News and Views

AGN ARTICLE

News from Kenya - By Ruth Oniang'o

The Kenya Agricultural Research Institute (KARI) and the International Livestock Research Institute (ILRI) have been selected as co-winners of this year's Outstanding Scientific Partnership Award.

This award, one of the four Consultative Group in International Agricultural Research (CGIAR) Chairman's Science Awards, is in recognition of the outstanding achievements of the two institutions in collaborative research to enhance smallholder dairying in Kenya. The award was presented on October 31,1997 in Washington D.C. during the international centres week.

The CGIAR Chairman's Science Awards were established in 1996 to honour scientific excellence and achievements in several categories. Each award consists of a plaque and a cash prize of US$ 5,000. I personally was very excited to learn of this achievement for both institutions. The award comes at a time when local scientists question the legitimacy and relevance of international centres. So much funding has, over the years, been channelled to these centres; some centres have made significant impact globally, and have thus justified the excellent remuneration packages they enjoy, and well equipped laboratories and logistical support. With diminishing support for agricultural research, however, there is increasing scepticism as to the real place of some of these international centres in the uncertain world of agriculture in developing countries. Some organizations exist as islands in their host country, with little interaction with local scientists. In contrast, ILRI needs to be commended for reaching out and working persistently with local scientists and farmers. All centres should take cue from this noble strategy, as it is the only way to justify continued support to their existence.

Similar credit goes to KARI, for adopting a new approach that has involved working with farmers on their own farms. For a long time in developing countries, agricultural scientists have worked, again in isolation, away from the farmer and also away from the extension worker. The scientists have often forgotten that their responsibility is ultimately the farmer. Failure to realise this fact has led to loss of credibility and with it, loss of funding both locally and internationally, for the past nine years. KARI has engaged in a new approach whereby demonstrations are carried out at the farm level, involving the farmer, the extension worker and the researcher. The Dairy Project, for which KARI has been recognized, is but one of the many projects KARI is carrying out in this way: applying a production-consumption systems approach.

Dr Cyrus Ndiritu has been Director of KARI for the past nine years. Dr Ndiritu deserves support as he adopts new and innovative strategies to face up to the new challenges of African agriculture, food security, and possibilities of industrializing and reducing poverty.

Awards are good because they serve both as incentives and examples. One only hopes that somebody somewhere will recognize the extension staff and the farmers, not necessarily with a cash award because there are many forms of recognition. Without these people, there would be no award for either KARI or ILRI.

Ruth Oniang'o is the current vice chair of the AGN (see page 2). She is a professor in food science and nutrition at Jomo Kenyatta University College of Agriculture and Technology, P.O. Box 62000, Nairobi, Kenya. Tel: 254 151 22646/9 Fax: 254 151 21764 or 254 2 631 200 Email: oniango@form-net.com

Assessing the Nutritional Vulnerability of Older People in Developing Countries

With increasing life expectancy and declining birth rates, the world is experiencing a major demographic shift. In 1990,42% of the world's population of older people lived in developing countries. By 2020, this figure will rise to 70%. And yet very little attention is paid to the nutrition of older people in developing countries or how it may affect their ability to lead an independent life. For the poor, retirement is often not an option, and the ability to lead an independent life is crucial to survival and well being.

A Symposium held at the London School of Hygiene and Tropical Medicine on 23-24 September 1997, brought together more than 70 representatives of NGOs, UN agencies and universities, to discuss the assessment of nutritional vulnerability in older people in rural and urban settings, and in refugee camps. The first half of the Symposium programme focused on the results of a research programme carried out by the Public Health Nutrition Unit of the London School of Hygiene and Tropical Medicine in collaboration with HelpAge International. The second half of the programme considered risk factors of nutritional vulnerability and how organizations could work with older people in developing countries.

1997 ACC-SCN Statement on Iron Iron deficiency anemia is the most widespread nutritional deficiency in the world today. There is overwhelming evidence that it has a serious impact on human development, on the formation of human capital: and on the social and economic development of most developing countries. Of greatest concern is that iron deficiency anemia in infancy results in irreversible cognitive impairment and in adults is associated with weakness and fatigue that reduce work capacity and productivity. Iron deficiency also impairs immune function. Iron deficiency anemia results in poor pregnancy outcomes by contributing to low birthweight and to perinatal, neonatal, infant and maternal mortality. Child growth is also affected. Prevalence rates of iron deficiency are very high in many developing countries and the severity of its consequences is so great as to represent a public health emergency. Good progress is now being made in launching large-scale programmes using effective control measures including fortification of cereal flours and complementary foods, supplementation, and changes in meal patterns to increase icon absorption. These are extremely important developments and need to be continued and strengthened. The elimination of iron deficiency as a public health problem must continue to receive priority attention. The Sub-Committee on Nutrition calls upon governments, donors, UN agencies, the food industry and the university and NGO community to explore actively new actions and initiatives which can be taken to achieve major reductions in iron deficiency over the next several years.

The collaborative research programme began in 1992. The objectives were to test simple but reliable methods of assessing nutritional status in older people, to identify factors that place the older person at risk of poor nutritional status and to examine the relationship between nutritional status and the ability to lead an independent life. Research was carried out in three settings: the urban slums of Mumbai (India), a refugee camp for Rwandans in Karagwe (Tanzania), and rural communities in Malawi.

