NEWS AND VIEWS

Iron Deficiency and Brain Function

Iron deficiency is the commonest nutritional problem in the world - nearly half the pre-school children and women of child-bearing age in developing countries have some degree of anaemia. Concern has widened in recent years about the effects of iron deficiency on children's behavior and development, as evidence has accumulated showing its probable depression of psychomotor development, attention, learning and school achievement.

A conference on “Iron Deficiency and Brain Function” was organized, under the auspices of the ACC/SCN and UNU, by Drs Ernesto Pollitt (University of California, Davis), Jere Haas and David Levitsky (Cornell University), and held at WHO, Geneva in October 1988. The conference concluded that iron deficiency anaemia probably was causing poor performance in children - adding further urgency to the need for widespread and effective control of iron deficiency.

The conference issued this summary statement -

“Many studies have shown an association between iron deficiency and less than optimal behavior in infants and children, as demonstrated by lower scores on tests of development, learning and school achievement. A problem with interpretation of past studies has been that iron deficiency anemia is associated with other adverse environmental and nutritional conditions. More recent studies using randomized designs with appropriate controls of environmental and nutritional variables have shown that iron therapy in preschool and school-aged children with iron deficiency anemia results in improvements in selective learning and school achievement tests. This evidence in humans and a number of animal studies [therefore] suggests that iron deficiency anemia is causally associated with less than optimal behavior. For this reason and others it is important that iron deficiency anemia be prevented and treated in all children. Since the specific mechanism and functional significance of these behavioral changes are not completely understood, further studies are essential both to clarify the effects of iron deficiency anemia itself and to determine the importance of lesser degrees of iron deficiency in children.”

Nutrition and AIDS

Possible connections between nutritional status and AIDS - either the initiation of the disease or its rates of progression - were reviewed at a symposium on Nutrition and AIDS at the ACC/SCN 14th Session at the World Health Organization in Geneva, from February 22 to 26, 1988.

It was noted that in the individual, malnutrition is a result of AIDS since progressive wasting is a common marker of progress of the disease. Discussion on the implications of the epidemic explosion at all levels, from households to national structures and infrastructures, focused mainly on two questions:

1. Does nutritional status or nutritional intervention influence the course of AIDS?

2. Are there indications that the spread of AIDS will lead to nutritional problems through reductions in supplies and services?

The development of the disease in persons already infected will reach alarming proportions within the next 10 years, regardless of any action now taken.

Unless the development and spread of the disease can be controlled, there is a real probability within the next decade of a major loss of population among young adults, the most productive age group, leading to severe disruption of family support infrastructures and of the production, distribution and support sectors in at least some countries.

At the level of individual families where one or more breadwinners are affected the long term availability of food might be impaired and local support for the sufferers' families might be needed. This might in some cases involve some type of food supplementation.

As the AIDS epidemic increases in adult populations where the transmission pattern is heterosexual there is an associated increase in HIV infection in newborn infants through the placenta during pregnancy or through blood at delivery. Current figures suggest a high fatality rate during the first two years. This cause of death is likely to show very soon in the national vital statistics data. In more seriously affected countries it may even wipe out the gains achieved during the past two decades in combating infant, young child and maternal mortality. Among other practical issues, in those countries where the prevalence of AIDS is high, there will have to be changes in interpreting low weight and high mortality as nutritional indicators in children.

Individual countries may react to this increasingly serious situation in several ways. For example, in labour-intensive agrarian societies, agricultural production may fall because of reduced manpower.

There might have to be a compensatory increase in agricultural mechanization. The health system will be faced with major increases in calls for services - calls which would have to be met with reduced manpower and disrupted infrastructures. Any of these would have major implications for food, nutrition and health planning. They could also badly affect both future needs for capital funding and debt repayment capabilities.

No plan as yet exists for avoiding these possible scenarios of the near future, but although there is growing evidence of major under-reporting of both the incidence and prevalence of the disease in many countries, enough epidemiologic data exist to give an early warning. National and international actions attempting to compensate for the effects of AIDS as they begin to develop can be implemented only if governments and UN agencies vigorously monitor the epidemiology of AIDS and the effects of the epidemic.

