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Preventing Anaemia
Policies to Improve Nutrition - What was done in the ‘80s
Weaning Foods - new uses of traditional methods

Preventing Anaemia

Recommendations on the deficiency control methods - especially supplementation - from recent ACC/SCN workshop.

¹ Proceedings of International Conference on Iron Deficiency and Behavioural Development, held in Geneva, October 1988. In: American Journal of Clinical Nutrition, 50 (suppl.), No. 3 (September 1989).

² Report of the Joint ACC/SCN Workshop on Iron Deficiency Control (Dublin, 6-8 June). To be published by ACC/SCN as Nutrition Policy Discussion Paper No. 9.

The meeting agreed the introductory statement shown in box 2.

Box 2 Controlling Iron Deficiency “Iron deficiency is the most common nutritional disorder in the world. It occurs when the amount of iron absorbed in the body is insufficient to meet its requirements, and if prolonged, results in iron deficiency anaemia (IDA). It is estimated that 1.3 billion people suffer from anaemia, of which most is due to iron deficiency. IDA is an important cause of morbidity and, when severe, mortality. This situation persists although the interventions required for prevention and treatment are available, effective and inexpensive. “The frequency of IDA is more than 50% amongst pregnant women and pre-school children in many communities, and progressively less in school children, non-pregnant women and adult males. IDA reduces work-capacity, with adverse effects on productivity, earnings and the ability to care for children and the home. In developing countries, severe anaemia can be an associated cause in 50% and the main cause in up to 20% of maternal deaths. Maternal anaemia results in intrauterine growth retardation, low birth weight and increased perinatal mortality. Iron deficiency in infancy and childhood is associated with apathy, inactivity and significant loss of cognitive abilities. “The target group of highest priority for intervention is women during pregnancy and early lactation. In areas where iron deficiency is highly prevalent, blanket coverage of the group with supplements is recommended. Major constraints on effective intervention include low accessibility and utilization of ante-natal care, inefficient supply and distribution of supplement (usually ferrous sulphate/folic acid tablets), inadequate training and motivation of first line health workers, insufficient and inappropriate counselling of mothers, and failure of effective screening and referral procedures (where these are required). Iron deficiency control, in other words, shares many of the same problems as primary health care and essential drugs programmes. Another priority group is premature and low birth weight infants, for whom an affordable preparation for administration in the first weeks of life needs to be developed. For pre-school children in areas of high prevalence, screening for anaemia and selective supplementation should be considered. “In general, supplementation programmes are of limited effectiveness outside these target groups and other approaches are needed to correct deficiency states. Of these, food fortification with a suitable iron compound is the method of choice in most situations. Attempts to improve iron intake and availability by dietary change are important in the long term, but behavioural change is gradual. Theoretically, there are three ways in which the amount of bioavailable iron in the diet can be improved: by increasing intake of haem iron; by increasing ascorbic acid intake to favour iron absorption; and by reducing inhibitors of iron absorption in the diet. “For the immediate future, raising the effectiveness of programmes providing iron supplementation during pregnancy and lactation as a component of primary care appears to be the most practical approach to alleviating the problem of iron deficiency and anaemia for the most vulnerable group in areas of high prevalence. The successful prevention of iron deficiency in a community will lead to improved health especially in women and children, reduction of maternal and infant mortality, increased productivity in adults and improved learning capacity in children. Programmes should be highly cost-effective with the costs being offset by a better economic performance. The control of iron deficiency is an essential component of primary health care, the Safe Motherhood Initiative and the AIDS Control Programme (the latter through the reduction of the need to transfuse blood in severe anaemia).” Source: Report of the Joint ACC/SCN Workshop on Iron Deficiency Control (Dublin, 6-8 June). To he published by ACC/SCN as Nutrition Policy Discussion Paper No. 9. Figure 1: Process Involved in Iron Supplementation In order to ensure that those people most in need actually do ingest iron supplements on a daily basis so as to raise their haemoglobin levels, a system of supply, delivery and consumption needs to be functioning smoothly. This has been seen in the past to be more manageable in smaller scale programmes than when these are scaled up to national level. Figure 1 above has been used to represent this system, in questionnaires distributed prior to the ACC/SCN workshop to help identify constraints in large-scale programmes. The top half of the “Y” shows how the iron-deficient population and the iron supplements reach the ‘distribution point’ e.g. an antenatal clinic, on a regular basis (marked “Entry into Programme”). People with iron deficiency need first to be identified. If the iron supplementation is carried out through health services, these people need access to the services and to be sufficiently informed and motivated then to utilise them. Iron tablets should be regularly available in sufficient quantities at the distribution point. This will involve considerations of cost, logistics, transport, distribution and finally storage within the clinic. The bottom half of the “Y” illustrates how, having entered into an iron supplementation programme, an individual’s haemoglobin levels can be raised. The human element is critical here. Staff at the distribution point need to be trained to reassure the patient of the benefits of supplementation, particularly if there are any initial side-effects. They need to know when and where to refer a severely anaemic patient, how to monitor patients within the programme as well as to motivate those who have dropped out. Finally, given regular ingestion of an appropriate dose of iron by the patient, dietary and disease factors can modify iron absorption and loss, hence the degree to which haemoglobin levels are raised.

The components of the system (as illustrated in Figure 1) from overall supply of tablets through to individual adherence provided a structure for the workshop, which is also followed in this article.

Target groups

Pregnant and lactating women are of highest priority, and generally require blanket coverage in areas of high anaemia prevalence. Premature and low birth weight infants are also a high priority target group. Supplementation of pre-school children should be considered in areas of high anaemia prevalence, and similar considerations apply to school age children. In adolescent girls pilot studies have shown benefit from supplementation through building iron stores before pregnancy.

Supply and logistics

Overall supply of iron tablets is frequently a major constraint. This arises not only from inadequate financing, but from failures in procedures for ordering and scheduling deliveries, ensuring quality control, storage, monitoring of distribution etc. at all levels of administration. An interesting illustration came from one programme discussed at the workshop: at district level, 83% of the target group were judged to be covered by supplement supply; at primary health centre level, this proportion was 67%; at sub-centre level it was 61%, and finally at village level, only 8% of the target group were in fact covered. Three factors were bringing down the coverage: the “needy” were considerably under-estimated at district level, distribution bottlenecks were progressively reducing the flow of supplements from district to village level, and (often) the supply actually reaching the villages was going to the “captive audience” of school children rather than the intended target group of pregnant women.

Higher priority for tackling iron deficiency at every level of decision-making in the health system is needed - as well as better recognition among those affected themselves - which in turn requires better communication and information. Heightened awareness among those affected would lead to an increased demand, which in turn would put pressure on the supply system; both demand and supply need thus to be developed simultaneously.

Service delivery

In the first place, iron supplementation through existing service delivery systems requires regular contact of those in need with the services - and this is commonly lacking in areas most affected by anaemia. Health services, often antenatal clinics, are the most common network for the delivery of iron supplements to the priority target group - pregnant women. Access and utilisation of such services, however, are very low (often below 50% of the target group) in many countries. Reasons for this included the lack of both physical access (clinics being out of reach) as well as economic access (transport costs, wages foregone in using services), and a lack of awareness of the possible benefits.

Within the heath system, capabilities for preventive measures, and for diagnosis, treatment and referral, need to be enhanced, starting at the village health post level. Blanket coverage of vulnerable groups (notably pregnant and lactating women) is recommended. Other delivery systems including the private sector show promise. The integration of iron programmes with others (e.g. Safe Motherhood, primary health care, family planning, school feeding etc.) can maximize opportunities to reach targeted groups. Other systems that have wide outreach, such as schools, churches, party networks should also be considered.