In adults, body mass index (BMI: weight/height²) is used to assess nutritional status. However, measuring height in older adults can be problematic due to curvature of the spine. Studies have shown that long bone measures (armspans and knee heights) can be used as proxies for height. As these bones are not affected by aging in the way that the spine may be, the research programme took these measurements to estimate height and hence BMI. The ability to live independently was assessed through questionnaire, observation and performance in specific pre-tested physical tests of functional ability. Socioeconomic and morbidity information was obtained also through questionnaire and examination. In India, blood analyses were also carried out.

The prevalence of malnutrition (BMI<18.5) was similar among urban Indians and rural Malawians (approximately 35%), but considerably lower in the refugee population (16.4%). There are several possible explanations for the relatively good nutritional status of the refugees: they came from a food secure rural region of Rwanda, HelpAge International provided good support in the camp, and only those with better nutritional status arrived at the camp. Physical impairment was highest in India, and increased with age in all populations. It also increased with deteriorating nutritional status and, in India, with lower haemoglobin levels. The prevalence of anemia in India was high: 38% among men and 52% among women, rising to 70% among women over 70.

Preliminary analysis of the data from the three studies has identified some risk factors of nutritional vulnerability, such as living alone, social isolation, reduced food intake, illiteracy, poor socioeconomic status, and certain disease conditions. Symposium participants identified other possible risk factors for different settings, but it was accepted that many would be specific to the location. A field handbook to assess nutritional vulnerability (including the assessment of nutritional status) has been prepared based on the research programme. This was introduced at the Symposium, and will be revised, field-tested and published by early 1998.

The Symposium achieved its primary objective, namely to advocate for greater attention to be paid by development and emergency organizations to the nutritional and related needs of older people in developing countries. Advocacy targeted to international and national policy makers is now needed.

For further information and the full report of the Symposium please contact Suraiya Ismail, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, U.K. Tel: (44-171) 927 2132 Fax: (44-171) 383 5859 Email: s.ismail@lshtm.ac.uk or, Kate Gregory or Karen Peachey at HelpAge International, 67-74 Saffron Hill, London EC1N 8QX, U.K. Tel: (44-171) 404 7201 Fax: (44-171) 404 7203 Email: helpage@dial.pipex.com

Reducing Mortality Rates in Severely Malnourished Children

Severe malnutrition¹ in childhood is widespread in the developing world, with an estimated 69 million children under five currently affected. Frequently associated with diarrhoea and other infections, the most severe forms of malnutrition are marasmus, kwashiorkor and marasmic-kwashiorkor. Growth deficits invariably persist into adulthood, adversely affecting work performance, and for girls, increasing the risk of bearing infants with low birthweight.

¹weight-for-age <-3SD of NCHS reference median

In 1992, the FAO/WHO International Conference on Nutrition specified the need to develop resources necessary to deal with nutrition problems more effectively, including the strengthening of existing capabilities and provision of improved and appropriate training. These broad objectives are being addressed practically by the WHO/UNICEF initiative on Integrated Management of Childhood Illness (IMCI). The treatment guidelines have made a substantial contribution to the IMCI strategy and are now ready for field-testing.

To help put these guidelines into practice, the next phase of this project involves the preparation of a training programme to teach relevant skills. This phase is currently underway and includes the development of training materials. In the final phase, it is proposed that centres of excellence be set up where practitioners can be trained to treat severely malnourished children using the training materials developed in Phase 2.

For further information about this project, please contact Claire Schofield, Research Fellow, Public Health Nutrition Unit, LSHTM, Keppel Street, London, London WC1 7HT, U.K.. Fax: (44 171) 383 5859 Email: c.schofield@lshtm.ac.uk

(modified from 'Ten steps to recovery' by Ann Ashworth, Alan Jackson, Sultana Khanum & Claire Schofield, Child Health Dialogue, 1996)

Tulimbe Nutrition Project: a Community-Based Dietary Intervention to Combat Micronutrient Malnutrition in Rural Southern Malawi

Micronutrient deficiencies have far-reaching consequences on growth, development and health. Deficiencies of vitamin A, iron and zinc are widespread in rural Malawi and elsewhere in Southern Africa, where staple diets are plant-based and contain high levels of antinutrients (i.e. phytate, dietary fibre, and polyphenols) which inhibit absorption of non-haem iron and zinc. In addition, intakes of flesh foods and dairy products are generally low. Consequently, the content and bioavailability of iron, zinc, preformed vitamin A and fat in rural diets in Malawi and other parts of Southern Africa are very low.

The approach used by the Tulimbe Nutrition Project to address these micronutrient deficiencies is one of dietary modification and diversification. This is more culturally acceptable and economically feasible than supplementation or fortification. This approach involves changing food selection patterns and traditional household methods for preparing and processing indigenous foods. The goal of the new dietary strategies is to enhance availability, access and utilization of micronutrient-rich foods throughout the year.

The name "Tulimbe" means "let us be strong" in the Yao language. The project, which is funded by CIDA (through the Micronutrient Initiative), World Vision Canada and UNICEF Malawi, began in 1995, working with two communities and 300 targeted families with 3-7 year-old children. Baseline assessment involved focus groups, with men and women, on food practices. Parental knowledge, attitudes and practices (KAP) and socio-economic status (SES) were assessed, and dietary (interactive 24-hour recall), anthropometric, biochemical, clinical and morbidity assessments were carried out on children aged 3-7y. Dietary and anthropometric measurements were repeated after six and twelve months. Morbidity was monitored on a monthly basis. KAP and biochemical measurements were repeated after twelve months.