(Source: Zelda Craig, from documents at ACC/SCN 14th Session.)

From WHO

· Malnutrition is not intractable. Access by all to primary health care and, through it, to all levels of a comprehensive health system, together with minimum social and environmental conditions such as adequate housing, literacy, education and other social services, could reduce malnutrition due to deficiency by half and virtually wipe out malnutrition due to excess.

· If primary health care is taken seriously, it is realistic to expect that, by the year 2000:

- at least 90% of newborn infants will have a birth weight of at least 2500 g;

- underweight infants and young children will no longer be a problem of public health significance in any region of the world and stunted growth will show sharply declining trends;

- disorders due to deficiency of vitamin A or iodine will no longer be problems of public health significance in any region of the world, and effective means to combat nutritional anaemia will have been developed;

- noncommunicable diseases for which diet is a major risk factor will show declining trends in all countries where they present problems of public health significance.

(Source: In Point of Fact, WHO, No. 58/1988, Based on WHO Mid-Term Programme. Joint Committee on Health Policy.)

In a statement made by the Executive Director of the World Food Council, Gerald I. Trant (in the meeting of WFC Members on the Cyprus Initiative against Hunger in the World, held in New York on 19 October 1988), the initiative was called “a practical expression of the commitment made by Council members to act together in their united strength to rid the world of the scourge of hunger and malnutrition”.

WFC are greatly concerned that present and future member governments of the Council make specific commitments under the Cyprus Initiative, which seeks to reinforce political determination and mobilize the action required to reverse the unwelcome prospect of increasing hunger and poverty. Council members noted the need for a critical assessment of past experience, for direction to ensure more effective policies in the future based on lessons learned, and for new initiatives designed to promote a cooperative course of action to combat hunger.

The initiative should seek to stimulate and reinforce efforts to improve information on the dynamics of the forces causing hunger. He emphasized that it must be a sustained effort over several years with a phased approach to implementation.

The Executive Director of WFC invited the developing country member governments to put forward specific proposals that they would undertake, and which could be supported by developed country members with international agencies and NGOs. He urged cooperative action in a small number of countries in developing regions, within the framework of the Cyprus Initiative.

(Source: Meeting of World Food Council Members, UN, New York, 19 October 1988.)

The following article by Alan Berg was published in The New York Times, 3 September 1988.

“Dazzling advances in research and ever-increasing harvests in many developing countries have not been able to protect the world's poor from malnutrition. But a simple rethinking of the ways governments give food assistance may achieve what high tech has not.

Such rethinking is now under way in some of the neediest and most debt-distressed countries. The best of their new food programs show that it is possible to reduce malnutrition substantially, quickly and affordably - without fostering dependence on welfare. The key is to target food programs to those in need. Obvious? Yes, but too many programs have squandered benefits on those who do not require special attention.

Until recently, Brazil's annual $1 billion wheat subsidy was available to the rich and poor alike. In a number of African countries, subsidies go to foods like meat and butter, which are out of the reach of the poor even with the subsidy - and the poor continue to go hungry.

An income test would seem the most sensible approach to deciding who gets benefits, but it is often unworkable. Even in the United States, where income reporting is systematized, the food stamp program has been jeopardized by charges of abuse. In the developing world, where income is less documented and often takes the form of food a family grows for itself, determining eligibility by income is next to impossible.

Some countries have found creative, alternative ways to reach the neediest. They target programs by place, type of food, age and signs of faltering growth in children, or even by season. In sub-Saharan Africa, for instance, several countries are beginning to concentrate food resources in scarce months, before the harvest, when malnutrition is most severe.

Thailand and Brazil now focus on regions where malnutrition is concentrated, in the northeast of both countries. Several Brazilian states have gone further. They target the favelas, the very poor neighbourhoods, by subsidizing basic foods for customers of small stores. Because better-off Brazilians prefer not to journey into favelas, even for lower prices, the benefits go to those who need them. In Colombia, poverty is scattered throughout the country. So the Government ranked each county accordingly to poverty criteria such as infant mortality and access to health care. Food coupons were distributed to the needy in the 30 percent of counties ranking the lowest in these categories.