Additional training of health and other service staff is often required for the prevention and treatment of anaemia. This applies to basic and in-service training, and should include management, surveillance, communication with people, screening, etc. In addition, increased awareness of managers and policy-makers is needed, and should be fostered.

Tablets, doses

Ferrous sulphate is currently the most suitable preparation, being of low cost and high bioavailability. For infants, however, low-cost paediatric preparations need to be developed. New forms of iron preparations providing sustained gastric delivery are promising, but have yet to be made widely available.

For prevention in pregnant and lactating women 60 mg elemental iron (= 200 mg ferrous sulphate, often with 250 mcg folate) per day (1 tablet) is recommended in areas where iron deficiency anaemia is of low prevalence; in areas of higher prevalence 2 tablets, i.e. 400 mg ferrous sulphate per day is recommended. For infants breastmilk should be adequate for the first six months, but in low birth weight infants supplementation may be required from two months onwards.

From six months supplementation may also be widely necessary. The preventive dose of elemental iron is 1 mg/kg/day. Suitable liquid preparations need to be developed. For children supplementation is less widely needed and screening may be advised; the dose is 100 mg ferrous sulphate per day (pre-school) to 200 mg (school age).

For treatment the dose depends on the severity of the anaemia. For severe anaemia in pregnant and lactating women 60 mg elemental iron (200 mg ferrous sulphate) three times daily is recommended; twice daily for mild-moderate anaemia. In infants and young children the recommended dose of elemental iron is 3 mg/kg/day; for adolescents and other adults 60 mg elemental iron daily is recommended for mild anaemia, and 60 mg twice daily for mild-moderate. Parenteral iron is seldom essential, and can be risky particularly in malaria endemic areas.

The potential toxicity of iron, while not counter-indicating control programmes, needs to be borne in mind. However, it is stressed that oral iron supplementation to normal pregnant women causes no risk of toxicity and present evidence indicates only minor undesirable side effects when the dose is relatively small. Furthermore limited periods of supplementation are not a concern even in patients susceptible to iron overload.

Adherence (compliance)

Side-effects from taking ferrous sulphate tablets are common - usually mild but sometimes unpleasant enough to discourage continuing daily supplements. Where supplies are not a problem, even with good access to health care, side-effects are thought to be a major reason for some women dropping-out of a prescribed course of iron, usually during pregnancy. How far does this effect the success of iron supplementation on developing countries? Information from the programmes reviewed and from previous literature indicates that side effects from ferrous sulphate are actually associated with only a relatively small proportion of drop outs from supplementation programmes in poorer countries. For example, in a 1985-86 ICMR study in India³, the drop-out rate varied from 9% to 87% between States with a mean of 58%. Over 80% drop-outs cited tablet supply failure as the reason; less than 3%, side-effects. Among the programmes reviewed, supply constraints tended to be more important in causing lack of adherence. Cultural issues and improved community understanding and participation in programmes are important.

³ Report of the Meeting on Prevention and Control of Nutritional Anaemia, Ministries of Health and Family Welfare, Government of India, New Delhi and UNICEF, New Delhi (November 1989).

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Fortification

An alternative approach is fortification, widely used in developed countries. While not necessarily substituting for supplementation, fortification can reduce its urgency and allow it to be more specifically targeted. Effective fortification programmes require long-term commitment, a bioavailable but non-reactive iron source, and suitable “vehicles” - foods to be fortified. A suitable food vehicle will be one that is centrally processed, technologically and economically fortifiable (with no change to taste, texture, appearance), acceptable, frequently used by the target group or whole population, and made available through an effective distribution system. Proven iron sources exist (such as iron-EDTA), as do several examples (but mostly in developed countries) of suitable food vehicles. In some cases fortification can be targeted to vulnerable groups, e.g. weaning foods.

Dietary modification

Iron deficiency can also, in principle, be tackled in the long-run by modifying dietary patterns. The three main ways in which diets can increase iron status are:

- increasing the intake of haem iron (from animal products);

- increasing the intake of vitamin C, along with foods promoting iron absorption e.g. acidic, fermented;

- reducing the intake of iron absorption inhibitors, e.g. in coffee, tea, some cereals.

Parasitic disease control

Control of hookworm and malaria are significant strategies for reducing iron deficiency anaemia. Hookworm transmission may be reduced by hygienic measures such as keeping faeces out of the soil (e.g. through the use of pit latrines), and keeping skin from contact with the soil (e.g. through use of adequate footwear). ‘De-parasitization’ should be carried out the first time a pregnant women attends an antenatal clinic, preferably in the first trimester. This will prevent iron loss due to hookworm in this pregnancy although there is then the probability of subsequent re-infestation. Ideally, de-parasitization needs to be complemented with hygiene education plus improvements in water and sanitation and the use of adequate footwear. Schistosomiasis, trichuriasis and Giardia infestation are other diseases adversely affecting iron status. In malaria-endemic regions the benefits of oral iron outweigh the risks (which exist partly because the malaria parasites need iron for replication).

Conclusions

For the immediate future, raising the effectiveness of programmes providing iron supplementation during pregnancy and lactation as a component of primary care appears to be the most practical approach to alleviating the problem of iron deficiency and anaemia for the most vulnerable groups in areas of high prevalence. Inadequate and unreliable supply of supplements and low service utilization are major constraints in most programmes. Programme effectiveness depends on outreach and effectiveness of service delivery. Recognition of the importance of iron deficiency must be increased at all levels, including among those affected. Adherence to a supplementation regime is a constraint, probably more related to unreliable supply to the individual than to undesirable side effects, although the latter also need to be tackled.

Blanket coverage of pregnant and lactating women in at risk areas is recommended. Greater attention is needed to iron supplementation in premature and low birth weight infants, for which new preparations are needed. In other age groups selective supplementation (e.g. using screening) may be desirable. Fortification and dietary modification are complementary approaches, and should be developed. In general, a mix of strategies is likely to be the most successful.

- S.R.G./J.B.M.

Other useful references

DeMaeyer, E.M. and Adiels-Tegman, M. (1985) The Prevalence of Anaemia in the World. World Health Statistics Quarterly 38, 302-316. WHO, Geneva.

DeMaeyer, E.M. (1989) Preventing and Controlling Iron Deficiency Anaemia through Primary Health Care: A Guide for Administrators and Programme Managers. WHO, Geneva.

INACG (1989) Guidelines for the Control of Maternal Nutritional Anaemia. Available from INACG Secretariat, ILSI-Nutrition Foundation, 1126 16th St., NW Washington DC, USA.

Odaybea Morrow (1990) Iron Supplementation during Pregnancy: Why Aren’t Women Complying? Safe Motherhood Programme, WHO, Geneva.

Rae Galloway (1990) Determinants of Medical Compliance. The World Bank (PHN), Washington DC.

Policies to Improve Nutrition - What was done in the ‘80s

Review of recent experience, focusing on household food security, malnutrition/infection, and caring capacity.

This situation persists, indeed malnutrition is growing in numbers, and only patchily declining in terms of proportions. Poverty alleviation is at the forefront of the development agenda - but waiting for poverty decline to alleviate malnutrition will take decades, and in the interim the misery and unnecessary deaths will continue. Is it necessary to only wait for economic advancement to prevent this suffering? What can be done in the interim?