The intervention introduced ways of increasing the intakes and bioavailability of micronutrients from foods, including the introduction of new cultivars, technologies, and methods for food processing and preparation. To enhance the diversity of the diet and to increase the fat and carotenoid content, soybeans, short duration pigeon peas, groundnuts, sunflower seeds and papaya seedlings were given to each family. The Malawi Industrial Research and Technology Development Centre built and installed solar dryers, seed oil presses and ovens in each community. In an effort to improve the nutrient density and bioavailabilty of calcium, iron and zinc in the porridges used for infant and child feeding, the use of soaked and fermented maize flour and germinated cereal flours was promoted. Parents were also advised on the characteristics of micronutrient-rich foods, meal frequencies, portion sizes and food combinations. Nutrition messages and recipes were introduced to parents through demonstrations, home visits, plays, songs, and booklets.

The impact of the intervention on children and their parents was evaluated using both quantitative and qualitative indicators. Although this evaluation is still in progress, the project appears to have been successful in changing parents' attitudes to child nutrition and child-care, and this is evident by their adoption of new dietary strategies. For the community, its participation in the nutrition project has been an empowering experience, one that has inspired new initiatives in community-based health care. Further reports on the Tulimbe Nutrition Project will appear in later issues of SCN News.

This article was submitted by Rosalind S. Gibson, Nancy Drost, Fiona Yeudall, B. Mtitimuni, and T. Cullinan, of the Department of Human Nutrition, University of Otago, PO Box 56, Dunedin, New Zealand, and the Bunda College of Agriculture and the College of Medicine, University of Malawi, Malawi, Africa. The Tulimbe Nutrition Project is supported by grants from the Canadian International Development Agency through the Micronutrient Initiative and World Vision Canada, and UNICEF Malawi. Further information about the project can be obtained from Professor Gibson, Tel: +64-3-479-7955 Fax: +64-3-479-7958 Email: Rosalind.Gibson@Stonebow.Otago.AC.NZ

Nutritional Situation of Eritrea

In 1991, Eritrea emerged victorious from 30 years of war against an Ethiopian regime. Currently the Eritrean government and people are trying to reconstruct the country's devastated infrastructure and economy.

Micronutrient deficiencies are of public health significance in Eritrea, and in recent years, the government of Eritrea has started to tackle this problem by creating a national multi-sectoral taskforce. This taskforce began by working towards iodizing salt, and it is hoped that universal salt iodization in Eritrea will be a reality within the next few years. In addition, the Ministry of Health is undertaking a nationwide survey of micronutrients, the results of which will be used to develop a wide-scale intervention to reduce micronutrient deficiencies.

As a consequence of Eritrean government policy however, many NGOs have recently decided to leave the country. The government of Eritrea advocates that self-reliance is the key for a sustainable and lasting solution to nutritional problems in the country, and has a policy against accepting food aid except under life-threatening emergency situations. It is presumed by the government that any aid ("Food Aid") may lead people to be idle, and it is believed that the long-term impact of this will be to direct communities to look for national or international aid rather than working hard to overcome their crisis. The government does not allow international NGOs to implement their own strategies, but allows them to participate in monitoring, evaluating and controlling utilization of funds. All NGOs who plan to launch a national or local programme in Eritrea are required to comply with the existing government policy (e.g. health, education and agriculture policies). If they do not fulfil specific criteria, they do not get a contract or license. With Eritrea being a country emerging from a long civil war and a continuous drought, the view of the author is that Eritrea requires not only food aid, but also aid for development programmes in general.

This article was submitted by Ghermai Berhe, Email: Ghermai_Berhe_at_WVCAN-PO@Worldvision.CA (formerly at World Vision Eritrea)

The Integrated Rural Nutrition Project, Kawambwa, Zambia: Successes of a Nutrition Education Programme

Results from the Integrated Rural Nutrition Project (IRNP) in Kawambwa, Zambia, show that nutrition education programmes can have a significant, positive impact on the nutritional status of children under five years of age. Initiated in 1985, the IRNP, supported by the German Agency for Technical Cooperation (GTZ), applies a multi-sectoral approach with a strong nutritional education component to address the problem of malnutrition. Through this project, combined efforts have been undertaken by the Ministries of Health, Education, Agriculture and Community Development with the aim of reducing the rate of malnutrition in children under five years of age (1996 DHS data: 42% stunting and 26% underweight).

Analyses show that young children in the project area had better weights (for their heights) than children in the non-project area, after controlling for other factors such as wealth, access to services (e.g., water, health), maternal and paternal education level, child gender and child age. For example, 3 year old children in the project area weighed on average 0.3 of a z-score more than 3 year old children in the non-project areas.

Results also show successes in breastfeeding practices. Most children in the district are not optimally breastfed, however children in the project area followed distinctly better breastfeeding practices than those in other areas of the district. Children in the project area were exclusively breastfed for longer periods. In the non-project areas 40-60% of children were introduced to non-breastmilk liquids in the first week of life, compared with 10% in the project area. At the end of the first month, less than 20% of the children in the project area had received non-breastmilk liquids as compared with 80-95% on the non-project areas.

