PUBLICATIONS

Healthy Nutrition
Facts for Life
Feeding the Child
Hunger and Society

Healthy Nutrition

Preventing nutrition-related diseases in Europe

by W. P. T. James in collaboration with A. Ferro-Luzzi, B. Isaksson and W. B. Szostak.

WHO Regional Publications, European Series, No. 24 (paperback) 150 p, SFr. 20. *

* The WHO - Collaborating Centre for Nutrition in Rome has recently undertaken the translation in Italian of the book. Five thousand copies are planned for distribution to family doctors as one of the components of a coherent Italian food and nutrition policy.

In general, dietary patterns in Mediterranean countries are found to be more conducive to good health than those in northern Europe. In their traditional pattern of foods, the ratio of energy derived from vegetable as compared to animal sources is relatively high. There is now however evidence of growing adverse change, both in the Mediterranean and eastern Europe.

Obesity and hypertension are highlighted as conditions predisposing to major health problems. A strategy for preventing obesity would include a reduction in the total fat and sucrose content of the diet. This could be compensated for by an increase in the consumption of cereals, roots, vegetables and fruit. In this way, the energy density of the diet decreases as nutrient density increases. Vitamin and mineral intakes also rise, minimizing problems such as iron deficiency anaemia and goitre, increased fibre intakes reduce the likelihood of constipation and diverticular disease and dental caries would become less common as the sugar content falls.

In any one country, cultural factors and availability will determine the types of cereals, fruits or vegetables consumed. Significant dietary changes however may necessitate an alteration in manufacturing practices to produce foods with a higher nutritional value. One example is salt, high intakes of which are associated with the development of hypertension. Reducing the use of salt at the table would have a small effect compared to a reduction in levels added during manufacturing.

Substantial dietary changes can occur within short periods. The introduction of subsidies on fat-enriched foods in Sweden and a national nutrition policy in Norway were respectively associated with significant increases and decreases in total fat consumption. However, just as it is not possible to prove that dietary factors are the sole causes of the disease conditions mentioned, secular changes in diet composition can not be solely attributed to policy initiatives.

A country's dietary goals should be consistent with the ability of its agricultural industry to adapt. The example of Scandinavian countries is cited, where in order to attain the goal of reducing the proportion of energy intake from saturated fatty acids to 10%, drastic changes in the breeds of farm animals would be needed, as well as the adoption of vegetarianism by a large number of people. Clearly then intermediate as well as ultimate goals are needed, and these are set out for several dietary components. Different conditions obtaining in different countries prevent agencies like WHO from producing a universally applicable model for achieving such goals. They can however identify common themes in recommendations thus facilitating a clearer policy formulation.

Food balance sheets, as produced by FAO, can be used to assess the sources of certain dietary components, enabling adjustments in policy, and consequently food and agricultural practices. Whereas, for example, the major proportion of saturated fats in Great Britain is derived from dairy products, the position is very different in Italy where olive oil consumption is particularly high. The introduction of low-fat dairy products in countries such as Great Britain is one possible means of achieving intermediate goals, although this could increase butter surpluses.

The book is concise and well-illustrated with graphics and a series of bar-charts illustrating international differences in dietary and disease patterns and their associations. It should serve as an accessible and informative sourcebook for policy-makers, nutritionists and health professionals as well as providing an interesting read for the increasingly health-conscious general public in Europe.

- S.G.

Facts for Life

A Communication Challenge

published by UNICEF, WHO and UNESCO

Almost certainly there will be debate about particular facts that are omitted or that should be modified. For example, in relation to nutrition, there is no mention that the nursing mother needs extra food. The omission is particularly apparent in the advice on maintaining adequate growth. Here it is not enough to say that breastfeeding is best, since growth can falter in the first months of life, even though the mother is breastfeeding. In this case breastfeeding frequency must be increased and the mother, herself, must eat and drink more. Likewise, the section on child growth (most of the messages are on child feeding), omits mention of the consistency of young children's food. We have found in our work that almost universally, young children's food is too watery and that just by reducing the dilution of the gruel, energy density can be increased substantially.

The critical issue with Facts for Life however, is how it will be used. It should be considered the standard against which health authorities in each country examine current practices in their own institutions and populations to arrive at their own "facts", and to adapt the ideal to the real situation. Several of the specifics, for example, how to improve the daily food intake of a young child, the recipe for ORS or maternal risk factors, will need to be adjusted locally. Likewise, school teachers, scout leaders, etc. must adapt the book not only to the health realities in their area but also in their programmes. How to do this is not evident in Facts for Life or its companion book, All for Health.

