORLD DEVELOPMENT REPORT, 1993 (REFERENCE #1)

Disability-adjusted life-years (DALY’s) are a measure of the combined effects of mortality and morbidity in a population (1). DALY’s are computations of the years of life “lost”, both because of premature mortality and because of disability, scaled to the severity of the disabilities due to incident diseases. DALY’s lost in a particular year in a population are discounted for the relative value of future years (3% per year). The World Bank has estimated DALY’s based on both direct measures of health and on expert judgment, which is critical in making estimates for developing countries, where good data often do not exist. Cardiovascular diseases, cancer, and diabetes already have equivalent or higher risks on a per-population basis for disability adjusted life years in developing countries compared to industrialized countries (figure 2).

Figure 2. Disability-adjusted Life Years Lost (DALY’s) per 1000 Population per year by Age and Economic Development

WORLD BANK, WORLD DEVELOPMENT REPORT, 1993 (REFERENCE #1)

Obesity is a very important chronic disease risk factor to consider in detail because it is tied to many chronic diseases, and it is easy to measure. Obesity, a useful indicator of caloric imbalance, has been increasing in nearly all countries in recent decades among both men and women (5). Almost all anthropometric surveys in industrialized countries that have repeated results over time show that an increase in BMI is occurring (5) (figure 3).

In developing countries good trend data are usually absent, but within country contrasts in lifestyle and in diets are often reflected by contrasts in urban versus rural cultures. Fairly consistent patterns are seen in countries where surveys have been done showing the prevalence of obesity is considerably higher and the mean body mass index higher in urban than in rural areas (6). A survey in Costa Rica of urban versus rural dwellers has shown not only higher BMI in urban than in rural-dwellers, but also adverse trends for diastolic blood pressure, saturated fat intake, smoking, blood glucose and blood cholesterol concentrations (7). Migrants from developing to more industrialized countries show rapid increases in body weight. Japanese men migrating from Japan to Hawaii or California showed increasing prevalence of obesity and higher body mass index with “westernization” of the diet and physical activity habits (8). The same phenomenon has been seen in the Western Pacific where Samoans from more traditional areas have migrated into progressively more “western”, “industrialized” areas, with a progressive increase in the prevalence of overweight (9) (figure 4). The “nutritional transition” is now underway in developing countries. The most prominent features of the changes in the “nutritional transition” are increases in the intake of fats in the diet, along with decreases in the intake of complex carbohydrates and fiber, accompanied by a decrease in physical activity.

Figure 3. Percent Change in BMI per Decade in Countries with Repeat Surveys

BYERS ET AL (REFERENCE #5)

Figure 4. BMI in Samoans According to Their Degree of Western Acculturation

MC GARVEY ET AL. (reference #9)

Nutritional deprivation can also happen in utero, where either genetic selection or phenotypic re-programming can occur (17). Low birth weight has been shown to be associated with many of the physiologic conditions that define “syndrome X” (18,19) (figure 5). The intrauterine environment, or perhaps other critical periods in early life (20), may not just select out certain fetuses for survival, but may actually program us nutritionally to have a particular metabolic phenotype. The data to support the conclusion of a thrifty genotype versus a thrifty phenotype is limited, but the common thread is that the ancestors of some peoples, or in fact their own early life environments, may have resulted in the creation of populations that are metabolically vulnerable to overnutrition.

Figure 5. Relative Risk of Syndrome X Among Adult Men, According to Birth Weight

* Relative Risk for syndrome x (non-insulin-dependent diabetes mellitus, hypertension, and hyper-triglyceridemia), adjusted for adult BMI.

Reference: Barker, reference # 18

There are two public health nutrition revelations of note. First, the control of nutrition deficiency diseases has been mostly completed in industrialized countries, but is still evolving in developing countries. The second is the control of nutrition-induced chronic diseases. We have not done a good job yet in industrialized countries with this second problem. Developing countries that are still trying to deal with the first challenge will now have to deal as well with the second one, which is rapidly emerging as the primary problem in terms of deaths and disability.