Some countries target by subsidizing foods consumed primarily by the poor. In Bangladesh, rice is the preferred grain for those with money; thus, a subsidy on sorghum, which is nutritionally splendid, benefitted only those too poor to buy rice. Morocco, which is restructuring its subsidies to emphasize foods eaten by the poor, expects to give the poor greater nutritional benefits for one-fifth the former cost. This year, Mexico established a similar but even larger program than Morocco's, dismantling many of its generalized subsidies.

Tamil Nadu, a state in India, targets a food and nutritional education program in the poorest areas for those at greatest risk. Nutrition workers in 9,000 villages weigh children monthly and provide daily feedings for 90 days to those whose growth is faltering. At the same time, they teach mothers of underweight children how to improve nutrition at home within their means. High-risk pregnant and breast-feeding women also receive food.

The benefit of the Tamil Nadu project has been dramatic and enduring. Serious malnutrition has declined by about 50 percent. Two years after children complete the program they are, on average, a significant four pounds heavier than children who did not participate. Sri Lanka is now developing a similar program.

What makes all of these targeted programs so attractive is that they are cost-effective. Food stamps and other broad subsidies often eat up 10 to 20 percent of national budgets. But the new programs get better results as projected costs are much lower than in conventional approaches. Because these programs provide food only when or where it is most needed, they are less likely to foster a welfare mentality.

None of this is to suggest that alleviating the underlying causes of poverty should not remain the most important goal. Education, jobs and access to land are all sorely needed. But the poorest cannot wait. A direct attack on malnutrition is needed as well, and governments willing to make that effort now have effective and affordable measures to make it happen.”

Seasonal Effects on Dietary Energy Balance

Research results from developing countries on seasonal variation in body weight and energy balance were discussed at an international workshop on the Biology of Adaptation to Seasonal Cycling of Energy Balance, held at the National Institute of Nutrition, Rome, 27-28 October 1988. This workshop was sponsored by the Italian Ministry of Foreign Affairs. Results of research studies, financed by the EEC and carried out in India, Benin and Ethiopia, in collaboration with the Universities of Wageningen and Glasgow, were presented. Methods used included measurement of energy intakes and expenditure, and topics such as the process of adaptation to low energy intakes, and energy adaptation in the Third World countries, were examined. The workshop report contains the materials presented and the discussions that followed. Further information can be obtained from: Human Nutrition Unit, National Institute of Nutrition, via Ardeatina, 546, 00179 Rome, Italy.

Rickets Workshop

Rickets was the subject of the 21st Nestle Nutrition Workshop held in Buenos Aires, Argentina from 5-8 December 1988. During the course of this workshop, over 20 papers were presented and discussed. The Workshop's scientific programme included physiology and biochemistry of vitamin D and parathyroid hormone, calcium and phosphorus homeostasis, histophysiology of bone growth plates, the process of mineralization, and placental transfer of vitamin D and minerals. Various types of rickets, particularly those found in premature infants, were also discussed. In addition, rickets epidemiology and prevention were given special consideration. The question of rickets as a public health problem was investigated through surveys conducted in Algeria, China, France, India, Libya, Northern Europe, Saudi Arabia and South America. More information on the workshop can be obtained from: Prof. D. R. Fraser, Department of Animal Husbandry, University of Sydney, NSW 2006, Australia.

IUNS - International Nutrition Congress and Workshops

The 14th International Congress of Nutrition, hosted by the Korean Nutrition Society and sponsored by the IUNS, will be held in Seoul, Korea from 20-25 August 1989. The Congress through invited papers, plenary and poster sessions, and workshops, covers a very wide range of items related to food and nutrition.