In putting the "facts" to use, it will be important to remember that the acquisition of knowledge alone, while essential and in a certain sense "liberating" to parents, is insufficient. Adapting the "facts" to local conditions in one step. The second is to motivate families to act on them. The users of Facts of Life should be urged to investigate barriers - those of culture, finance, logistics, and time - and to demonstrate how parents can overcome these barriers in order to act on advice given. For example, generally women know that breastfeeding is best, but they seldom breast-feed their children exclusively for four to six months. A woman's confidence in her ability to breast-feed is a critical factor, but is that changed just with information? Likewise, many people know that they should boil water, wash their hands, and keep utensils clean, but does that mean they follow what they know? Usually not. These facts need careful crafting to turn them to meaningful messages.

As the introduction to Facts for Life states, the book is "a starting point for discussion" and for that it is excellent. It is our job to use these facts and our own expertise to shepherd this discussion along a path that will lead to relevant, sustainable communications programmes in each of the ten areas touched in the book. This will ensure that the technical information ultimately will reach those who can benefit from these labours, the parents of the world's young children.

Marcia Griffiths
President, the Manoff Group Inc.

To obtain a copy contact: UNICEF, DIPA, Facts for Life Unit, 3 U. N. Plaza, New York, NY 10017, USA.

Register of Development Activities of the United Nations System 1987, Compiled by the Advisory Committee for the Co-ordination of Information Systems (ACCIS). 752 pages.

The Register of Development Activities of the United Nations System 1987, is an enormous volume of 752 pages providing descriptive and financial information on over 20,000 social and economic development activities. The register provides a comprehensive information source of the activities of the United Nations, its specialized agencies, and the International Atomic Energy Agency.

The Advisory Committee for the Co-ordination of Information Systems (ACCIS) was established in 1983 and as part of its mandate, was requested to prepare an annual register of all development activities within the United Nations system. The time-consuming and labour-intensive task of compiling the information was complicated by the diverse programming and reporting systems of the U. N. agencies. Among the U. N. agencies, there is considerable variation in methods of identifying, formulating and approving projects, reporting on expenditures and classifying countries and areas by region. Nevertheless, ACCIS has done an outstanding job of compiling the data and producing a valuable source of information on the U. N. system's activities.

The Register, which includes all development activities current during the 1987 calendar year, is divided into four basic sections: 1) activities executed in individual countries/areas, 2) regional activities, 3) inter-regional activities, and 4) global activities. Within each section, activities have been assigned to 16 sectors according to the ACC Programme Classification. The sectors include agriculture, natural resources, population, health, education, industry, and humanitarian aid and relief. For each activity information is provided on: reporting organization, activity identifier, project title, funding source, type of activity, executing agencies, project years, and expenditure data.

The database management system used for the Register database was UNESCO's CDS/ISIS (Mini-micro Version 2). ACCIS can provide the data from the register on 5 1/4 inch diskettes in a format which can be used by a number of different software packages including dBASE III+. In addition to the information found in the Registry, the database contains more detailed expenditure data and descriptors for each activity which reflect the subject content of the activity title.

The 1988 register of development activities is now being finalized and will be available in early 1990. The 1987 Register costs $30 US and can be obtained from United Nations Sales Sections in Geneva and New York or by contacting ACCIS Address: ACCIS Secretariat, Palais des Nations, 1211 Geneva 10, Switzerland

ACC/SCN Secretariat has benefitted from the ACCIS database, for assessing flows of external resources relevant to nutrition. With additional data on multilateral loans and bilateral loans and grants we are assessing the overall flows. A report is planned for 1990, and some results will be given in future issues of SCN News.

Paula Yoon

Protecting, Promoting and Supporting Breast-feeding

A Joint WHO/UNICEF Statement on Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, has been published by the World Health Organization, Geneva in 1989. This statement has been prepared to increase awareness of the critical role that health services play in promoting breastfeeding, and to describe what should be done to provide mothers with appropriate information and support. It is intended for use, after adaptation to suit local circumstances, by policy-makers and managers as well as by clinicians, midwives and nursing personnel. It outlines practical steps that can be taken to promote and to facilitate the initiation and establishment of breastfeeding (see box).

Ten Steps to Successful Breast-feeding Every facility providing maternity services and care for new-born infants should: 1. Have a written breast-feeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breast-feeding. 4. Help mothers initiate breast-feeding within a half-hour of birth. 5. Show mothers how to breast-feed, and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming-in - allow mothers and infants to remain together - 24 hours a day. 8. Encourage breast-feeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breast-feeding infants. 10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.

Copies may be obtained (at SF6 each) from Distribution and Sales Services of the WHO, Geneva or through local authorized sales agents.

- M.L.