How can developing countries deal with, on the one hand, micronutrient deficiencies (eg, iodine deficiency, vitamin A deficiency, iron deficiency) that are still plaguing large parts of populations, while chronic diseases are emerging as well? Often this plays out as a rural problem for micronutrient deficiencies and an urban problem for caloric overload. What is the commonality in public health strategies for fortification, infection-control, and nutritional supplementation, that deal with micronutrient deficiencies, and for fat reduction, fiber promotion, and physical activity promotion, that relate to chronic disease-relevant nutrition? There is a potential common link in the promotion of fruits, vegetables, and whole grains in the diet.

Clearly, as we eat more fruits, vegetables, and whole grain in the diet we can substitute these for high fat foods. In addition, it is increasingly clear that the micronutrients in whole foods have profound effects on heart disease and cancer risk. Our clinical trials have thus far been unsuccessful in giving high doses of single micronutrients to prevent chronic diseases, but it is clear that there is a powerful effect in fruits and vegetables that reduces chronic disease risk. At the same time we cannot, of course, forget infection control, supplementation and micronutrient fortification, but the promotion of fruits and vegetables in the diet may be a useful commonality between strategies for preventing micronutrient deficiency and chronic diseases that can he a basis for food policy and education in the future. Because of the importance of caloric balance, and the emerging problem of obesity in developing countries, nutritional interventions should always include the promotion of regular physical activity, which can allow for greater intakes of foods, and thereby also prevent micronutrient deficiencies that can lead to chronic diseases.

We need to decide how we are going to educate people and what kinds of food policies we are going to promote. What kind of actions can we suggest that be taken? We need to improve surveillance of adult health risks and risk factors in developing countries. But in isolation surveillance is not going to be particularly informative unless we link our future surveillance to intervention policies and to intervention programs. So how do we strategically develop collection systems for surveillance data linking it to policies and interventions’? We need to develop, of course, culturally relevant interventions. In the case of foods, it is particularly important to develop interventions and educational approaches for developing countries that play on the strengths of their heritage and their history and their culture and really build on the roots of their civilizations.

Finally, in developing countries, as well as in industrialized countries, we need to find out how to implement policies to promote healthy diets and physical activity. How can we really have policies that promote fruit and vegetable and whole grain intake, and how can we build and design our cities and our lifestyles to promote regular physical activity? These are important challenges for all countries (23,24). Price supports can encourage the production and consumption of some foods in preference to others, but price support systems can cause inefficiencies in free markets. If countries choose not to engage in price supports for promoting healthy commodities, they should at least be careful to avoid hidden subsidies for high fat diets, such as subsidies for the production of high fat meats or high fat dairy products. The challenge that faces developing countries is that with the emergence of obesity and chronic diseases due to changes in diet and physical activity in some segments of the society, undernutrition and poor economic development continue to lead to the opposite problems of starvation and physical stress in other areas. There must be a social balance between feast and famine, and between sedentariness and over-exertion. Otherwise, the future economic and social burden of high rates of heart disease and cancer will become a costly burden for developing countries.

References

1. World Development Report 1993: Investing in Health. Oxford University Press, 1993.

2. Hughes, Kenneth. Trends in mortality from ischaemic heart disease in Singapore, 1959 to 1983. Intl J Epidemiol 1986; 15: 44-50.

3. INCLEN Multicentre Collaborative Group. Risk factors for cardiovascular disease in the developing world. A multicentre collaborative study in the International Clinical Epidemiology Network (INCLEN). J Clin Epidemiol 1992; 45: 841-847.

4. Li N, Tuomilehto J, Dowse G, Virtala E, Zimmet P. Prevalence of coronary heart disease indicated by electrocardiogram abnormalities and risk factors in developing countries. J Clin Epidemiol 1994; 47: 599-611.

5. Byers T, Wolf R, Williamson D. World-wide increases in body size during the Twentieth Century: global fattening? Proceedings of the XV International Congress of Nutrition. New York, NY, Gordon and Breech (in press).