These results of poverty - hunger, sickness, early death, debilitation and fatigue - revolve around nutrition. Nutrition is the result, and preventing malnutrition is an aim, and one that can be monitored.

We know more now (than say ten years ago) about how the nutrition situation is evolving. Much painstaking research in many countries has allowed a coherent picture to be built up - hence, for example, the SCN was able to describe trends in its reports on the world nutrition situation¹, and this process continues. We can now look at examples of where nutrition has improved, and begin to figure out why, drawing lessons for future actions. These actions cost money - requiring allocation of resources by governments and through international assistance. Decisions need to be made as to how to spend that money, and this is complex. Nonetheless decisions have to be made, and these can now be better-informed than in the past.

¹ ACC/SCN (1987) First Report on the World Nutrition Situation; ACC/SCN (1988) Supplement on Methods and Statistics to the First Report on the World Nutrition Situation; ACC/SCN (1989) Update on the Nutrition Situation: Recent Trends in Nutrition in 33 Countries. ACC/SCN, Geneva.

² ACC/SCN (1990) Estimates of Flows of External Resources in Relation to Nutrition. Paper prepared by Paula Yoon and John Mason for the 16th Session of the ACC/SCN, February 1990.

Box 1 NUTRITION GOALS FOR THE 1990s The nutrition goals for the 1990s can be divided into the following two categories: a) The control of protein-energy malnutrition, including: i) The reduction of both moderate and severe protein-energy malnutrition in children under five years of age by one half of the 1990 levels; ii) The reduction of the rate of low birth-weight (less than 2.5 kilograms) to less than 10 per cent (an indicator of the status of maternal nutrition); b) The control of micronutrient deficiency disorders, including: i) The reduction of iron deficiency anaemia (haemoglobin level in the blood, or serum ferritin) among women of child-bearing age by one third of the 1990 levels; ii) The virtual elimination of IDD (urinary iodine, or serum thyroid hormone); iii) The virtual elimination of vitamin A deficiency and its consequences, including blindness (serum retinol, or some other measure of vitamin A status). The indicators to be used in monitoring the achievement of the micronutrient goals are given in paragraph b) above; those for protein-energy malnutrition in children are as follows: underweight (low weight-for-age); wasting (low weight-for-height); and stunting (low height-for-age). Source: UNICEF. (1990) Strategy for Improved Nutrition of Children and Women in Developing Countries. A UNICEF Policy Review. 15-16.

The SCN, with its mandate for harmonizing policies in the UN for preventing malnutrition, has started to address these questions. Essentially, this is in two stages: first to look at and evaluate recent experience - drawing on information on trends accumulated for reports on the world nutrition situation; and second to seek the best possible consensus on what should now be undertaken in the decade of the 90s. This article is based on background material³ for a meeting convened by the SCN, with support from the German government’s development agency (GTZ), in London in November 1990. The next article scheduled for SCN News No. 7 will give the forward-looking conclusions of that meeting, to be reviewed by the Subcommittee in February 1991.

³ Gillespie, S.R. & Mason, J.B. (1990). Nutrition-Relevant Actions in the Eighties: Some Experience and Lessons from Developing Countries. Draft background paper for the ACC/SCN Ad Hoc Group Meeting on Policies to Alleviate Underconsumption and Malnutrition in Deprived Areas, November 1990, London.

Figure 1: Trends in Prevalences (%) of Underweight Children in Selected Countries INDONESIA THAILAND BOTSWANA CHILE COSTA RICA COLOMBIA (Prevalences are for children under five years for Indonesia, Thailand and Botswana; for under six year olds in Chile and Costa Rica; for 6-36 month olds in Colombia. Data for Indonesia, Colombia and Costa Rica are from surveys; Thailand and Botswana from weighing programmes, and Chile from health centres.) Source: ACC/SCN (1989) Update on the Nutrition Situation; additional 1989 Indonesian data supplied by Dr. B. Kodyat, November 1990.

In Africa, trends in prevalences of underweight children from clinics in Botswana and Ghana were taken as one measure of nutritional outcome. In Botswana recurrent drought threatened food security, livelihoods and nutrition throughout the 1980s. Yet the evidence is that this was contained; indeed nutrition may have improved towards the end of the decade (uncertainties arise due to changes in the reporting system). Vigorous efforts to provide public works employment and food distribution, as well as about the best outreach of any health system in Africa, may partly explain the success. In Ghana, far-reaching policy changes began to resolve the severe economic crisis of the early 80s - when food prices and inflation rocketed, employment and wages crashed, drought and bush fires wreaked havoc in the countryside. The situation was under control by the late ‘80s and malnutrition fell. In Indonesia and Thailand steady improvement in the 80s in child nutrition was indicated (by underweight prevalences, from surveys and weighing programme data, respectively). In Thailand especially this was no doubt helped by the sustained rapid economic growth. Both countries increased their outreach of family health services, with explicit nutrition components. In Indonesia, the State Rice Marketing Organization (BULOG) helped stabilize staple food supplies and prices. The situation in Tamil Nadu State in India was also considered: here a combination of state food interventions and specific child programmes (ICDS, TNINP) are thought to have contributed to improving child nutrition.

Several countries from Latin America have positive experiences in nutrition. One of the best known is Costa Rica. Here substantial expenditures on health and social services have helped reduce infant and child mortality to very low levels, and child malnutrition has been nearly eliminated in many areas. Both Chile and Cuba provide similar examples in outcome, with variations in approach⁴. In Colombia continued economic development, with a period of specific food and nutrition programmes, as well as other factors may account for the nutrition improvement seen.

⁴ Horwitz, A. (1987) Comparative Public Health; Costa Rica, Cuba, and Chile. Food and Nutrition Bulletin 9 (3) 19-29.

Thus macro-economic policy decisions may have the nutrition of the population as a sub-objective, but are seldom primarily driven by this. Structural adjustment, for example, in the first instance address such problems as balance of payments deficits and restarting economic growth - although they may include short-term compensation, similar in principle to social security. On the other hand, for example, policies for food distribution do have food security as an objective, and thus are more directly influenced by considerations of nutritional outcome.

Policies may aim to protect current consumption and hence nutrition; or may give priority to investment for future well-being. This contrast has been called “growth” compared with “support”, and a balance is usually sought, in other terms, between investment and social security. In “Hunger and Public Action” Jean Dreze and Amartya Sen⁵ evaluate such options, citing examples from China, Jamaica, Sri Lanka and Costa Rica (among others), which emphasized support; others they quote, such as South Korea and Singapore emphasized growth along with active public provisioning. Both approaches brought improvement in survival and nutrition. Others still achieved growth, but their ‘unaimed opulence’ did not improve quality of life to the extent of the others. In general, neither growth alone or public support work sustainably in isolation; and growth policies must deliberately include the poor if they are to alleviate poverty - and reduce malnutrition. In fact, such observations have led to considerable consensus on overall policy. The World Bank in the 1990 Development Report, UNDP in its Human Development Report 1990⁶, (and indeed Dreze and Sen) agree on an approach which in the present context includes:

- economic growth that deliberately involves participation of the poor as the long-term solution to poverty;

- in the interim social security for the poor is imperative and need not retard growth; the means for this importantly are good access to food (not least because maybe 70%-80% of income is spent on food) - or “food security” - and there is experience now on how to achieve this; equally health access must be ensured, and the means for this are also becoming known.

⁵ Dreze, J. and Sen, A. (1990) Hunger and Public Action. Clarendon Press, Oxford.