Feeding the Child

by Ruth K. Oniang'o and others (Kenya)

The second part of the book is devoted to presenting a collection of locally available foodstuffs as well as giving information on their preparation and use. In the authors' view, lack of food is only rarely the most important problem in Kenya. It is, however, necessary to know how to prepare nutritious meals for children, using local ingredients. It is for this reason that part three of the book contains a whole set of recipes for weaning dishes. These recipes - developed as part of a research project - according to the authors, were collected from different parts of the country and were carefully tested, standardized and in some cases improved to give a nutritiously balanced meal suitable for child feeding.

This easy-to-read and extensively illustrated book is written by Dr. Ruth K. Oniang'o, a senior lecturer in the Kenyatta University, with contributions from Prof. N. O. Bwibo, Dr. I. O. Ndombi and Dr. K. O. Rogo from the University of Nairobi. It is published by the Heinemann Kenya Ltd. (1988). Copies from: Heinemann Kenya Ltd, Kijabe Street, P.O. Box 45314, Nairobi, Kenya.

- M.L.

Improving Young Child Feeding During Diarrhea

A Guide for investigators and Programme Managers, by M. Griffiths, E. Piwoz, M. Favin and J. Del Rosso, June 1988.

Flowers need water

Diarrhoea takes away water from the body. Like a flower without water, the body droops.

Unlike a flower the child's body also needs salt. Sugar is required to help the body to absorb the salt and water.

(Source: Reproduced from 'My Name is Today' (1986), Fig. 138, D. Morley & H. Lovel, TALC, P.O. Box 49, St. Albans, Herts. AL1 4AX, U.K.)

The manual is available from the following address:

Manoff International, 2001 S Street, NW, Washington, D.C. 20009-1125, USA. Tel: 202-265 7469.

- M.L.

Breastfeeding: A Preventive and Treatment Necessity for Diarrhoea

By Sandra L. Huffman and Cheryl Combest - Centre to Prevent Childhood Malnutrition, 1988, 27p.

A dose-response relationship of breastfeeding with mortality from diarrhoea was evident in the Brazil study, where each additional daily breastfeed was associated with a reduction in the risk of death due to diarrhoea. The authors conclude that "few other interventions have been shown to be as effective as breastfeeding". Breastfeeding through its role in preventing malnutrition may exert an additional independent effect on the severity of diarrheal morbidity. Numerous studies have been quoted to show that continued breastfeeding during diarrhoea also reduces the risk of dehydration, as well as the negative nutritional consequences of diarrhea. It has also been shown to be effective in treating protracted diarrhoea. All such data point to the need to extend the duration of exclusive breastfeeding to at least 4-6 months.

The authors believe that "while many Diarrheal Disease Control Programmes and some Child Survival Programmes have included breastfeeding promotion in their campaigns, much more needs to be done to take advantage of potential benefits of breastfeeding in reducing diarrhea-related morbidity and mortality among young children".

Guidelines are given to ensure successful breastfeeding and actions are proposed for enhancing programme effectiveness in reducing diarrhoea. The authors emphasize that because breastfeeding promotion activities are feasible and cost effective, they need to be considered an integral part of programmes for child survival.

Copies of this paper, at US$3.75 each plus postage, are available from:

The Centre to Prevent Child Malnutrition, Department of International Health, The Johns Hopkins University, Suite 204, 7200 Wisconsin Avenue, Bethesda, MD. 20814, USA.

- M.L.

Iron Deficiency and Behavioural Development

A recent supplement to the American Journal of Clinical Nutrition, Vol. 50, No. 3 (September 1989) comprises the proceedings of a conference held in Geneva, October 10-12, 1988, on the subject of iron deficiency and behavioural development (see SCN News No. 3, p13-14). The conference was co-sponsored by the ACC/SCN, UNU, INACG and WHO.

Improving Young Child Feeding in Eastern and Southern Africa

Household-Level Food Technology Proceedings of a workshop held in Nairobi, Kenya, 12-16 October 1987

Hunger and Society

Edited by Latham, M. C., Bondestam, L., Chorlton, R. and Jonsson, U.

Vol. 2: An Examination of Country Cases

Vol. 3: Causes and Strategies in Tanzania

Cornell International Nutrition Monograph Series Nos. 17-19. Ithaca, N.Y., USA: Division of Nutritional Sciences, College of Agriculture and Life Sciences, Cornell University, 1988. US $3 per volume.

The papers in these three volumes were originally presented at a workshop sponsored jointly by UNICEF and the Tanzanian Food and Nutrition Centre (TFNC) and held in Iringa, Tanzania in December 1983. This followed the circulation to a number of scholars worldwide of a conceptual framework on hunger and society, by Dr Jonsson of UNICEF (Dar es Salaam).