6. Sobal J, Stunkard A. Socioeconomic status and obesity: a review of the literature. Psych Bull 1989; 105: 260-275.

7. Campos H, Mata L, Siles X, Vives M, Ordovas JM, Schaefer EJ. Prevalence of cardiovascular risk factors in rural and urban Costa Rica. Circulation 1992; 85: 648-658.

8. Curb D, Marcus E. Body fat and obesity in Japanese Americans. AJCN 1991; 53: 1552s-1555s.

9. McGarvey ST. Obesity in Samoans and a perspective on its etiology in Polynesians. Am J Clin Nutr 1991; 53: 1586S-94S.

10. Reaven G. Role of insulin resistance in human disease. Diabetes 1988; 37: 1595-1607.

11. Beaglehole R. Cardiovascular disease in developing countries: An epidemic that can be prevented. (Letter) BMJ 1992; 305: 1170-1171.

12. Popkin BM. The nutrition transition in low-income countries: An emerging crisis. Nutrition Reviews 1994, 52: 285-298.

13. Prosnitz L, Mandell G. Diabetes mellitus among the Navajo and Hopi Indians: The lack of vascular complications. Am J Med Sci 1967; 253: 700-705.

14. Sugarman JR, Hickey M, Hall T, Gohdes D. The changing epidemiology of diabetes mellitus among Navajo Indians. West J Med 1990; 153: 140-145.

15. King H, Rewers M, and the WHO Ad Hoc Diabetes Reporting Group. Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults. Diabetes Care 1993; 16: 157-177.

16. Neel JV. The thrifty genotype revisited. In: Koberling J, Tattersall RB, eds. The Genetics of Diabetes Mellitus - Serono Symposium No. 47. London, Academic Press, 1982.

17. McCance DR, Pettitt DJ, Hanson RL, Jacobsson LTH, Knowler WC, Bennett PH. Birth weight and non-insulin dependent diabetes: thrifty genotype, thrifty phenotype, or surviving small baby genotype? BMJ 1994; 308: 942-945.

18. Barker D. Maternal and fetal origins of coronary heart disease. J Royal Coll Physicians of London. 1994; 28: 544-551.

19. Valdez R, Athens M, Thompson G, Bradshaw B, Stern M. Birthweight and adult health outcomes in a biethnic population in the USA. Diabetologia 1994; 37: 624-31.

20. Dietz W. Critical periods in childhood for the development of obesity. Am J Clin Nutr 1994; 59: 955-9.

21. McKeigue PM, Shah B, Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 1991; 337: 382-386.

22. McKeigue PM, Ferrie JE, Pierpoint T, Marmot MG. Association of early-onset coronary heart disease in South Asian men with glucose intolerance and hyperinsulinemia. Circulation 1993; 87: 152-161.

23. WHO Scientific Group. Cardiovascular disease risk factors: new areas for research. WHO Technical Report Series #841. Geneva, 1994.

24. WHO Study Group. Diet, nutrition and the prevention of chronic diseases: A report of the WHO Study Group on diet, nutrition and prevention of noncommunicable diseases. Nutrition Reviews 1991, 49-291-301.

THE CONTRIBUTION OF URBANIZATION AND LIFESTYLE CHANGES TO CARDIOVASCULAR DISEASES, DIABETES MELLITUS, AND OBESITY IN DEVELOPING COUNTRIES

by Dr A Wielgosz, Head, Division of Cardiology, University of Ottawa

Table 1. Project growth of megacities

	Population in millions
	1992	2000
Tokyo	25.8	28.0
Sao Paulo	19.2	22.6
New York	16.2	16.6
Mexico City	15.3	16.2
Shanghai	14.1	17.4
Bombay	13.3	18.1
Los Angeles	11.9	13.2
Buenos Aires	11.8	12.8
Seoul	11.6	13.0
Beijing	11.4	14.4
Rio de Janeiro	11.3	12.2
Calcutta	11.1	12.7
Jakarta	10.1	13.4
Tianjin	9.8	12.5
Manila	9.6	12.6
Cairo	9.0	10.8
New Delhi	8.8	11.7
Lagos	8.7	13.5
Karachi	8.6	11.9
Bangkok	7.6	9.9
Dacca	7.4	11.5