⁶ World Bank (1990) World Development Report, World Bank, Washington D.C.; UNDP (1990) Human Development Report, Oxford University Press for UNDP.

Nutrition objectives will be reached by suitable decisions on resource allocations, both to sectors and to areas within them, and hence to effective activities. Should funds be allocated to rural health centres or hospitals? To cash crop production or subsistence? To one sector or another? Such information flows and decisions are pictured in Figure 2. This illustrates one important level of decision-making: allocation of resources between sectors, and to different activities within sectors. It also means to display the communications issue: nutrition concerns may be of priority in one sector, but action is required by others - hence effective use of information and advocacy are needed by those promoting nutritional aims.

Illustration of Decisions on Resource Allocations & Use Figure 2. The example imagines a nutrition unit in a Ministry of Health, wishing to make or influence decisions that affect nutrition. Often this may involve persuading others to make decisions. These may get progressively more difficult - but sometimes more important - in the examples A-E: (A) decisions by a nutrition unit on the use of its own resources: e.g. nutrition education vs. nutritional surveillance; (B) recommendations on use of resources by departments within the same sector - e.g. including nutrition education activities in primary health care; (C) recommendations on allocation of resources between departments within the same sector, e.g. hospitals vs. rural clinics; (D) recommendations on use of resources by other sectors: e.g. nutritional considerations in agricultural projects; (E) recommendations on allocation of resources between sectors. Source: Mason (1988) Nutritional Surveillance: Extension at Country Level and Required Indicators, paper for AID workshop, Annapolis, 20-22 April, 1988.

Allocations to social sectors are illustrated in Table 1, for some of the countries considered here. One purpose of these figures is to see how affordable social action is - it has been argued that expenditure on social security is beyond the reach of the poorest countries. This issue is considered in some detail by Dreze and Sen in ‘Hunger and Public Action’. They point out that in fact some of the poorest countries have successfully used social security. The costs need not be prohibitive, partly because much of the services are labour-intensive, and thus less expensive in poorer countries with lower wages. This implies that it is more the proportion of national income devoted to the social sectors, than the absolute funding. The figures in Table 1 show considerable per capita allocations, and higher levels proportional to GNP, in countries such as Botswana, Chile, and Costa Rica, in relation to the others. Poorer countries do seem to be less able to afford social security. But nonetheless, some resources are available even there - around $12 per head per year in Indonesia, $23 in Ghana, as examples.

Table 1: Resource allocations to social sectors for selected countries in 1987

Country	GNP per capita ($)	Total expenditure on health/education/social security and welfare ($/capita/yr)		Total expenditure on health/education/social security and welfare ($/capita/yr)		% of total social expenditure from external sources
		Government budget	External aid	Govt. + External	%GNP per cap.
Costa Rica	1610	244	1.4	245	15	0.6
Chile	1310	246	0.1	246	19	0.04
Botswana	1050	135	23.3	158	15	14.7
Thailand	850	57	0.2	57	7	0.3
Indonesia	450	11	0.7	12	3	5.8
Ghana	390	21	1.5	23	6	6.8
India (central govt. only)	300	5	0.1	5	2	2.0

Sources: ACC/SCN database on external resource flows, from ACCIS, World Bank, and OECD; World Development Report (1989) (World bank) for GNP, health & education budgets; IMF Financial Statistics Yearbook (1989) for social security and welfare figures.

We said in the background paper “It is often possible to decide on a single or a few useful, if not optimum interventions. There is generally not an inescapable need for a complicated mix of actions. This is not to say that campaign-style quick fixes are warranted - they undermine the institutional capability for broad responsiveness. But not everything has to be done at the same time. Responsible planning identifies the best feasible approaches at any one time, with an eye to future needs.” This view seems to be accepted. “There is thus no absolute need for governments to develop all-embracing statements which constitute a ‘nutrition policy’. Such a document may promote the notion that a centralized inter-sectoral planning approach is required. Decisions and actions are more important than statements.”

To describe recent experience, with a view to determining where to go next, we need to summarize activities, as well as to keep the scope manageable. The immediate causes of malnutrition are dietary intake and infectious disease. Dietary intake depends considerably on the ability of the household to acquire food - or household food security; and infectious disease depends substantially on exposure to disease in the environment, and access to services. But both these are modified by what happens within the household, especially by women’s roles - for example maternal care of children. Therefore a grouping of factors, and policies that impinge upon them, that provides a useful summary is to distinguish these three clusters: household food security, malnutrition and infection complex, and “care” factors. This formed the basis for UNICEF’s nutrition strategy, as shown in Figure 3. This framework has been adopted in reviews of past policies, and in recommendations for the future. Here we use it to draw conclusions from recent experience.

Figure 3. Causes of malnutrition and death Source: UNICEF “Strategy for improved nutrition of children & women in developing countries”. UNICEF Policy Review 1990-1.

Household Food Security

Household food security refers to the ability of household members to assure themselves sustained access to a sufficient quantity and quality of food to live healthy active lives. The term also implies assurance of future intake - removing the fear that there will not be enough to eat. These aspects could be called “current” and “future” food security. In principle, the idea for current intake can be illustrated as in Figure 4. This shows the range from low to high food energy (kcal) intake. The effect on the individual of sustained low energy intake is to lose weight, and at the other end of the scale to gain weight. At the extremes, these involve starvation and hunger, and overeating and obesity. The individual at a certain low level of food intake will respond by reducing activity, usually first discretionary activity for leisure, and then productive activity itself. In a sense, the individual may protect against loss of body weight by conserving energy through reduced activity, but clearly this is a policy of some desperation. At the other end of the scale, given adequate food availability, the individual regulates food intake particularly through appetite control. Clearly the objective is to have food accessible somewhere in the region where productive and discretionary activity are supported, and there is enough food available that the individual can choose how much to eat. In practice there are measurement difficulties, both because of the concept and because of the data. In terms of concept, the time dimension is not easy to incorporate. However, in common sense it is clear that the objective is to sustain food availability such that “insecurity” is not a major problem, and this is likely to be around the levels quoted at population level for “requirement”. “Future” security is rather different, since it involves assessing individuals’ perception of what will happen. Probably one needs to know both the public action available - for example employment guarantees - as well as private insurance such as food stocks or savings. Security in this sense is the converse to vulnerability, and social security is an important means of dealing with it.

Figure 4. Illustration of implications of dietary energy intake.

Causes of food insecurity are clearly related to poverty, but it is important to distinguish underlying trends and “shocks” that may turn vulnerability into actual deprivation. In this context, we will emphasize the policies in different sectors that affect food security (reducing vulnerability). Again, more emphasis has been given to those that are more likely to be influenced by nutrition considerations, and this tends to be those which support consumption in the relatively short run - related to social security.

Macro-economic adjustment programmes are now established as affecting nutrition. Broadly there are two types. Stabilization programmes aim at reducing imbalances in external accounts and domestic budgets, reducing government expenditure and restricting credit. Secondly, structural adjustment programmes aim to change the economy over the medium term, through an expansion of supply of tradeable goods, and increasing exports and import substitutes. In both cases, compensatory programmes may be included, to cushion the effects on consumption. The latter are particularly relevant to nutrition, should be carried out with the aim of reaching the most vulnerable, and monitored using nutritional information.