In the first volume, a theoretical analysis of the underlying causes of hunger and malnutrition in society is undertaken. The first chapter comprises a critique of contemporary schools of thought in development theory with regard to their relative implications for the problem of hunger, and includes a basic characterization of four such theoretical traditions, termed here: the Growth and Modernization School, the Dependency School, the Global Political Economy School and the Another Development School. Subsequent papers focus on the ideological bases for nutrition planning, the type of indicators for measuring nutritional impact of development projects, the effects of bilateral and multilateral aid organizations on food and nutrition, and the concept of food as a human right.

Country-case studies examining the nutritional and welfare effects of different types of development policy are developed in the second volume. Papers concern the relationship between transnational capital, food dependency and nutrition in the Caribbean; 'free-market' politics and nutrition in Chile; export-oriented industrialization and welfare in Sri Lanka; and hunger and famine in Ethiopia in the 1960's and 1970s.

The causes of hunger and the strategies - both attempted and potential - for alleviating it in Tanzania are examined in the final volume. As well as an evaluation of the work of the pioneering Tanzanian Food and Nutrition Centre, problems of the environment and women's lack of resource control, are investigated. Subsequent chapters focus on the causes and responses to urban food shortages, the use of social indicators in nutritional surveillance, and the making of a nutrition programme.

The underlying causes of hunger in Africa are largely identified as being embedded in the continent's historical development through colonialism and the policies of industrialized countries, multinational development agencies and corporations. Despite the delay in publication, many of the arguments remain relevant and challenging, although a more balanced critique might have included an examination of one or two countries in which development policies have had positive welfare and nutritional impacts.

The various deliberations of the workshop participants concerning the causes and solutions of malnutrition are brought together in the 'Declaration of Wanging'ombe'. In brief, in order to achieve progress in nutrition and health, these conclusions highlight the need for popular participation, equitable access to and control of productive resources (particularly for women), priority for food crops and promotion of immunization, ORT, early malarial treatment and child growth monitoring.

- S.G.

Food Subsidies in Developing Countries

by Per Pinstrup-Andersen

IFPRI Food Policy Statement No. 9 October 1988 4p.

Food subsidies may be expensive for governments but they may also be effective policy tools for reaching objectives such as those aimed at enhancing health and nutrition. They may, in the short run, compensate for losses in real incomes of the poor caused by economic recessions or adjustments or an inappropriate development strategy. Food consumption has increased e.g. 15-18 per cent in India and Bangladesh during subsidy programmes, and decreases in prevalence rates of underweight children have been observed e.g. in the Philippines.

Conversely, where a development strategy that emphasizes employment generation and productivity growth among the poor is pursued, subsidies may be unnecessary. If misused, they may be harmful to growth and equity e.g. by providing disincentives to producers.

Benefits of subsidies to vulnerable groups may be increased simultaneously with decreasing fiscal and economic costs through targeting. Political and logistical factors as well as insufficient information may present difficulties in this. Targeting has been done by geographical area, by nutritional status, by season and by commodity. The latter has proved to be particularly successful as self-selection of target groups may occur through subsidizing less-preferred staples consumed by the poor. The costs as well as benefits of subsidies may be targeted e.g. revenue may be raised by taxing luxury goods.

If the primary goal of a subsidy programme is nutritional improvement, cost-effectiveness is likely to be improved by combining it with a primary health care programme. Growth monitoring at health centers could be used to target households which would then be given food stamps to exchange at private retailing outlets.

Pinstrup-Andersen concludes by pointing out the potential for using food subsidies to create self-sustained income-generating capacity e.g. by linking them to public-work schemes aimed at infrastructure creation allowing future small-scale entrepreneurship.

The question is not whether consumer food subsidies are good or bad but when and how they are applied.

- S.G.

Rapid Rural Appraisal Annotated Bibliography

Rapid Rural Appraisal (RAP) is an appropriate tool for the collection of information on food consumption and nutrition-related issues. This is considered particularly relevant for quickly identifying nutritionally vulnerable groups and their food consumption problems at the household and community levels, in order to take appropriate actions. The aim of RAP is to develop a quick, cost-effective and accurate understanding of the rural situation, be it farming, nutrition, health, food consumption, poverty, women's roles, etc., or indeed combinations of these.

An annotated bibliography, prepared by Jeanette Hassin-Brack for Nutrition Economics Group, Technical Assistance Division of the United States Department of Agriculture, surveys a selection of recent literature relevant to rapid rural appraisal. This is one of a series of publications prepared under a Nutrition in Agriculture Cooperative Agreement involving the University of Arizona and the University of Kentucky with the Nutrition Economics Group, Office of International Cooperation and Development, and United States Department of Agriculture (see "News and Views" in this issue). The volume two of this bibliography came out in December 1988. For more information contact: Dr. Timothy Frankenberger, Office of Arid Lands Studies, College of Agriculture, University of Arizona, 845 N. Park Avenue. Tucson, Arizona 85719, USA. Tel: 602-621-1955.