The main activity of IRNP in the agricultural sector is a seed multiplication component aimed at increasing the availability of legumes (beans and groundnuts). Although results showed that the availability of legumes improved through the project intervention period, shortening the "hungry season" (which usually lasts from December to April) by 3 months, this increased food availability did not result in improved anthropometric results in children. Positive results were only shown in children who were not part of the seed multiplication programme. The reasons for this might be that the extra legumes were not used for home consumption, but were used as a cash crop. It is also possible that the agricultural extension staff did not put sufficient emphasis on the nutritional message but focused mainly on the technical side of the agricultural production. These possibilities are currently being investigated.

Throughout the project, the question was raised whether nutrition education alone (via training of extension workers, via direct extension or via social marketing and mass education), can have a significant impact on nutrition without emphasis on increased food production. Through the observations and personal experience of the IRNP project advisor, Juliane Friedrich, the activities aimed at increasing food availability were not as successful as the nutrition education component - those activities aimed at improving nutritional knowledge, attitudes and practises.

This article was submitted by Juliane Friedrich, IRNP Project Advisor, c/o GTZ-PAS, Private Bag RW 37X, Lusaka, Zambia. Fax: + 260 1 291946 Email:gtz-imp@zamnet.zm

Highlights of the XVIII IVACG Meeting, Cairo, Egypt, September 1997

The exciting findings reported from the second field trial of the Nepal Nutrition Intervention Project - Sarlahi (NNIPS -2), were one of the highlights of the International Vitamin A Consultative Group (IVACG) Meeting, held this year in Cairo. In this randomized, double-masked community trial, weekly vitamin A supplementation, equivalent to 7000mg of retinol and provided either as preformed retinyl palmitate or as b-carotene, was given to women of childbearing age. The project was a high-input research trial of great magnitude, involving over 44 000 women who were visited at home on a weekly basis by 432 trained staff. Results showed that this low-dose weekly supplementation markedly reduced the risk of pregnancy-related mortality. Combining the effects of the two interventions, pregnancy-related mortality decreased by 45% compared with that of a placebo control group. b-carotene had a greater effect than preformed vitamin A, and it was suggested that this may be due to the additional antioxidant and immunoregulatory properties of b-carotene. No detectable effects of supplementation were observed on fetal mortality or early infant mortality rates.

The incidence of night blindness was also markedly reduced in pregnant women receiving the vitamin A supplementation. This protection was extended into the postpartum period: compared with the placebo group, the incidence of night blindness in the first 6m postpartum was reduced by ~60% in the preformed vitamin A group and by ~30% in the b-carotene group. The effect of supplementation on iron deficiency anemia was less marked, as parasitic infections - in particular hookworm infection -modified the effect of vitamin A on iron status. It was suggested that vitamin A interventions might play an important role in controlling maternal anemia in Nepal only if combined with hookworm control. Preliminary findings also suggested that supplementation may reduce the risk of ocular birth abnormalities in newborn children.

Currently, 28 countries are providing high-dose vitamin A supplementation to postpartum women. The results of NNIPS-2 suggest that low-dose vitamin A supplementation for women of childbearing age is a strategy that can reduce maternal mortality and may provide significant health benefits for their breastfed children. These quantities of vitamin A are possible to obtain by dietary means as well as through supplementation.

Other news from the meeting included an announcement by USAID of a new initiative to avert one million child deaths each year that are attributed to vitamin A deficiency. Through collaborative effort with other donor agencies, USAID will lead activities in several countries to incorporate vitamin A in all child survival activities and to use vitamin A coverage as a key child survival indicator. Evidence of successful integration of vitamin A supplementation into WHO's Expanded Programme on Immunization (EPI) and national immunization day activities was also provided, as were food-based approaches, including food fortification, to improve vitamin A status.

The mission of IVACG is to guide activities for reducing vitamin A deficiency in the world. Through its international meetings, IVACG provides a forum for new ideas, encourages innovations, recognizes important research findings, increases awareness of the latest survey data, and promotes action programmes, A complete report of this meeting will be available in spring 1998 from the IVACG Secretariat, ILSI Research Foundation, 1126 Sixteenth Street, N.W., Washington, D.C. 20036-4810, U.S.A; Tel: 202 659 9024 Fax: 202 659 3617 Email: OMNI@ilsi.org. Source: IVACG Meeting abstracts and news release,

The Integrated Child Development Services Scheme (ICDS) 1997

The Integrated Child Development Services (ICDS) Scheme was initiated in 1975 and has since developed into one of the worlds largest and most unique programmes for early childhood care and development. It delivers an integrated package of health, nutrition and education services to 3.8 million expectant and nursing mothers and 20.3 million children under the age of six from disadvantaged groups, with the objective of enhancing childhood care and development. A package of services, including supplementary nutrition, immunization, health check-up and referral services, is provided with early childhood care and pre-school education provided to children below the age of 6 years, and nutrition and health education provided to women of child bearing age and adolescent girls. The programme takes a holistic view of the development of the child and attempts to improve both the pre-natal and post-natal environment. The ICDS operates through a network of anganwadis, or courtyard play centres, which form the focal point for delivery of services at the community level. Some 350,000 trained community-based anganwadi workers and an equal number of helpers, supportive community structures and women groups are involved.