Urbanization

Most remarkable about the epidemiology of urbanization, is the rate of its occurrence. In 1960 about 30% of the world’s population was urbanized. In four years’ time, it will reach 50%. The fastest rate of urbanization is occurring in Africa, at 10% per year. In the Eastern Mediterranean region the population has doubled over the last two decades and in the 5 year span from 1985 to 1990, urbanization increased from 39% to 44%. It is likely to reach 50% by the turn of the century.

In some, urbanization is proceeding at an unprecedented rate and most of the growth is taking place in developing countries. Of 21 megacities (more than 10 million population) projected for the year 2000, 18 will be found in the developing world, as shown in table 1.

Lifestyle Changes

Along with urbanization come a number of lifestyle changes. Over the course of thousands of years, populations have struggled to achieve a balance between food intake and energy expenditure, for the most part, trying to avoid a caloric deficit. This is true whether the lifestyle was nomadic or settled. In many developing countries, we can still see traditional food sources and food types, that have not changed over the millennia. However, significant changes have occurred in the availability of food, its caloric value, and in energy expenditure.

Table 2. Comparison of American and Rural Chinese Diets

	American	Rural Chinese
Total fat (% of kcal)	38-40	15
Dietary fibre (g/day)	10-12	34
Soluble carbohydrate (g/day)	240	470
Calcium (mg/day)	1140	540
Protein (g/day, 70 kg male)	90-95	64
Animal protein	70	7
Iron (mg/day)	18	34
Thiamin (mg/day)	1.4	2-3
Retinol (RF/day)	990	30
Total carotenoids (RE/day)	429	836
Vitamin C (mg/day)	73	140
Riboflavin (mg/day)	1.9	1.8
Energy Intake (k-cal/day)	2360	2640

One of the significant innovations associated with development and urbanization is mechanized transportation. The consequence of this is a decrease in physical activity. Furthermore, modern food production, processing and storage require less expenditure of human energy, thus contributing to the imbalance between consumption and output. I consider energy expenditure relative to food intake a crucial aspect of nutrition.

Sometimes the lifestyle changes brought on by innovation and development are overlooked because of an overriding “greater good”. Mass education is an example. We take young children and constrain their physical activity in classrooms over the course of 10 or 15 years. Granted, they become educated but at the same time they develop lifestyle habits that diminish their expenditure of energy. Of course, education can and should include physical activity but all too often it is neglected and as children become adults they become accustomed to a lesser degree of activity. Passive entertainment, facilitated by attractive technologies also contributes to a culture of decreased energy expenditure. An increase in salt and sugar intake is associated with modern food production, food storage, processing and marketing. Total fat consumption increases and the balance between saturated and unsaturated fat is altered, while the intake of anti-oxidants is decreased. Table 2 shows a comparison between a typical American diet and a traditional, rural Chinese diet. Perhaps the most striking difference here is the total fat as percent of calories, which is significantly higher in the Western industrialized diet (38% to 40% compared to 15% in the Chinese diet). The “urbanized” Western diet has much less dietary fibre and the intake of total carotenoids and vitamin C are half that of the Chinese diet. Yet interestingly, the energy intake in terms of kilocalories per day is higher among the rural Chinese who appear to burn off more calories than the average American.

Development brings about a change not only in the constituents of nutrition, but also in the culture of eating. Food is marketed with compelling messages to eat. The public is bombarded by advertising that encourages consumption. At the same time lifestyles are changing with less energy expenditure. The consequence is an imbalance in energy intake relative to output. This can only result in obesity and disease.