Agricultural policies and development programmes may influence household food security through their impact on both the supply and the demand for food; through determining food availability and the levels and fluctuations of household incomes, through their impact on food prices, women’s labour demand and time allocation, and on the nutrient content of foods made available. The focus should be on people and their means of acquiring as well as producing food. Higher and more stable real incomes for people dependent on unskilled agricultural labour may be the most important contribution agricultural policies can make to human health and nutrition in developing countries. The labour intensity of agricultural strategies is increasingly becoming a major priority. While there are a number of very relevant concerns in agricultural policy, the issue of cropping policy has been used to illustrate these. The effects on household food security of a shift towards commercialized agriculture, or cash cropping, are mediated by changes in employment and income distribution. This is likely to have a greater nutrition impact than that through effects on food availability. However, households may become more dependent on fluctuating markets, and the propensity to consume more calories out of additional income can be quite low, even in poor households; often more expensive rather than simply more calories are bought. Income from commercialized agriculture thus may or may not benefit nutrition. This depends partly on the expenditure behaviour of families which is influenced not only by total income but by its source and form, and by who controls it.

Cash crops are therefore neither good nor bad per se. This depends on their role in the economic process as a whole, which will differ between different areas. For example, some cash crops may be labour-intensive and provide employment for agricultural labourers without other possibilities. Recent research on the effects of agricultural commercialization has shown little impact - either positive or negative - on the nutritional status of children. Thus it is as much the details of how policies affect households, particularly the control of income and the effects on women, as the cropping policies themselves that affect nutrition. This argues for more effective incorporation of nutritional concerns in their planning and implementation. (See article in SCN News No. 3)⁷.

⁷ ACC/SCN (1989) Does Cash Cropping Affect Nutrition? SCN News No. 3, p 2-10.

A number of options exist for distribution schemes, aimed at subsidizing consumption and alleviating problems for net consumers arising from producer price increases. These try to guarantee food security through the provision of some form of social safety net, thus compensating to some degree for the lack of social security systems in many countries. The example of Chile, for example, where the safety net was largely successfully maintained during a political dictatorship, is illustrative.

General food subsidies, in which the government pays a proportion of the total production, storage, and marketing costs of a commodity, while not explicitly targeted, may reach different populations determined by marketing channels. They tend to benefit the urban rather than the rural population. General subsidies are usually expensive - for example in 1975 their costs accounted for 21% of Egypt’s total budget, 19% of Korea’s, 16% of Sri Lanka’s, and so on. General food subsidies are difficult to implement on a small scale, and they are expensive and administratively complicated on a large scale, particularly for rural areas. Generally market-wide subsidies are not regarded as a sustainable and cost effective way of reducing chronic food insecurity among the poor.

Targeted food subsidies may be more cost effective, but are politically difficult. However, a number of examples do exist. For example, the national coupon programme of Colombia only accounts for about 1% of the national budget; positive income and consumption effects of targeted subsidies have been demonstrated in Sri Lanka, Kerala (India), and Bangladesh.

Subsidies may be targeted by community, household, season, or commodity. In some cases geographic targeting has proved to be effective, for example food subsidy and food coupon schemes in Brazil and Colombia. Targeting by season can counteract variations in food prices, but has yet to be widely explored.

Subsidies for weaning foods and special foods for pregnant and lactating women are other options for reaching the most vulnerable, on which there is some more experience. Targeting by commodity is a promising possibility. These subsidize foods largely consumed by the poorest groups, for example coarse grains. A study in Indonesia has shown that reducing the prices of less-preferred foods such as corn and cassava, while increasing the prices of rice, can actually benefit the food security of the poor. Selected subsidization like this has also worked in Bangladesh. A mix of targeting - by area, age, income etc. - is likely often to be the most efficient method. We described one such scheme in SCN News No. 4, from the Philippines⁸.

⁸ Garcia, M. and Pinstrup-Andersen, P. (1987) The Pilot Food Price Subsidy in the Philippines: Its Impact on Income, Food Consumption and Nutritional Status. Research Report No. 61. IFPRI: Washington D.C.; SCN News No. 4, p 12-14, 1989.

Food stamps provide a further alternative for subsidized food distribution. These differ from rations mainly in that the quota is in terms of currency value rather than weight or volume. Again, the rationale for using stamps rather than cash is that the effect on food consumption may be higher with such methods than simply by transferring cash; moreover cash transfers tend to be politically more difficult. Examples exist from Sri Lanka and Jamaica, as well as the United States.

Subsidies, rations, quotas, food stamps and coupons are all means of lowering the real price of food for targeted consumers. Supplementary feeding programmes are also in fact a form of highly targeted ration or in-kind transfer schemes. They are aimed more at reducing the undernutrition in individual groups, rather than improving household food security overall.

Employment policies affect nutrition through their impact on the levels, fluctuations and distribution of income and purchasing power. Clearly policies that favour employment opportunities for the poor are central to long term prevention of malnutrition. At the macro level, structural adjustment has led to a deterioration in the overall employment situation in many countries. One indicator of this is the decline of modern sector wage employment, another is the widespread fall in real wages. For example, out of 20 African countries with comparable and recent data only three, Burundi, Senegal and the Seychelles, have reported modest increases in real wages since 1980.

The segmentation of labour markets between formal and informal, agricultural and rural non-farm sectors is also gradually disappearing at the household level in many countries, as many urban household re-establish links with rural areas as a strategy to survive in the face of adjustment-induced drops in real wages. Such occupational multiplicity, however, is at the expense of labour productivity and output, and could ultimately prove harmful to economic growth - a possible example of the counterproductive nature of many short-term adjustment “shocks”.

In poor rural societies, agricultural policies are effectively employment policies. As production is forced to intensify and populations grow in many countries, higher proportions of people are involved in agriculture as wage labourers, fewer as net producers. Their livelihoods will depend on the sustained ability to assure themselves of secure regular employment at a remunerative rate of pay. This once again stresses the need for labour-intensive agricultural strategies that put people and not production in the forefront. Equity should be seen more in terms of production, not just as distribution.

There is a distinction between long term employment creation, and provision of employment by public works (cash-or-food-for-work) which are a means of providing food security in the short-run.

Public works have been effectively used to cushion the effects of food crises, particularly in times of drought - examples of this come from India, Indonesia, Botswana, and a number of other countries. Public works employment is also used effectively as a safety net for the very poor in normal times, frequently being self-targeting by setting the remuneration rates below those of other employment. Employment provision obviates the need either to move food to families, or families to feeding programmes, as work can be offered close to home, at the same time building up the assets of the community and infrastructure. Public works may also preferentially benefit women where they form a great majority of the work force on such schemes, through raising their incomes. India’s success in such programmes is well established, and there may be unexplored potential in Africa, where, unlike India, much land is publicly owned. Ghana, Kenya, Lesotho, Malawi, Zimbabwe, Tanzania, and Mozambique have all used this method of employment provision. Food-for-work programmes fall within this category providing food as payment in kind, with potential for immediate impact on nutrition.

“Thank God! A panel of experts!”

A major choice concerns whether such schemes should provide a guarantee of employment. Such a safety net will obviously be more costly. The Maharasthra Employment Guarantee Scheme, for example, is financed by taxes on richer urban sector workers, and was originally introduced as one means of reducing rural-urban migration into Bombay. In Bangladesh, aid is used to fund such schemes with wages paid in kind.

Increasing income through employment provision is however not always sufficient to maximize the food security of all household members. A crucial question remains: who controls the increased income? Some considerations involve within-household decisions, and are looked at again under the heading of caring capacity.