In 1992, a national evaluation of ICDS was completed and published by the National Institute of Public Cooperation and Child Development, New Delhi ("National Evaluation of Integrated Child Development Services"). A revision of this report was reprinted in 1997. Between the release of the National Evaluation of ICDS in 1992 and its reprint in 1997, several changes have taken place in the policy, thrust and implementation of the scheme.

There has been a strategic shift in policy to focus on reaching the younger child and to adopt a preventative, rather than curative approach to malnutrition. The programme is now focusing on improving the quality of caring practices for children under 3 years of age, on preventing malnutrition as early as possible and promoting psychosocial development during early years.

Pre-school material in local languages has been developed for use in the anganwadis, and linkages between the anganwadis and primary schools have been strengthened. Efforts have been made to strengthen the training component of workers and helpers by focusing on field-based, participatory training that is relevant to local needs. The basic infrastructure facilities in the anganwadis have been improved with new provision of storage facilities for supplementary food.

To ensure that the benefits under the scheme reach the most disadvantaged areas, 180 new focal districts have been identified for coverage. Greater and more effective involvement of NGOs has also been attempted by exclusively earmarking new ICDS projects for implementation by NGOs. Attempts will be made to hand over 10% of projects in every state to NGOs.

A community-based monitoring mechanism has been introduced to ensure that monitoring and evaluation of the schemes occurs by members of the community. This provides a powerful stimulus to the community to effectively participate in all stages of implementation. A plan for introduction of services has also been formulated through which to initiate new ICDS projects. This emphasizes two phases of activities to precede each project: first, administrative and community preparation, and second, training of frontline workers.

Emerging from two decades of rich experience, the task of the ICDS now is not only to tackle disease and malnutrition, but also to ensure equality of opportunity to present and future generations of disadvantaged groups and to promote every child's right to development with special focus on girls and children with disabilities. The spectrum of ICDS services has broadened with the interventions related to the empowerment of women and communities and convergence of sectoral services. This emerging profile of ICDS has rededicated itself to promoting early child development.

Further information about the ICDS and the ICDS publications mentioned in this article, can be obtained by contacting Dr Adarsh Sharma, Additional Director, National Institute of Public Cooperation and Child Development, 5, Siri Institutional Area, Hauz Khas, New Delhi 16, India. Fax: 91116851349 Email: syscon@del2.vsn1.net.in

New Recommended Normative Values for Thyroid Volume in Children Aged 6-15y

A recent survey conducted among school children in 12 European countries used ultrasonography to assess thyroid volume in 3474 children (aged 6-15y) born and living in areas where iodine intake is normal (median urinary iodine above 100mg/l), and derived thyroid volume reference values from these data. The survey was conducted by the ThyroMobil Study Group (principal investigator: Prof. F. Delange, ICCIDD; see SCN News No.13), and results have recently been published in the Bulletin of the World Health Organization (75 (2), 95-7).

Although inspection and palpatation are normally used to determine thyroid volume in areas of moderate-severe iodine deficiency, ultrasonography is considered to be a more precise and objective method in areas of mild endemicity. Presented in the report are the recommended upper normal limits for thyroid volume (assessed by ultrasonography) by age, for iodine-replete boys and girls. Also presented are the recommended upper normal limits for thyroid volume as a function of body surface area, for iodine-replete boys and gins. The latter is more appropriate than thyroid volume as a function of age, for use in countries with a high prevalence of child growth retardation. These reference values are recommended by WHO and ICCIDD for interpreting survey and surveillance ultrasonography data among school children.

Source: 'Update: Recommended normative values for thyroid volume in children aged 6-15 years. World Health Organization and International Council for Control of Iodine Deficiency Disorders (1997). Bulletin of the World Health Organization, 75 (2), 95-7' Requests for reprints should be sent to the Nutrition Unit, World Health Organization, 1211 Geneva 27, Switzerland. Fax: 41 22 791 0746.

Human Milk - an Invisible Food Resource

In a recent IFPRI Food Consumption and Nutrition Division discussion paper, Arne Oshaug and Anne Hatløy argue that overlooking human milk production in calculations of food supply, food and nutrient availability and food economics, has negative consequences for breastfeeding practices, children's health and nutritional status. Based on breastfeeding frequency data, age, demographic data and information on the amount of human milk consumed by children of different ages, the quantity of human milk production was calculated for Koutiala County, Mali, and compared with national data from Demographic and Health Surveys (DHS) and other sources. The annual production of human milk in Koutiala County was estimated to be 116kg per child, with a 9-10% higher production in rural areas than in urban areas. To put the economic value of human milk into perspective, the authors compared human milk production with that of cow's milk, and suggested that the volume of human milk is at least 50% that of cow's milk production in Sub-Saharan Africa.

Infancy is the only period in life when humans obtain nutrition security by consuming one food, breastmilk. When a mother breastfeeds her child, food security, care and protection against diseases are provided simultaneously. Breastmilk meets all the nutritional requirements of infants during the first 6m of life and is the most important food for more than 10% of the population of Sub-Saharan Africa (i.e. children less than 3y of age). No other single food has such a positive impact on nutrition and health.