- M.L.

Food Aid in Disasters

In 1983, Diakonisches Werk published a manual entitled "Food Aid in Disasters" for those involved in the emergency relief activities. A revised edition of this book, by P. Glasauer and C. Leitzmann, has been compiled and published in May 1988, for the Diakonisches Werk of the Evangelical Church in Germany. This 118-page English edition, contains six chapters on the causes of disasters and their influence on food supplies; aspects of food aid in disasters; some aspects of nutrition in disasters; food aid through local purchase; early warning systems and food security programmes.

To obtain a copy, at DM20.00, contact: Ms. Erika Friese, Press and Information Department Diakonisches Werk of the Evangelical Church, Central Office, Stafflenbergstr 76, D-7000 Stuttgart 1, Federal Republic of Germany. Tel: 0711-21590.

- M.L.

Health Surveillance and Management for Food-Handling Personnel

This is the report of a WHO Consultation which met in Geneva from 18 to 22 April 1988. Published as WHO Technical Report Series No. 785 by the World Health Organization, Geneva, in 1989, it contains the collective views of an international group of experts on the subject. Some of the main topics covered are: the potential of food-handling personnel to transmit diseases via food; selected diseases and their relevance to food safety; limitations of routine health examinations of food-handling personnel; effective preventive measures and management; and finally conclusions and recommendations of the meeting. Copies from: Distribution and Sales, World Health Organization, 1211 Geneva 27, Switzerland.

- M.L.

Requirements of Vitamin A, Iron, Folate and Vitamin B₁₂

With the availability of a lot of new information during the past twenty years, it was considered by FAO and WHO as appropriate to convene another joint expert consultation following the previous two in 1965 and 1969 - to review vitamin A, iron, folate and vitamin B₁₂ requirements. Considering that both vitamin A deficiency and nutritional anaemia are important public health problems particularly in developing countries, these recommendations on human requirements of such micronutrients, are of special value. The report of this Joint FAO/WHO Expert Consultation which met in March 1985 in Geneva, is published by FAO in 1988 and provides a much required reference in these important areas. This publication will be reviewed in the next issue of the SCN NEWS. Copies of "Requirements of Vitamin A, Iron, Folate and Vitamin B₁₂" are available from FAO, Rome, and from authorized distributors in most countries.

- M.L.

FAO Review of Food Consumption Surveys - 1988

The review of country level food consumption surveys conducted during the period of 1977-86 was published by the FAO in 1988 (FAO Food and Nutrition Paper 44), as a continuation of a series of reviews published between 1958 and 1985. It presents the methodology as well as data from selected surveys in which household food consumption is classified by income, total expenditure or by some other indicators of economic status.

The publication is divided into two parts. Part I, The "Descriptive Notes" gives the main characteristics of the methods used in planning and executing the surveys. In Part II, the "Tables" provide information on expenditure and consumption of a standardized set of food items, classified by economic status. Information on the number of households covered and their average size is also shown for each economic group. The data reported have been recorded on standard floppy discs utilizing Lotus spread sheets in the Commodity and Trade Division of FAO and can be made available to interested analysts for use on personal computers.

The FAO Technical Papers can be purchased locally through the authorized FAO Sales Agents or directly from Distribution and Sales Section, FAO, via delle Terme di Caracalla, 00100 Rome, Italy.

- M.L.

Food Composition and Analysis

The Journal of Food Composition and Analysis is an official publication of the United Nations University, International Network of Food Data Systems. It is devoted to all aspects of the chemical composition of human foods, with the primary goal of providing sufficient description of food samples, analytical methods, quality control procedures and statistical treatments to permit the end users of the data to evaluate the data's appropriateness in their projects. The main features are data and methods for natural and/or normal chemical and biochemical components of human foods (such as nutrients, toxicants, flavors, colours etc.) and methods for determination of inadvertent materials in foods including pesticides, agricultural chemicals, heavy metals, general environmental contaminants, chemical and biochemical toxicants of microbiological origins. Sample copies and privileged personal rates are available upon request. For more information contact: Academic Press Inc., Promotion Department, 1250 Sixth Avenue. San Diego, CA 92101, USA. Tel: 619 699 6742. Manuscripts may be submitted to Dr. Kent Stewart, Department of Biochemistry. Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA.

- M.L.