Symposia will be held within the following subjects: Metabolism, Nutrition Integrated to Basic Sciences, Clinical Nutrition, Nutrition and the Life Cycle, Nutrition Planning and Policy, Nutrition and Culture, Animal Nutrition, Methods in Nutrition Research, Food Science and Technology and Regional Issues. Workshops will be held on a range of topics. The SCN is organizing one of these on “Managing Successful Nutrition Programmes”. Further details from: Secretariat/The 14th International Congress of Nutrition, c/o Dept. of Food and Nutrition, Ewha Womans University, 11-1 Daehyun-dong, Suhdaemun-ku, Seoul, 120-750, Korea. Phone: 082-02-363-4441, Telex: BTCICCS K26666, Fax: 02-393-5903.

Nutrition Policy in Europe

A Conference on Nutrition Policy in the European Region is planned for 1-6 October 1990, in Budapest, Hungary, organized by the Nutrition Unit, WHO Regional Office for Europe.

The Conference will have five main themes: a) how to set policy objectives - from nutrients to food supply; b) what did and do people eat? - elements of a nutrition information system; c) the scientific basis for nutritional recommendations, how they are set and how dietary guidelines are formulated in line with these; d) different models for organizational requirements; and e) measures for implementation such as agricultural policies, price interventions, mass catering, nutrition information, and new food technologies.

The Conference will include case studies of different countries' experiences, practical work on approaches to designing and implementing nutrition policy, and an exchange of views between of farmers, food industry retailers, consumers, nutrition scientists and economists. Further information can be obtained from Elizabet Helsing, Nutrition Unit, WHO Regional Office for Europe, 8, Scherfigsvej, 2100 Copenhagen 0, Denmark.

Nutrition Month in the Philippines

The need to integrate the nutrition effort in the overall development programme of the Philippines was strongly emphasized by observing July 1988 as Nutrition Month in the country. The month-long celebration was highlighted by symposia, exhibitions, project launching and various promotional activities of key agencies aimed at broadening public awareness and involvement in nutrition work. “Nutrition problems”, said the Chairman of the National Nutrition Centre “cannot be solved from the perspective of nutritionists and food experts alone... it requires the combined efforts of all sectors and all levels of society.”

(Source: Nutrition Centre of the Philippines (NCP) Bulletin, July/September 1988.)

The Human Nutrition Planning Centre of the Department of Public Health in Zaire has developed a Nutrition Data Bank which collects published data in the area of nutrition. Dr Mayambu, the Director of the Centre, can be contacted for further information: Centre National de Planification de Nutrition Humaine, Dept. de la Santé Publique, 35 Av. du Comité Urbain, Gombe BP 2429, Kinshasa, République du Zaire.

WHO Collaborating Centre for Nutrition

The Human Nutrition Unit of the National Institute of Nutrition in Rome has been designated as a WHO Collaborating Centre for Nutrition. The Centre will have the responsibility for national advocacy and analysis of nutrition policy formulation. It will serve as a reference centre for research for prevention and control of malnutrition in developing countries, and will be a focal point for research on nutritional aspects of aging. WHO Collaborating Centres form part of an inter-institutional collaborative network in order to support regional or global resources in terms of information, services, research and training with regard to health development. Contact: Prof. A Ferro-Luzzi, Human Nutrition Unit, National Institute of Nutrition, via Ardeatina, 546, 00179 Rome, Italy.

Nutritional Status of Somali Refugees, September 1988 - March 1989

Reported by Save the Children Fund, UK

During the summer of 1988, several hundred thousand Somali refugees entered remote areas of eastern Ethiopia from areas of northern Somalia affected by civil disturbance. They were settled in three camps, at Harshin, Hartisheik, and Aware.

The first survey of child nutritional status at Hartisheik, the largest camp, was carried out in early September 1988, when the population was estimated at 100,000 persons. A random cluster survey of 36 clusters totaling 1080 children under 110 cm in height found 13.5% to be below 80% of the median weight-for-height (Wt/Ht) of the World Health Organization (WHO) reference population - about equivalent to moderate malnutrition. The proportion below 70% of median Wt/Ht (roughly, severely malnourished) was 1.8%. Six weeks later, a similar survey found proportions of 21.7% and 2.2% below 80% and below 70% of the WHO reference population Wt/Ht median, respectively; this 8% increase in moderate malnutrition was statistically significant. A third survey, carried out in January 1989, found 16.9% of children below 80% of the reference population Wt/Ht median. During that survey, only 40% of children identified as either moderately or severely malnourished were registered in supplementary feeding programs. In the latest survey, in mid-March, 26.4% of children were below 80% and 4.3% below 70% of the reference value - the highest malnutrition prevalence so far. Results of surveys are shown in the Table