Malnutrition and Infection

Interactions between nutrition and infection, to produce the “malnutrition/infection complex” cause the major public health problem in the world (see SCN News No. 4). Infection influences nutritional status through its effects on intake, absorption and utilization of nutrients, and in some cases on the body’s requirement for them. A child’s rate of growth may be retarded by too little food and/or too many infections or parasites. Malnutrition is associated with lowered immunity. Infections can lead to loss of appetite, decreased efficiency of food and nutrient utilization, to increased energy requirements, and decreased rates of child growth. The relationship between diarrhoeal disease and physical growth in children has been widely shown. This cycle is discussed in more detail in ‘Malnutrition and Infection’⁹.

⁹ Tomkins, A. and Watson, F. (1989) Malnutrition and Infection: A Review, ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 5. ACC/SCN, Geneva.

¹⁰ ACC/SCN (1990) Appropriate Uses of Anthropometric Indices in Children, ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 7. ACC/SCN, Geneva.

The synergism between disease and malnutrition is an essential reason that the health sector has a major responsibility in addressing malnutrition. Effective health services are among the most important interventions for dealing with malnutrition. Primary health care is the cutting edge for health for all, and of itself essential in dealing with malnutrition. Beyond this, it is possible to include specific nutrition activities within health services.

Here, we can look first at the nutritional activities which could be emphasized within the health services, contributing to the prevention and management of specific infectious diseases. Secondly, the possibilities of including more extensive nutritional activities - for example supplementary feeding - within health services needs to be considered. Third, policies for developing primary health care can have differential effects on malnutrition and infection. For example, there are trade-offs between pursuing a few selected interventions, such as ORT and immunization, compared with broader more institution-building approaches. This has some parallels with the questions of “growth-mediated” versus “support” strategies; they need not be mutually exclusive, if care is taken.

A number of priority actions within health directly addressing nutrition were discussed in the SCN publication on “Malnutrition and Infection”, and in the summaries given in SCN News Nos. 4 and 5. These merit brief reiteration in the present context. They would include the following points - it must be stressed that they are emphasized in the context of the usual activities of primary health care.

Exclusive breast feeding needs constant emphasis, as the best protection for babies up to four to six months. This is particularly important in preventing diarrhoea, and the need for continuing breastfeeding during episodes of diarrhoea as a primary method of management needs to be widely and continuously communicated. In older children, and particularly during persistent diarrhoea, the importance of continued feeding during the disease and in convalescence needs to be promoted. The role of vitamin A in relation to measles must be stressed: adequate vitamin A status in populations vulnerable to measles, and supplementation during treatment of the disease, are crucial. Supplementary feeding itself, to increase protein and energy intakes as well as micronutrients, before, during, and after measles, is important. Respiratory tract infections are becoming better recognized as major killers in young children, and nutrition has a role to play here too. Adequate vitamin A status, and increasing and maintaining food intake, possibly through supplementary feeding, in relation to these diseases is gaining more emphasis. In dealing with parasitic diseases, not only treatment of the parasite but increasing food intake is necessary.

Many of these considerations apply to childhood diseases. But concern for the nutrition of women, especially but not only as mothers, is increasing. Although general supplementation of mothers’ diets is not often feasible, changing attitudes to highlight its importance may be. Here, the possibilities of increasing the effectiveness of distribution of iron supplements through the health system, particularly targeting reproductive age women, requires heightened priority (see first article in this issue of SCN News).

Conventional nutrition interventions can be regarded as being aimed directly at malnutrition and infection. At a certain stage in the development of a country’s economy, these direct interventions may be useful as an interim measure to nutritionally buffer vulnerable individuals, while poverty is tackled in the long run. However, in some of the poorest areas in the poorest countries, with hardly any infrastructure or capability for service delivery, the very first priority, as mentioned above, may be to develop some kind of health care, communications, with nutrition programmes of somewhat lower urgency. Nonetheless, the type of emphasis on specific nutrition actions discussed above may still be possible. At the other end of the development spectrum, priority for nutrition programmes may tail off as countries industrialize, food becomes more plentiful, and health care extensive. This, it has been argued, is the position in countries such as Costa Rica, where the priority should shift again from nutrition to health. The value and success of direct nutrition interventions may depend on factors such as their historical timing as well as their relation to the real nature of the problem, the infrastructure and management capacity for implementation, and the political support and resources to ensure sustainability.

Supplementary feeding programmes are generally targeted to vulnerable individuals, for example by the age of the child, or the state of pregnancy or lactation of the mother. They are perhaps the most common type of nutrition intervention. While their benefits are not always clear, it seems sure that under the right circumstances they provide a direct means of increasing the intake of total energy as well as other nutrients. One problem has been that the benefits may not always be readily detected in terms of increased child growth - as discussed in “Uses of Anthropometry”; for children above two years of age much of the growth deficit may be irreversible. But, as also stressed in “Uses of Anthropometry”, growth is only an indicator of benefit, and not the sole objective itself. Therefore children may benefit by increased activity, improved immunity, and hence better health and development. This includes supplementary feeding of school-age children (as discussed in SCN News 5). One caveat here is that the poorest children often may not get to school.

Other common interventions include growth monitoring and promotion, nutrition education, home gardening, and so on. Growth monitoring must be linked with “growth promotion” - in addition to problem diagnosis, it should facilitate and accompany actions designed to remedy the causes of growth faltering. Growth promotion can be attained through linking monitoring to the identification of at-risk children, individual counseling and appropriate subsequent actions to at least prevent further deterioration. This has been easier to achieve in small-scale programmes due to the relative ease of frequent social interaction between health workers and mothers.

The need for nutrition education is especially pronounced where large changes have occurred in the environment constraining household decision-making, such as rural to urban migration or shifts from subsistence to cash cropping; in fact, any change that significantly alters the magnitude and source of household incomes and the availability of food and non-food commodities. Although nutrition education or behavioural change obviously has its limits where the causes of malnutrition are primarily economic, notable successes have been reported in several countries e.g. Indonesia.

Evidence suggests that home gardens have a positive impact on micro-nutrient intakes, more than on energy. Like growth monitoring and nutrition education, they are generally more effective undertakings on a small scale and problems of expansion will need to be dealt with. Sufficient land and labour are also prerequisites which are likely to be scarce amongst the most needy. However, experience from Zimbabwe has shown that community gardens (within which each person has a private plot) may be a viable option in Africa, with economies of scale in both farming methods and training.

Caring Capacity

At the individual level, nutritional status is determined by dietary intake and by infection. Dietary intake clearly depends to some degree on household food security, and the incidence, duration and severity of disease depends upon exposure to infection, access to health services, and the health environment. However, within the household there are a number of very important factors which operate. For example, breastfeeding and child feeding practices may be only partly governed by household food security, and much more affected by factors such as the availability of women’s time, control over income, etc. Equally, hygienic practices, care of sick children and other matters which are particularly the responsibility of mothers can mitigate the effects of an unhealthy environment. In the first place, many policies may directly or indirectly change such factors, often as a spin-off: a classic example is when agricultural development causes changes in cropping patterns, potential effects on nutrition of increased income may be modified by changes within the household. Or, increased employment for women may have detrimental effects on child care, unless other measures are taken. Further, it is possible to improve caring capacity directly by interventions, focusing on, for example, women’s education/literacy, her social security, etc. More direct effects may come through the promotion of breastfeeding, provision of weaning foods, or access to health services.