Chemistry of Tropical Root Crops: Significance for Nutrition and Agriculture in the South Pacific

The Chemistry of Tropical Root Crops is a compilation of data on chemical composition and nutritional value of a wide range of Pacific root crops produced by the Australian Centre for International Agriculture Research (ACIAR). This comprehensive text should be of value to agriculturalists and nutritionists all over the world. It contains a literature review summarizing previously published data as well as the original data generated by the ACIAR project.

The monograph, written by J. H. Bradbury and W. D. Holloway, and published in 1988 as ACIAR Monograph No. 6, is the culmination of more than four years work in Canberra, Australia, on the chemical analysis of tropical root crops (sweet potato, taro, yams and cassava) obtained from seventeen collaborators located in nine countries of the Pacific. Analyses made for all important nutrients fill many gaps in previous data sets for starch, sugar, dietary fibre, minerals, vitamins, organic acids, amino acids, etc.

Because of consistency between averaged data across the countries of the Pacific and also (where comparisons are possible) between present data and that of earlier studies in other countries, the results are not country specific, but will be applicable worldwide. The book thus gives a comprehensive compilation of nutritional data on tropical roots crops.

Further information from: Dr. J. H. Bradbury, Department of Botany, The Australian National University, GPO Box 4, Canberra, ACT 2601, Australia. Tel: 062-495111.

- M.L.

Palm Oil

The Palm Oil Research Institute of Malaysia (PORIM) has recently published two information brochures on palm oil. The first one, came out in January 89, entitled "New Findings and Facts on Palm Oil" is a compilation of materials previously published. Reproducing communications from various authorities in their original forms has been one of the objectives of the publication.

The second publication "Palm Oil, A compilation of Documented Facts on Nutritional Effects Palm Oil" - dated February 89 - is a collection of 16 basic facts about palm oil, reviewed and endorsed by a panel of leading nutrition scientists. It has been written for easy reading and according to Professor Augustine S H Ong, Director-General of the PORIM, it should be useful as a convenient foundation of knowledge and a guide for further reading, particularly for those intending to do nutritional research on palm oil. Promoting human consumption of palm oil may become of increasing interest, as it is a high natural source of vitamin A precursors. Enquiries should be addressed to: Mrs Mardhiah Mohd Zin, Librarian/Head of Unit for Director General PORIM, No. 6, Persiaran Institusi, Bandar Baru Bangi, 43000 Kajang, Selangor Darul Ehsan, Malaysia, Peti Surat 10620, 50720 Kuala Lumpur. Telephone: 03-8259155, 8259775.

- M.L.

Data Management and Analysis Software for Epidemiology (EPI-INFO)

Epi-Info is an applications software programme designed to facilitate the management and analysis of epidemiological data with emphasis on disease surveillance. Epi-Info contains modules for defining data entry screens; setting data entry validation checks; performing data entry; listing data; and producing analytical outputs including frequency distributions, cross-tabulations, analyses of variance, multiple linear regression statistics, and simple graphs. In addition, it includes utilities for importing from and exporting to other common data formats such as Lotus 123, dBase III, SPSS, and SAS. Also included is a module for the calculation of anthropometric indices required in nutritional surveys.

Since 1987 more than 4,000 copies of Epi Info (which is in the public domain) have been distributed in 34 countries. It is used in routine communicable disease surveillance systems, for disease outbreak investigation, data management for HIV/AIDS surveillance, nutritional surveys, and by universities in teaching bio-statistics and epidemiology. Earlier versions of Epi Info were produced in the Epidemiology Program Office, Centers for Disease Control (CDC), Atlanta, Georgia. Version 5 is a joint CDC/WHO effort. In addition to the features of versions 3 and 4, version 5 includes many new features, and a new manual.

Hardware required.

The hardware specifications for using Epi-Info Version 5, are as follows:

1. IBM compatible microcomputer with DOS 2.0 or above.
2. 512K Random Access Memory (640K is better).
3. 2 floppy disk drives; or 1 floppy drive plus hard disk (better).

For more effective use, you need a hard disk, 640K RAM, a color monitor, and a printer.

“Think back ... which keys did you press?”

Capacity.

Data files may contain up to 4,000,000 records of up to 300 variables. A questionnaire may consist of up to 500 lines or approximately 20 screens.

Description of Epi-info.

Several aspects of Epi-Info make it useful for the processing of nutritional survey data. First, it is extremely easy to learn the minimum required for data entry, processing, and output. More advanced functions are available which allow sophisticated applications. One of Epi-Info's strongest features is its ability to create a custom data entry screen (much easier than in dBASEIII, for example), and to set-up internal checks for errors at data entry. These features will allow a much reduced error rate at data entry, thus saving time in later data cleaning.