Decision-makers do not generally consider human milk to be a food resource, and data on human milk are not normally considered important in the context of food supply statistics. The authors maintain that by not including human milk in food supply data, inadequate attention to breastmilk and breastfeeding will continue to exist with serious health consequences. This is particularly important where accelerating urbanization and other types of social changes may contribute to the decline of breast-feeding. The authors challenge economists, statisticians, and others who are involved in the generation of health and food statistics to include human milk in their calculations, and to compare these data to the economic and social costs of purchasing infant formula due to the decline in breastfeeding, and to additional health expenditures due to the increase in childhood morbidity and malnutrition.

Arne Oshaug and Anne Hatløy work at the Nutrition Institute, University of Oslo, B.P. 1046 Blindern, N-0316 Oslo, Norway. Tel: 47 22 8513 79 Fax: 47 22 85 13 41 Email: ame.oshaug@basalmed.uio.no. IFPRI FCND Discussion papers contain preliminary material and research results and are circulated prior to a full peer review in order to stimulate discussion and critical comment. Copies of discussion papers can be obtained from FCND, IFPRI, 1200 Seventeenth Street, N.W., Washington, D.C. 20036-3006 USA. Tel: 202 862 5600 Fax: 202 467 4439. The full paper will be published in the December 1997 issue of the Journal of Human Lactation (No.13).

Approaches to Reduce Vitamin A Deficiency in Lagos State, Nigeria

A recent study by Dr U.A. Adirieje of Optonet International, Nigeria, showed evidence for vitamin A deficiency (VAD) in some communities of Lagos State, Nigeria. Based on the clinical presence of keratomalacia and night blindness, the prevalence of VAD was found to be 10.1% in a sample of 496 people presenting for examination. Dr Adiriege argues that this figure might underestimate the true occurrence of VAD as those with mild or subclinical deficiency were missed.

In response to this problem, Optonet have produced a leaflet "Save a life from Vitamin A deficiency and xerophthalmia - Give Vitamin A", in which recommendations are given aimed at reducing VAD and the consequences of VAD are explained.

Optonet Recommendations to Reduce VAD in Lagos State:

· Vitamin A supplementation: this is recommended for children and babies with signs and symptoms of VAD.

· Diet: it is recommended to feed the family with meals containing lots of green leafy vegetables and fruits, yellow vegetables, yellow fruits, liver (especially of fish), whole milk, eggs and red palm oil.

· Breastfeeding: it is recommended to feed babies with breastmilk alone, for the first 4-6 months of life.

For further information and a copy of the leaflet, please contact Dr U.A. Adirieje, Executive Director, Optonet Int'l & Afrihealth Info Projects, P.O. Box 4127, Oshodi, Lagos, Nigeria. Tel: 846892 Email: nipem.lag1@rcl.nig.com or nipem.lag1@rcl.dircon.co.uk

Simple Test Kits to Determine Cyanogens in Cassava Roots and Cassava Flour

A simple and inexpensive test to determine the amount of cyanide compounds (cyanogens) present in cassava and cassava products has been developed and field-tested, and is now available. Cassava is a staple food for 500 million people and is the third most important crop in the tropics after rice and maize. Cyanide intoxication can occur from eating cassava, with symptoms including stomach pains, diarrhoea and dizziness. According to Dr Bradbury (see below), in the past 15 years or so, around 5 000 -10 000 people (mainly children) in Mozambique, Tanzania and Zaire have developed "Konzo", a disease caused by cyanide intoxication and characterized by an irreversible paralysis of the legs. In very rare cases, deaths have occurred. Consumption of cassava containing cyanogens also worsens iodine deficiency disorders, as cyanide is detoxified to thiocyanate in the body, which in turn reduces the uptake of iodine by the thyroid gland.

In the test, a small weighed sample of cassava tuber or cassava flour is mixed with water and placed with a buffered paper containing an enzyme, linamarase, that reacts with cyanogens. Indicator paper containing picric acid changes from yellow when there is no cyanogen present, to brown when high levels of cyanogen are present. The colour change is then compared to a colour chart with 10 levels to determine how much cyanogen is present in the sample. This field test requires only a small amount of clean water and a table in the shade to set up the test kit.

In Mozambique in October 1996, the test was used in a field trial to analyze 80 samples of cassava flour. The average level of cyanogens in the samples was found to be 4.5 times the level recommended as safe by FAO/WHO (10ppm)¹ and, in two cases, values of 200 ppm were obtained. Possible interventions to reduce the extent of this health hazard in Mozambique include improved methods of processing to reduce the cyanogen content of cassava flour and introduction of low cyanide cultivars of cassava.

¹Recommended safe level: 10mg hydrogen cyanide per kg flour=10 ppm. Codex Alimentarius Commission of FAO/WHO (1988). Report of the 8 Session of the Codex Coordinating Commission for Africa. FAO/WHO.

This article was submitted by Dr J. Howard Bradbury, Division of Botany and Zoology, Australian National University, Canberra, ACT 0200, Australia. Tel 61 2 6249 0775 Fax: 61 2 6249 5573 Email: Howard.Bradbury@anu.edu.au.