The poster shown in figure 1, from North Karelia (in Finland) advocates intake of fresh fruits, particularly berries. There is an interesting story behind this poster and behind the public health message. North Karelia until recently had the highest rate of cardiovascular disease mortality among men in the world. Although the initiative for change came from the public, when it became obvious that one of the things that had to change was the diet, many people resisted, complaining that their traditional diet was being tampered with. Anthropologists and sociologists were called in to study the traditional diet. They found that the so-called traditional diet, which had a high content of dairy products and animal fat, was consequence of the Second World War, a form of compensation for hard times, and that the pre-war traditional diet had included a lot of berries rich in vitamin C. Finland is heavily forested and has abundant berries. The public began to respond to the message to get back to heart healthy diets. Many societies in developing countries are distancing themselves from their own heart healthy diets as they become urbanized and industrialized and start to adopt Western ways of eating. It is imperative that those traditional diets at least be documented so that they can be referred to and their continued consumption can be encouraged.

Figure 1

I would be remiss in talking about the consequences of modernization without mentioning the problem of tobacco, its production and marketing. There is no question that tobacco leads to premature death from non-communicable diseases, but it also has other effects, including some that impact on nutrition. Tobacco cultivation results in environmental spoilage and competition for limited resources, occupying up to 70% of the land available for agriculture in some developing countries. In Malawi and Tanzania, there is wide-spread destruction of forests to provide fuel for flue curing of tobacco. Unfortunately, such behaviour is motivated by short-term economic gains. Zimbabwe for example derives most of its foreign exchange from tobacco. No wonder then, that smoking is increasing in the developing world. In Jakarta, Indonesia, the prevalence is as high as 60% among men. This is a serious problem and it is not enough to talk about tobacco control. The objective must be tobacco eradication.

Urbanization and Adaptation

We heard earlier about the famous study of Japanese men who were examined and compared in Japan, Honolulu and California. We know that the prevalence of risk factors as well as the prevalence of coronary heart disease increased across a gradient of change. But I do not think the degree of change refers to the extent of urbanization. I do not believe that California is any more urbanized that Japan or Hawaii. What these findings reflect is the impact of migration and of undergoing a rapid change in lifestyle particularly to one that fosters non-communicable diseases.

The complexity of urban life requires adaptation i.e. survival skills. To succeed both individually and collectively, requires time. Newly urbanized or urbanizing societies have not had time to adapt. While Western societies still have problems of urban living to reckon with, they have had a head start in adapting. Societies in developing countries are much more vulnerable because they have not had the same opportunity to fully adapt and they are urbanizing at an unprecedented faster rate.

The transition to urban life involves changes in social relationships. These include changes in the structure of the family unit and in the roles of its individual members, particularly women. Research in social medicine is pointing out the importance of personal control, control of one’s work and home environments. Social isolation and the lack of social support add to the stress and increase risk of disease and death. Much of the mortality difference within society is explained by the social gradient from rich to poor, advantaged to disadvantaged and educated to uneducated.

While many Western industrialized countries are beginning to enjoy a decline in mortality from cardiovascular diseases, there are indications of an epidemic rise in diabetes, obesity and cardiovascular diseases in the developing world. Over half the deaths caused globally by cardiovascular diseases occur in developing countries. Admittedly in most of these countries there are significant problems with disease surveillance, making the validity of data often suspect. But I fully endorse the comments made earlier this morning, that we need to take the data that we have at hand, allow for best estimates and work with them. When we do that, we see that in 1990 there were about 8 to 9 million cardiovascular deaths the developing world. That represents about 70% more than the 5.3 million death that occurred in the developed world. Cardiovascular deaths in developing countries still represent a much smaller fraction of total mortality (15-30%) than the approximately 50% experienced in developed countries. But that is changing and the contribution of non-communicable diseases to total mortality is expected to rise in the developing world in an epidemic fashion.