This important area of concern has recently been highlighted, particularly by UNICEF, and is now considered to be a central aspect of policies aimed at improving nutrition. It is however the least well described, not least in terms of empirical findings; in our review we had to depend more on concepts than hard results. What is given here is therefore initial thoughts on the topic, to be made firmer in future work. The features of the problem are not difficult to describe in general terms, however. They relate particularly to the role of women. Women have a primary responsibility for their families’ nutrition in most parts of the world. Therefore their ability to cope, their contribution to household decisions, and their time availability, are central to good nutrition.

Women have multiple roles in many poor households. (See “Women and Nutrition”, now published)¹¹. They may be mothers, home managers, producers and community organizers. Two of their primary resources, which often conflict, are income and time. The capacity of a mother to care adequately for her children will depend to some degree on how she allocates her time between productive and domestic work, as well as her access to health services, water and fuel supplies, and markets for foods. Within the household, her status will govern her degree of control over her time and income, and hence her capacity to ensure the health and well being of her children. The nutrition and health status of children has been considered a function of the quantity and allocation of income and time, which has itself been referred to as “household real income”. Increases in female income may thus not translate into increased food intake for children, since child feeding requires time, and the control over income is a crucial factor. Time may affect other activities, including bringing children for preventive health care such as immunization, protecting the child from unsanitary conditions, and providing a healthy environment. Food and water collection, and food gathering may be constrained by lack of time. As a first step to defining problems and relevant policies in this area, we distinguished the possibilities for direct intervention, from the broader policies primarily aimed at improving women’s position. This has now been developed more in the context of the policy statement (to be considered by the SCN in Feb/March), but the specific interventions are worth considering here, although they are in fact familiar.

¹¹ ACC/SCN (1990) Women and Nutrition, ACC/SCN Symposium Report, Nutrition Policy Discussion Paper No. 6. ACC/SCN, Geneva.

Child Feeding Practices. The availability of time for mothers to care for children importantly affects child nutrition through feeding practices. This concerns breastfeeding, frequency of feeding, energy density of foods, and other factors. Mothers’ time for adequate food preparation and attention to feeding is a major constraint. These can be affected by conventional nutrition programmes, and technology has a role. Access to processed foods or labour saving means of processing them, better cooking facilities, etc., are important. Not to be forgotten in, at least, middle income countries is access to satisfactory food storage, particularly refrigeration. The importance of feeding sick, anorexic children, and those convalescing from illness is constantly being re-emphasized. This may be a particular place where maternal time and caring capacity has an effect on child nutrition.

Exposure to Infection and Utilization of Health Services. Reducing exposure to infection comes down to factors such as women’s time to undertake household chores, income to purchase the necessary supplies, adequacy of water supplies and sanitation, etc. Labour saving technology again may have a role here. Health education and facilitated access to simple supplies, e.g. soap, may be part of health and nutrition programmes.

The care of sick children in this context, to reduce the severity and duration of current infection, and to prevent secondary infection, as well as to prevent worsening of minor injuries, require both time and knowledge. Home visits by health workers, and better utilization of health services are important here. Constraints to adequate use of health services are time available for attendance, money available for transport/medicaments and sometimes clinic attendance itself. Increased use of home remedies - in particular oral rehydration - can clearly be improved by intervention. Distribution of oral rehydration salts, and the necessary information to use them correctly, is already increasing.

Children’s Well Being. A child that receives plenty of loving care from parents, guardians, relatives and friends, thrives better. This is understood in terms of psychological and cognitive development, where stimulation is known to be beneficial. It may also be the case in terms of health. Certainly a miserable and neglected child is going to be more exposed to infection, and there may be other effects through the immune system. It hardly needs proving that loving care is valuable in its own right; and it may legitimately fall within the concern for health and nutrition. Here, it is possible that such measures as adequately organized and supported day care may have a direct benefit on nutrition.

Women’s Control of Resources. This area has been explored elsewhere, and needs emphasis here because of its important influence on nutrition. It essentially concerns the social and economic status of women and how this governs their degree of control over resources within and outside the household. In most poor societies, patriarchy is likely to be the main obstacle to securing a fairer distribution of work and decision-making power between adult household members. Gender divisions however are not written in tablets of stone; they can be altered.

The social status of women has been seen to be improved by raising their economic status. Measures aimed at increasing women’s economic productivity will affect their own position in the immediate family as well as their valuation in society in general. Direct unmediated access to income drastically reduces a woman’s dependency and thus strengthens her ability to realize her own preferences within the family; of which the health and well-being of her children is likely to be seen as a priority.

In the longer term, as women’s economic status improves, so will the opportunity cost of not investing in their welfare; raising female earning power may thus be critical to increasing the effective demand for such services as education, health and family planning. Maternal literacy and schooling has been associated with a more efficient management of limited household resources, greater utilization of available health care services, better health care practices, lower fertility and more child-centred caring behaviour. The education of daughters would also be seen as more of a priority, reducing gender inequities in school enrolment, attendance and literacy levels. The future pay-offs of this would include reduced fertility and reduced infant mortality rates. The increased awareness, communication and exchange of ideas would generate more effective political demand, consolidating these changes.

The problem of women’s lack of power is often not captured by national censuses or agricultural surveys.

These may need re-designing. A gender-specific disaggregation of indicators of labour participation, time allocation to domestic and productive work, wages, power over decisions made are examples that would show the relative status of women vis-a-vis men in different societies.

* * *

This review gives one possible agenda for deciding on policies for improving nutrition in the future. It includes both short-and long-term measures, and may be supportive of broader policies for development. The meeting in November reached a considerable degree of consensus on ways ahead. This, it is hoped, will be reported in SCN News No. 7, scheduled for mid-1991.

- J.B.M./S.R.G.

Weaning Foods - new uses of traditional methods

Fermentation reduces contamination; adding germinated grains reduces bulk - both help safer weaning.

Safer weaning can be achieved through preparation of hygienic and nutritionally balanced weaning foods with high energy density per unit volume, of which enough can be eaten. How to reach these goals in simple, practical and economical ways has been the subject of extensive studies by investigators from Ghana, India, Tanzania, Sweden and other countries in recent years. The efforts, concentrated on traditional food preparation methods, have resulted in offering cheap and practical answers to these problems from familiar, indigenous and culturally acceptable home-processing practices. “Dialogue on Diarrhoea” has recently produced an issue in which two methods of fermentation and germination are discussed for a safe weaning. Some of the data provided are used in this article.

Both fermentation and germination or malting are reported to have the potential for contributing to safer weaning, tackling the twin problems of bacterial contamination and bulk.

Firstly, cereal fermentation is used for reducing the risk of contamination under the existing inappropriate conditions for food preparation and storage in many households. Secondly, trials in some developing countries indicate the value of using a tiny amount of sprouted grains’ flour in preparation of weaning foods as a magic way to thin down the viscosity without decreasing energy density. Nutrition and health promotion programmes can benefit greatly from such strategies in order to reduce the prevalence of food-related diarrhoeal diseases, as well as to increase energy intakes of many poor weaning-age children around the world.

A brief description of how these familiar methods can help to achieve safer weaning comes next.

Reducing Contamination through Fermentation

Many weaning foods have a serious level of faecal contamination. That contaminated feeds are a principal cause of gastroenteritis in children and even adults is well documented.

A method to eliminate pathogenic bacteria and inhibit their growth during storage of weaning preparations can benefit nutrition and health in young children considerably. Use of fermented foods for feeding children of weaning age appears to be an effective solution. Fermented foods have lower levels of diarrhoeal-germ contamination, they are suitable for child feeding, and can be safely stored for much longer periods of time than fresh foods. The practice has been a traditional way of food preservation in many parts of the world. The antimicrobial properties of fermented foods and their relative higher safety - documented since the early 1900s - has been indicated in a number of studies (e.g. Mensah et al, 1990). In Ghana, it is common to ferment maize dough before cooking it as porridge. In Kenya, cereal-based porridge (called uji) and milk are traditionally fermented. Preserving milk in the form of yoghurt has been known to many households living in hot climates.