Epi-Info's data management programmes allow easy conversion to other's such as dBASEIII and LOTUS 1-2-3. Likewise, files from these packages can be converted for use in Epi-Info, and dBASE files can be used directly in the ANALYSIS module of Epi-Info without any prior conversion. All files used in and created by Epi-Info are ASCII files, so can be transferred into any other software package even if there is no conversion option for the package. This avoids constant problems with file incompatibility.

The ANALYSIS programme is meant for more applied applications and not upper level analyses. Statistical output for the analysis of tables are quite extensive (e.g. Chi-square), as is the ANOVA routine. Regression gives a standard output with B coefficients and the ANOVA table; however, no residual analysis is available. No log-linear regression, discriminant analysis, life tables, or time series analyses are included. Particular mention should be made of its sorting routine, which is done quickly and on one to several fields at once, regardless of whether they are character or numeric fields. Also, custom reports can be created for feedback and/or updating information.

A graphics routine is being developed, called Epi-Map, which is a companion programme to Epi Info. Epi-Map will provide the ability to create map boundary files using a digitizer, a mouse, or the cursor keys. Thematic data may be displayed using color/hatch patterns or dot density displays. The maps can then be displayed on the monitor, printed, or output to a color plotter. GPA/WHO is currently creating a library of global and country maps that will be distributed with Epi-Map. One application might be to graph the prevalences of malnutrition by country; mapping for Africa is now available and other regions will shortly become so.

The ANTHRO module.

ANTHRO is a module which calculates anthropometric indices and provides options for their presentation. It was developed jointly by WHO and CDC. It has been designed as a replacement for the CASP software which had been widely distributed over the past years but had some operational problems. Data entry and the management of data files is done in Epi-Info, and can be linked directly to the ANTHRO programme.

ANTHRO performs batch processing of multiple records containing basic measures of weight, height, sex and age. This can also be done interactively. However, for data analysis the batch procedure is useful whereby anthropometric indices can be created for a whole data set at one pass. The variables can be handled in different units, i.e. lbsozs, ft-inches, or metric, and age in years, months, or computed from the date of survey minus the date of birth. The default file format for ANTHRO is dBASE (.DBF) files, although the capability to import, or "translate" other file structures, including ASCII, PRN/Comma-delimited, WKS/WK1 (LOTUS), SYLK (Microsoft Multiplan), PFS (PFS: File), DIF (Visicalc) and EPI-INFO is being developed.

For each record, the following variables can be calculated (based on NCHS/WHO standards): percentiles, percent-of-median values and S.D. scores for the three indices weight-for-height, weight-for-age, and height-for-age; BMI, and ages from dates. The user selects which of these is required. In addition to these, an extra field called FLAG is created which identifies records with either missing data or a strong likelihood that some data may be incorrect (based on extreme S.D. scores). There are default criteria for "flagging" but these can be adjusted by the user.

There are standard analytical procedures in the software, which include calculation of either prevalences or frequency distributions. For prevalences, the user indicates which mode to use, i.e. centiles, % median, or S.D. score, as well as the corresponding cut-off point(s). In the second case, descriptions of entire distributions are represented either in terms of centiles or S.D. scores and shown alongside "expected" distributions of the reference population. The size of the intervals used are based on recommendations of a WHO Working Group (Bull. WHO (1986) 64(6) 929-941). In all cases, analyses can be performed on subsets of the data stratified by age group, sex and/or a third variable such as geographic region, socio-economic status, etc.. For more elaborate analyses, files created in ANTHRO can be exported for use with other statistical software packages, or in Epi-info ANALYSIS. The ANTHRO module can be set-up in English, French, or Spanish.

In summary - Why Use Epi-info?

There are several major advantages of using Epi-info in processing nutritional survey data. First, a program to calculate anthropometric indices is included, which can interface directly with Epi-info. Epi-info is very easy to learn therefore requiring little effort in training. The package stands alone, so there is no need to obtain other commercial packages, such as LOTUS123, dBASEIII, etc.. It contains only those functions most needed in survey analysis, which usually require two or more separate packages, and it thus takes relatively less storage space. Finally, it is free for distribution (see below).

The disadvantages of Epi-info are not substantial but must be considered. Because it is an applications software package and includes aspects of many different types of packages, it has some limitations. In particular, higher level word processing, upper level statistics, and "fancy" graphics are not available. Secondly, support is not as extensive as some commercial packages - in terms of reference guides and locating others who are familiar with the package. Thus, if help is needed, it may be more difficult to find.

How to obtain a copy of Epi-info.

Version 5 is currently being tested and is scheduled for release in January 1990. A French version is planned for release in mid-1990. Version 1 of Epi-Map is scheduled for release in April 1990.