Since January 1989, several hundred cases of scurvy have been reported. In addition, cases of hepatitis have been documented. Mortality data were not available during this September-March interval. The nutritional status of children at Harshin was similar to that at Hartisheik, with 12.5% of surveyed children below the 80% of median Wt/Ht cutoff. During the period between the September and January surveys, delivery of various ration components to Hartisheik had been inconsistent, with corresponding deficits in food availability. For example, lentils had not been available for any regular food distributions. Oil had been unavailable during much of this interval. Cereals were the only consistent source of calories. These quantitative ration delivery problems slowly improved by year's end, although further interruptions of food delivery ocurred in February and March 1989, a time during which child malnutrition rates increased at Hartisheik.

These data describe the occurrence of important nutritional problems among a large group of refugees in Africa. The malnutrition prevalence rates reported here compare adversely with those reported among refugee populations in Malawi and Thailand, and are more comparable with those reported in Somalia and Sudan. High mortality rates were reported among the refugee populations in the latter two countries. Children with weight-for-height measurements below 80% of the WHO reference population median have been shown elsewhere to be at increased mortality risk.

Scurvy among refugee populations has been reported several times in recent years in the Horn of Africa, at least in part because, as in this situation, rations provided to refugees often fail to provide the minimum requirements of 6 mg/day of vitamin C. There are logistic problems in delivering large quantities of vitamin C-containing foods (such as fresh vegetables and fruit) to refugees in remote regions of Africa; however, enrichment of cereals with vitamin C by donors is a potential solution. Similar factors were felt to be contributing to malnutrition in both surveyed camps.

Recommendations to improve nutritional intervention and assessment included regular and full ration distribution, inclusion of foods containing vitamin C in the ration, an expanded system of supplementary and therapeutic feeding programs with improved outreach to achieve better coverage of malnourished children, expanded collection of direct mortality data, and continued monitoring of children's nutritional status. In addition, based on experience in coping with past disasters and refugee crises, the Ethiopian Ministry of Health has recently published a revised set of health relief management guidelines which set out principles for the management of relief programs and other assistance provided to refugees and disaster-affected populations.

Nutritional Status of Random Cluster Samples of Somali Refugee Children < 110 cm, Hartisheik and Harshin, Ethiopia, September 1988 - March 1989

Camp	Date	Children Surveyed	Prevalence <80% Wt/Ht	Prevalance Proportion <70% Wt/Ht
Hartisheik	Sept. 1988	1080	13.5%	1.8%
Hartisheik	Nov. 1988	1350	21.7%	2.2%
Hartisheik	Jan. 1989	1350	16.9%	2.3%
Hartisheik	Mar. 1989	1350	26.4%	4.3%
Harshin	Jan. 1989	1350	12.5%	1.8%

Percentage of Sampled Children < 5 Years of Age with Moderate or Severe Malnutrition in Recent Refugee Populations

Country and Camp (date)		< 80% weight-for-height
Ethiopia (March 1989)
	Hartisheik (n = 1350)	26.4%
Malawi (June 1988)
	Nsanje (n = 575)	6%
Thailand (November 1979)
	Sakeo	18%
	Khao-I-Dang	5%
Somalia (May 1980)
	Sabacad	35%
	Amalow	24%
	Malke Hiday	26%
Sudan (January 1985)
	Wad Sherife	52%
	Wad Kowli	32%

Letters

Andrew Schachtel, a Nutrition Worker, Directorate of Health Services, Thimphu, Bhutan writes:

“Would it be possible for future issues of the SCN News to include:

1. The safety of iodized oil injections for pregnant women;

2. The value of oral iodized oil in the prevention of iodine deficiency;

3. A list of courses in nutrition being offered worldwide to nurses, paramedical workers, and doctors from less developed countries;

4. Results of national nutrition surveys performed by various countries, in tabular form, especially listing percentage of children under 5 years with Wt-for-ht, Ht-for-age, < 2SDs below reference median, etc.?”