Again I come back to the contribution of smoking. Peto and Lopez have estimated that smoking kills about 6 people a minute world-wide: one in the European Union one in the United States, one in other developed countries, one in the former USSR, one in China and one in other developing populations. Taking the former USSR as a rapidly industrializing part of the world and adding China and other developing nations, results in about half the mortality coming from the developing world. That is a significant toll. Unfortunately tobacco consumption is being driven by the forces of development.

Table 3 Barriers to Prevention

competing priorities
technology - based interventions
inadequate epidemiological data
poor presentation of messages to policy-makers and the media
failure to recognize the importance of prevention and cost-effectiveness
anonymity
economic and social constraints
vested interests
lack of community mobilization

The problems I have outlined call for action and in many places a response has begun. But there are barriers to preventive action and I would like to go over some of them, listed in table 3. One is competing priorities. Each developing nation has to determine its own priorities. Donor countries and donor agencies also have competing priorities. The global agenda is full. In the face of multiple requests to help out with a range of problems, often the responses are not proportional to the size of the problem. The need to treat seems more compelling than the need to prevent so we end up with the all too familiar “too little, too late”. Technology based interventions are favoured. They are more glamorous. They are the quick fix and that is why we see such heavy investments in interventions. It is often argued that there is inadequate epidemiologic data and as an epidemiologist I cannot but agree. However, I think there are enough data to support the initiation and implementation of preventive actions.

Another barrier is the poor presentation of messages to policy-makers and the media. We have to talk their language. We have to talk in ways that policy - makers understand and are sensitive to. In that regard, the economic burden of disease provides a compelling argument. The messages have to be clear and consistent. Discordant messages from the scientific community greatly undermine attempts to influence policy. The public can only resist change if they perceive that we ourselves are not even sure whether butter or margarine, both or neither are harmful, or that we keep changing the message. There is an urgent need to develop ethical guidelines on the dissemination of early scientific findings.

Encouraging leadership in the realm of preventive action is beset with barriers. There is often a failure to appreciate the importance of prevention and its cost-effectiveness. The effects are not immediate. Whoever embarks on a career of disease prevention is guaranteed anonymity. It does not bring quick results nor credit for what is done. Consequently, there are not too many heroes in this arena.

Even when the public is informed about heart healthy lifestyle choices, there may be economic and social constraints. Vested economic interests can block availability or impede necessary policy implementation. To effect change, the community must be mobilized. I mentioned North Karelia - there, the initiative came from the people themselves. When the population is mobilized to action, politicians fall in line and start to pay attention.

Who in the developing world is demanding change? Who even recognizes the problems and issues? Prevention of non-communicable diseases starts with education and heightened awareness that a problem exists. For many in all sectors, it is not apparent that a problem even exists, let alone that there are effective strategies available. We heard earlier today about physicians who do not prescribe an appropriate diet for their diabetic patients. Clearly a lot of work needs to be done.

There is a need to place health high on the list of national priorities. This can be achieved in a meaningful way only by a multi-sectorial partnership. The Victoria Declaration on Heart Health emphasizes the importance of a partnership of the community, of its various sectors, both political as well as non-governmental including international organizations and agencies concerned with health and economic development.

Conclusion

I would like to close with a thought about guiding the process of development. Countries in transition have a unique opportunity to profit from innovation and development while avoiding many of its detrimental effects including disability and premature death from non-communicable diseases. This can be achieved only if the lessons learned by already developed nations are made known and brought to the fore as part of the process of aiding development itself. To achieve this requires a code of behaviour that obligates investors and donors as well as recipients. Such guidelines would govern urban planning, introduction of new technologies, implementation of policies - in fact everything that we put under the banner of development.

Suggested Reading

1. World Health Statistics Quarterly. 1993, Vol 46, No 2 (A. Wielgosz, ed)

2. Health Promotion Research: towards a new social epidemiology. WHO Regional Publications. European Series. No 37, 1991 (B. Badura and I. Kickbush, eds)

3. The Victoria Declaration on Heart Health 1992, Health and Welfare Canada.

4. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr. Mortality from Smoking in developed countries 1950-2000. Indirect estimates from national vital statistics. Oxford University Press 1994.