Costa Rica National Nutritional Study 1996

In 1996, a national nutrition study was carried out in Costa Rica to provide information on the nutritional situation of the population and to compare this with data from the 1982 national nutrition study. Results are now available for anthropometric, micronutrient, intestinal helminth, food consumption and oral health analyses. Anthropometric results showed an improvement in nutritional status, but also an increasing prevalence of obesity. Height for age (HA), weight for height (WH), and weight for age (WA) for pre-school children; and body mass index (BMI) for school children and adults, were used as indicators to determine nutritional status.

In pre-school children (1008 children aged 1-6y), 22.4% of children had low WA compared with 30.9% in 1982. The prevalence of stunting (low HA) decreased from 29.3% in 1982 to 21.4% in 1996, In contrast, the prevalence of children who were overweight increased from 2.5% in 1982 to 4.2% in 1996. In children of school age (582 children aged 7-12y), 16.5% were underweight and 14.9% were overweight. Girls represented a higher percentage of those overweight (16.3%) compared with boys (13.6%). Undernutntion was equally prevalent in girls and boys. In women aged 15-19y (69 women), 23.2% were overweight and 1.4% were underweight. In women aged 20-44y (865 women), 45.9% were overweight and 9% were underweight. Obesity was higher in rural zones (50.6%) compared with metropolitan areas (42.3%) and other urban areas (44.8%). No significant differences in undernutrition were found according to geographical area. In women aged 45-59y (120 women), 75% were obese and 2.5% were underweight. In all women, malnutrition decreased from 1982 to 1996, whereas obesity increased (graph).

For further information, please contact Dr Luis Tacsan Chen, Jefe, Departmento de Nutricion, Ministerio de Salud, Republica de Costa Rica. Source: translated from the leaflet 'Ensuesta nacional de Nutricion, 1996 - Anthropometria'. Ministerio de Salud, Costa Rica, 1997.

Public Nutrition - an Emerging New Field of Study

Public nutrition is concerned with improving nutrition in populations from both poor and industrialized countries, and forms links with public health nutrition and complementary disciplines. The term was initially proposed in a letter to the editor of the American Journal of Clinical Nutrition (1996; 63, 399-400), which in turn, led to a meeting on public nutrition, held on July 24-26 1997 at the University of Montreal, Canada, organized by Dr John Mason of Tulane University, U.S.A. The aim of the meeting was to define a focused approach for redressing the problems of nutrition in populations, and a report of the proceedings of this meeting is due to be published at the beginning of 1998.

The definition of public nutrition as an emerging field of academic study, research and action was discussed in depth at the meeting. Public nutrition encompasses epidemiology, public policy and programme analysis, and in this sense is a field of study that can lead to a professional qualification. The scope of public nutrition is broad, encompassing but not supplanting more focused topics. On this point, there was general agreement that public nutrition is compatible with public health nutrition, but that public nutrition is broader in scope.

A number of proposals to develop the idea of public nutrition as an emerging new field of study were discussed, including the possibility of establishing new courses in public nutrition at universities, developing new training materials on public nutrition, and engaging the public sector in efforts to improve public nutrition. The possibilities of establishing a professional association and national and regional networks for public nutrition were also considered, and it was agreed that further discussion among participants and interested parties should continue by email.

For further information about the outcome of this meeting, and details about publication of the meeting report, please contact Yaw O. Agyeman and John Mason, Dept of International Health and Development, Tulane University, School of Public Health and Tropical Medicine, 1440 Canal St, Suite 2200, New Orleans, Louisiana 70112, USA. Tel: 504 586 3987 Fax: 504 584 3653 Email: masonj@mailhost.tcs.tulane.edu/yagyema@mailhost.tcs.tulane.edu

Current Issues in Diabetes

By Jak Jervell

Immediate Past President, International Diabetes Federation

Diabetes mellitus is characterized by high levels of blood glucose and occurs when the body is not able to make use of glucose in the blood for growth and energy. For glucose to enter the cells and be utilized, the hormone insulin (produced in the Islets of Langerhans in the pancreas) is required. Diabetes occurs either because the pancreas in not able to make enough insulin, or because the insulin that is available is not effective (insulin resistance), or both. It gives acute symptoms and late complications involving the eyes, kidneys, peripheral nerves (micro-vascular complications) and increased tendency to atherosclerotic disease (coronary heart, cerebrovascular and peripheral artery disease). There are two common types of diabetes:

· Insulin dependent or Type 1 diabetes (IDDM) and
· Non-insulin dependent or Type 2 diabetes (NIDDM).

Global prevalence of diabetes

Recently compiled data show that approximately 135 million people suffer from diabetes mellitus worldwide, and that this number will rise to 300 million by the year 2025 (World Health Report 1997, WHO). The epidemic of diabetes (and other noncommunicable diseases, e.g. coronary heart disease) is particularly serious in developing countries, e.g. China, South Asia (India, Sri Lanka, Bangladesh), the Middle East and Latin America. These are also countries where living conditions are changing most dramatically, and urbanization and demographic changes are the greatest. In developing countries, higher total prevalence rates are found and the prevalence starts to rise at an earlier age.

The International Diabetes Federation (IDF) The IDF is a federation of 146 diabetes associations in 121 countries. It has strong links with WHO. IDF and WHO have one permanent working group and a number of joint working groups and publications. The IDF involves people with diabetes, health care professionals and scientists. Professor Jak Jervell (a current member of the AGN - see page 2) is the immediate past president of the IDF.