1. The use of iodized oil (injected or oral) in pregnancy for correction of iodine deficiency and prevention of iodine deficiency disorders (IDD)

Many tens of millions of iodized oil injections (and more recently oral iodized oil) have been given over the past forty years for the prevention and treatment of iodine deficiency disorders particularly as an interim or rapid approach in moderate or severely iodine deficient areas. Experience has been on a global scale - i.e. in American, African, South East Asian and Western Pacific Regions of the world. The priority target group for use of iodized oil is primarily women of child bearing age including those who are pregnant (especially first trimester) followed by children 0-5 years, older children, and finally adult men 16-45 years. With all this vast experience there appears to be no scientifically sound evidence of any significant or enduring harmful effects of iodized oil when administered at any stage of pregnancy in either injected or oral forms. Indeed it has been clearly and repeatedly demonstrated in severely iodine deficient areas (e.g. Indonesia, Nepal) that iodized oil in pregnancy increases survival, birth weight and development quotient of the offspring and eliminates cretinism. Pregnant women should specifically be included in any such prophylatic programme.

2. The value of oral iodized oil in the prevention of iodine deficiency

While much less is known about the use of oral iodized oil in terms of its metabolism, absorption and duration of action when compared with injected iodized oil, widespread use has been reported and now seems quite common in many parts of the world. The advantages that have become apparent in using iodized oil capsules include ease of administration including less cost, less training, fewer instruments, less time required, and avoidance of certain hazards such as injections and improper disposal of needles. It can be easily included as a basic activity in primary health care systems in remote areas. Based on current studies it appears that the effect of oral dosing lasts about half as long (i.e. 12-18 months) as the same dose by injection. A suggested schedule for both oral and injected iodized oil is shown opposite.

3. Courses in nutrition

A list of institutions offering courses in nutrition is available from Dr D. Benbouzid, Nutrition Unit, Division of Family Health, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.

Proposed dosage schedule for iodine supplementation using iodinated oil

4. Results of national nutrition surveys

The SCN's Supplement on Methods and Statistics (ACC/SCN, December 1988) to the First Report on the World Nutrition Situation contains national nutrition survey data in tabular form. This is available upon request from the SCN.

WHO's Nutrition Unit has available Global Nutritional Status: Anthropometric Indicators, (1987), (Ref: NUT/ANTREF/3/87, Geneva) which gives such national data in a standard form (i.e. prevalence less than -2SD for Wt-for-ht, Ht-for-age, Wt-for-age by graphic and administrative regions, and sex). The format is shown in SCN News, No. 1, page 11. The Nutrition Unit is in the process of updating this report with several more survey reports as well as expanded presentation using other cut-off points and mean SD sources to express distributions of anthropometric indicators in different population groups. More information can be obtained from the Nutrition Unit, Division of Family Health, WHO, Geneva.

***

Dr H. A. B. Parpia, Co-Chairman of Development Councils for Food Processing Industries, Mysore, India writes:

“There can be no nutrition without elimination of poverty and increasing supplies of food. The development of an agro-food system and particularly post-harvest technology development in the Third World countries bring about the much needed socio-economic transformation through:

1. Preventing 30-40% losses of durable foods and 40-50% losses of perishable foods at pre- and post-harvest levels. This will increase food supplies without bringing more land into cultivation and destroying ecology;

2. Generate largest employment per dollar invested and prevent migration of people to urban areas which is resulting in disastrous consequences to environment, health, nutrition and habitat;

3. Ensure better quality food for the people by preventing deterioration of nutrients and contamination;

4. Convert subsistence agricultural economies to more balanced economies and stimulate crop production as better markets would be available at post-harvest levels;

5. Integrate culture through food and create better understanding among people, even nutritionists and food scientists;

6. Provide better political and social stability and create more purposeful links between the economies of rural and urban areas; and

7. Help nations improve balance of trade by export of value-added processed foods.