Copies of Epi-info including the ANTHRO Module may be obtained by writing to WHO.

Please specify 5 1/4 inch or 3 1/2 inch disk.

Contact: Nutrition Unit, World Health Organization, CH-1211 Geneva 27, SWITZERLAND

CORRECTION

We regret that in our last issue five lines were omitted by mistake from the review of "Adjustment with a Human Face, volume II" in the Publications section of SCN News No. 3, on page 29. Since this removed the sense of the whole paragraph, and the correct paragraph is less interesting out of context, we are reproducing the review again here in full:

Adjustment with a Human Face, Volume II, Ten Country Case Studies, A Study by UNICEF

(Giovanni Andrea Cornia, Richard Jolly and Frances Stewart (Editors) Clarendon Press, Oxford, 1988 - 310 Pages)

A prerequisite of orthodox stabilization programmes is to reach quantitative targets: contraction of the money supply, credit restriction, wage freeze. Unemployment statistics and per capita GNP are considered to be economic indicators rather than terms used to quantify human distress. Reduction of government spending on poverty alleviation seems logical if the rationale is deficit correction or foreign debt servicing.

The IMF inadvertently contributes to a cycle of deprivation in its role as net recipient of capital from developing countries. It is a source of conditional loan finance to whom needed resources are delivered in the form of interest payments. Debt servicing obligations siphon export earnings and divert cash from social welfare programmes. In 1985, Brazil paid the equivalent of the entire budget of the federal social welfare and medicare system. The external debt in the Philippines is 82% of GNP (1985) and is so debilitating that it makes economic sense to convert it to equity, or to repudiate it. The IMF, as ringmaster of debt rescheduling, may be forced to modify the monetarist solution by shifting the emphasis from inflation to unemployment. If unemployment, rather than inflation, is defined as the social malady, the monetarist paradigm may be skewed to incorporate a humanist clause.

The modification of government strategies to include or exclude this human and quantifiable dimension, and the evolution of this process as it relates to IMF stabilization planning, is the subject of Adjustment with a Human Face, Volume II, Ten Country Case Studies, A Study by UNICEF. Edited by Giovanni Cornia, Richard Jolly and Frances Stewart, each monograph adopts the same format: a retrospective look at the administration of austerity plans during the 1970-1985 period in the context of world recession and local catastrophe, an update on trends from 1985, and a prognosis. Investigative reporting forms the backbone of the text, using social sector data to measure the impact of stabilization economics on human structures. The deterioration, or in some cases amelioration, of social conditions is analyzed in the language of input, process and impact indicators which provide detailed information on government expenditure correlated with access to employment, food, education and health service at the household level. Unemployment translates into a familiar arithmetic of low food purchasing power, malnutrition, increased child morbidity and mortality rates. Positive health interventions translate into child survival.

Among the other countries chosen for this research, Botswana, Peru, South Korea and Zimbabwe emerge on the credit side for combining adjustment with allocation of resources to vulnerable groups, compared with Brazil, Ghana, Jamaica and the Philippines, who have less political will in this regard.

The contributors to these country case histories are aware that an analysis of the cycle of deprivation is insufficient without the corollary analysis of response: what decisions add up to a workable crisis resolution tactic. Botswana and Zimbabwe are cases in point. Their respective governments chose to fund a drought relief programme despite budgetary restrictions. At the onset of the drought in 1982, underweight prevalence rates were measured and an appropriate response organized in the form of direct and supplementary feeding. Zimbabwe reduced its infant mortality rate to 83 per 1000 in 1983-84. In Ghana, the mechanism for coping with drought was undirected, resulting in an infant mortality rate of 120 per 1000 in the same period.

A sharp decline in wages in Brazil caused the infant mortality rate to increase from 65 to 73 per 1000 from 1982-84. State and city governments worked with community groups to form buffer mechanisms to moderate adverse conditions. In Sao Paulo, wholesale food markets, food convoys and food network schemes provided poorer members of the community with food they could not otherwise afford. In Chile, these OEPs (people's economic organizations) provide 3% of the 1.2 million Santiago shanty town population with food. When unemployment is endemic, it is the woman who is responsible for the sustenance of her family. The ingredients for the stabilization agenda - or menu - directly affect what goes into the cooking pot.

These examples provide valuable insight to both the economist and the nutritionist on the variation in causes of, and responses to, the economic crises that currently afflict many developing nations.

They serve most of all to highlight the capacity of some countries to successfully buffer the short term effects of structural adjustment on the health and well-being of the poor.

And no one exists alone
Hunger allows no choice
To the citizen or the police
We must love one another or die.

(W H Auden)

Rosemary Kevany

The importance of a balanced diet ... known since prehistoric times.