Impact of diabetes

A study on the global burden of disease giving estimates of cause-specific mortality has recently been published jointly by WHO, the World Bank and Harvard University. Figures presented in the study ranked diabetes as the 16^th leading cause of mortality worldwide (see Table), however, as the number of deaths related to diabetes result from complications and infections, the actual number of deaths will be far greater than those ascribed to diabetes on death certificates. Correcting this figure to account for excess mortality in people with diabetes from complications gives 2 800 thousand deaths - equivalent to fifth ranking.

Table: Leading causes of death worldwide in 1990

Rank	Cause of deaths	No. of deaths (thousands)
	All causes	50 467
1	Ischaemic heart disease	6260
2	Cerebrovascular heart disease	4381
3	Lower respiratory infections	4299
4	Diarrhoeal diseases	2946
...
16	Diabetes	571
#5	Diabetes	2800

# corrected for excess mortality in people with diabetes from micro and atherosclerotic complications. (Adapted from Murray, C.J.L. & Lopez, A.D. (1997). The Lancet 349,1269-76).

Diabetes therapy

The main objective of diabetes therapy is to relieve acute symptoms and prevent late complications. Microvascular complications are best prevented by normalization of blood glucose. Specific interventions early on can delay progression, e.g., laser therapy of the retina can prevent blindness. The atherosclerotic complications however, need a much wider approach - smoking control, dietary changes and increased exercise. Finally, education of those with diabetes and their families is most important for success in reaching these goals.

The role of WHO

WHO's role has been of great importance to the recognition for the impact of diabetes, and for advocating national programmes and encouraging their implementation. In the NCD (non-communicable diseases) division at WHO headquarters in Geneva, we are lucky in having Hilary King as the diabetes officer, who collaborates extensively with 30 collaborating centres worldwide. The regional offices of WHO in Europe, PAHO, and in the Eastern Mediterranean have been very active in diabetes, jointly with the IDF. The St. Vincent declaration (1989) has led to a permanent process for improving diabetes care in Europe, in partnership with WHO and IDF internationally and between Departments of Health and IDF member associations nationally. A similar process was started in the Americas last year, with the Diabetes Declaration of the Americas. In the Middle East, many countries have developed National Diabetes Programmes together with EMRO (WHO Eastern Mediterranean Regional Office) and IDF. In Africa similar processes have started.

Current Issues in Diabetes · Diabetes (and Impaired Glucose Tolerance) is one of many non-communicable diseases (NCDs). It can be used as a marker for the risk of NCDs in a population. · Can diabetes and the other NCDs be prevented? Primary prevention cannot be achieved through the health services, but has to be done through changes in the way we organize our societies. Historically, Homo sapiens were hunter-gatherers, and later, farmers. Our biology has been adapted to those life styles - physical activity and a low fat, fibre-rich and varied diet. Positive selection factors may have been a preference for calorie-dense food, avoidance of unnecessary physical activity, and ability to gorge when food was available. The life style of the late 20th century is not suitable for the hunter-gatherer. We must organize our societies so that a healthier life-style becomes the simplest, cheapest and most enjoyable. On the other hand, let us not forget that in this century the duration of life has increased more than 20 years in most countries, infant mortality and mortality due to infectious diseases have decreased markedly and the general health have improved almost everywhere. · Most of the cost of diabetes, in suffering, in health care, in lost years and lost working capacity, comes from its complications. Investment in primary care, education, simple drugs and monitoring technology is very cost effective. In most countries - developing and developed - too many resources are spent on treatment rather than on 'secondary' prevention and good management to prevent the complications. In Gaza, diabetes is the main reason for non-traumatic amputations, in the U.S. it is the main cause of blindness in younger adults, and in Japan it is the main cause of renal failure. · Insulin was discovered in 1921, but is still not available to all those who need it. Two thirds of all insulin produced is used on one fifth of the world population, in the fully industrialized market economies. A child with type I diabetes who does not have daily insulin injections will die. The prevalence of type I diabetes in developing countries is low but survival is very short, and children often die undiagnosed. This is part of the general problem of lack of basic health care in many poorer countries, a problem that today can be solved by concerted efforts by governments together with the international community. · A chronic disease like diabetes needs a different relationship between the 'patient' and the health services. The outcome depends very much on the choices made by the person with diabetes. The roles of the health care professionals are chiefly that of adviser, facilitator of learning, and provider of necessary services. It has been stated that the role of the health care providers is to help people with diabetes avoid becoming 'patients'. · The hypothesis that early (intrauterine and first years of extrauterine) undernutrition increases the susceptibility to diabetes, coronary heart disease and hypertension in later life, is gaining acceptance, not only from studies in industrialized countries but also in developing countries. This is yet another argument for looking better after the nutrition of women and children, and an argument I have found leaders in developing countries to be receptive to.

This article was submitted by Jak Jervell, Immediate Past President, IDF, Medical Department B, Rikshspitalet, 0027 Oslo, Norway. Tel: 47 2286 8306/5 and 47 2255 2787 Fax: 47 2244 4895. Editor's note: a WHO factsheet on Diabetes Mellitus (September 1997) is also available from the WHO Press Office, 1211 Geneva, 27 Switzerland. Tel: +41 22 791 2111 Fax: +41 22 791 0746.