The same porridge shown both before the addition of kimea (inset), and a few minutes afterwards (main picture).

Source: Dialogue on Diarrhoea, issue No. 40, March 1990.

Ulf Svanberg/Wibald Lorri

What are the underlying mechanisms by which fermentation processes help to prevent or reduce contamination? A possible answer suggests that during fermentation process foods become more acid. This explains why diarrhoea-causing bacteria are not able to grow in fermented foods as rapidly as in unfermented ones. It is also hypothesized that some of the germs present in the foods are killed or inhibited from growing through the action of antimicrobial substances produced during fermentation (Dialogue on Diarrhoea, 1990). The fermented foods can, therefore, be kept for a longer time compared to fresh ones. It has been shown that while contamination levels in cooked unfermented foods increase with storage time, fermented foods remain less contaminated.

Whatever the underlying mechanism, the fact is that the exercise reduces contamination without adding to the household cost both in terms of time and money. Its preparation is easy. The cereal flour is mixed with water to form a dough which is left to be fermented; addition of yeast, or mixing with a small portion of previously fermented dough is sometimes needed. The dough can be then cooked into porridge for feeding to the child. Although beneficial unfortunately the practice is going out of fashion, partly because of current emphasis on the use of fresh foods particularly for children. For example, a study on the use of fermented foods for young children in Kenya (Dialogue on Diarrhoea, 1990), demonstrated that while foods are still frequently fermented at home for child feeding, their use is becoming less popular particularly in urban areas where commercial products are more available. Consequently, the fermented foods have now been replaced by these products. It was also noticed that health workers are discouraging the use of fermented foods, being unaware of their benefits. The potential benefits of using fermented foods for child feeding, particularly where risk of contamination under poor environmental conditions is high, are now recognized and need to be promoted.

More liquid but not diluted!

A new, cheap and simple solution challenges the old problem of bulky low-energy density weaning foods, traditionally made around the world from rice, sorghum, wheat, maize, millet, tapioca, sago and the like. The water-holding capacity of cereals makes them swell upon cooking in water. This high volume and viscous characteristic of a diet is known as dietary bulk. The resultant thick and bulky gruel is not easily consumed, especially by sick and anorexic children. When water is added to make it more liquid, the energy and other nutrient density of the meal declines. This means that a large volume is required to satisfy the energy needs. For example, it is calculated that a liquid gruel which usually has about 5% dry matter, will have an energy density of about 0.2 Kcal per gram. To meet energy needs a young child should consume 4 to 5 liters of such gruel (Mosha and Svanberg, 1990). The upper limit of dry matter is normally 20% (0.7-0.8 Kcal per gram), because beyond this level, the gruel would be too thick to stir.

The new solution tackles this same problem of high viscosity. The trick lies in using flour of sprouted grains, known as “power flour” or amylase rich flour (ARF). During germination, amylolytic enzymes or amylases are developed and become activated. These enzymes break down the long chains in a complex carbohydrate such as starch into shorter dextrins, while at the same time free the water trapped in the gel. When germinated flour is used or added to an already made thick gruel (up to even 30% solid concentration), the meal becomes liquified almost instantly. A meal prepared in this way with 25 to 30% dry matter would have an energy density above 1 Kcal/gram. This is the level of energy density recommended for a weaning diet, on the basis that breast milk has an energy density of around 0.7 Kcal per gram. Use of power flour has been shown to be a most effective and practical approach to reduce the viscosity and dietary bulk. In Chile, Alvina et al. (1990) have shown that the energy density of an extruded pea-rice mixture can be doubled from 0.8 to 1.6 Kcal/g without any change in viscosity by adding different amounts of malt flour. (The initial extrusion treatment produced a lower consistency by cleavage of starch molecules, therefore energy density of 0.8 Kcal/g could be achieved in the absence of malt flour).

The germination process is simple and well-known. Any cereal or legume grains can be soaked overnight and allowed to germinate for 2-3 days (depending on the type of the grains used) in the dark, covered by a wet cotton cloth. The germinated seeds are then dried in the sun for 2 days (as moisture will destroy the enzymes) and ground into a flour, which should be stored in a dry cool place.

While the procedure for making power flour is simple, routine use of germinated flour itself for preparation of weaning foods is a rather time consuming task and adds to the already heavy work load of women in these societies. This may in fact explain why this practice - benefits of which are already recognized in some communities in Asia and Africa - has not been widely used. For this reason it is proposed to use germinated flour as an additive to weaning foods prepared with ungerminated cereal grains (Gopaldas et al., 1986; John and Gopaldas. 1988; Hansen et al. 1989; and others). The amount of germinated flour needed to be added to already prepared gruels is small (4-5% of the total flour used). It has been shown that higher amounts usually have no further effect on viscosity. As little as 100-200 grams of any cereal (or legume) grains may be used for making germinated flour, enough to thin down a child’s daily gruel for one month according to Gopaldas (1990). The cost is a fraction of a US cent, much lower than commercially available weaning foods.

Germination is traditionally used in many countries in Asia and Africa. As an answer to the problem of bulky and low-density weaning foods it was used by the Tanzanian Food and Nutrition Institute in the early 1980s when the UNICEF/WHO Joint Nutrition Support Programme promoted the use of power flour (called Kimea) in the Iringa region of Tanzania. A number of trials in various countries have reported that use of power flour is acceptable to both mothers and their children. Community trials in Chile, India and Tanzania have shown that the food and energy intakes of children have been increased substantially upon consumption of gruels to which power flour was added. In India both acceptability and growth trials indicated the potential of power flour for improving the growth of young children (Gopaldas, 1990). It is also suggested that the use of power flour may prove to be a valuable way to feed anorexic children, as well as during and after a diarrhoeal episode (Dialogue on Diarrhoea, 1990).

Both fermentation and germination are practical, economical and familiar to the mothers in many countries. They seem to have the potential for making weaning a much safer experience for many young children living under poverty and undesirable hygienic conditions.

Mahshid Lotfi

SOURCES:

Alvina. M. et al. (1990). Ecology Food and Nutrition, 24, 189-193.

Desikachar, H.S.R. (1980). Food and Nutrition Bulletin, 2 (4), 21-23.

Dialogue on Diarrhoea, Issue no. 40, March 1990.

Gopaldas, T. (1990). Concept of Amylase Rich Food (ARF) and its Role in Infant Feeding and Growth. Communicated by Tare Gopaldas, Faculty of Home Science, Baroda-2, India.

Gopaldas, T. et al. (1986). Food and Nutrition Bulletin, 8 (4), 42-47.

Hansen. M. et al. (1989). Food and Nutrition Bulletin, 11 (2), 40-45.

John. C. and Gopaldas, T. (1988). Food and Nutrition Bulletin, 10 (4), 50-53.

Mensah, P.P.A. et al. (1990). Fermentation of cereals for reduction of bacterial contamination of weaning foods in Ghana. Lancet, 336, 140-143.

Mosha, A.C. and Svanberg, U. (1983). Food and Nutrition Bulletin, 5 (2), 10-14.

Mosha, A.C. and Svanberg, U. (1990). Food and Nutrition Bulletin, 12 (1), 69-74).