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NEWS AND VIEWS

Agronomic Research in Mali Identifies Local Sources of Micronutrients

New results from research into the micronutrient content of local plant species in Mali have shown that applying very simple measures may enhance nutrient bio-availability. Over the last three years, Malian agroforesters, in collaboration with the Novartis Foundation and Roche’s Sight and Life Task Force, have discovered that the simple practice of drying baobab leaves in the shade doubles the pro-vitamin A content of the baobab powder. Furthermore, the choice of small leaves (which is tree specific) also increases pro-vitamin A levels by 20%. The combination of small leaves and shade-drying result in a pro-vitamin A content of up to 27 micrograms retinol equivalents (RE) per gram of dried leaf powder, a very high level (see graph; reference 1). These results are particularly important for a country such as Mali, classified as having ‘clinical’ or severe vitamin A deficiency by WHO (1995)1, and where few vitamin A-rich foods are consumed on a regular basis. An exception to this are locally gathered baobab leaves, which are typically sun-dried, pounded into powder, and cooked in the daily family sauce.

1 WHO, 1995. Global prevalence of Vitamin A deficiency, MDIS working paper #2.

SOME DEFINITIONS...

Agronomy:

a branch of agriculture dealing with food crop production and soil management

Agroforestry:

land management for the simultaneous production of food, crops and trees

Malian agroforesters and collaborators from the Novartis Foundation and Roche’s Task Force Sight and Life, have also discovered a remarkable tree-to-tree variability in vitamin C content in the fruit of baobab trees (2). This variation ranges from 150 to 500 mg vitamin C per 100g fruit and remains stable from one year to the next. Baobab fruit pulp is known to be rich in vitamin C, and across West Africa baobab fruit pulp is consumed in cool drinks and warm gruels. It has also recently become a popular ingredient in iced products in urban areas. Researchers have grafted branches from trees with a high content (500 mg/100g) of vitamin C onto over 100 young baobab frees at the Cinzana Research Station in the Su region of Mali. It is hoped that this ‘vitamin C’ orchard may serve as important graft stock for Sahelian vitamin C orchards in the future (3).

Both iron and zinc are lacking in foods eaten by Malian children. Although the mineral content has been characterised for many trees and plants in Mali (4), little is known about the genetic variability of the mineral content within different species. To this end, an iron and zinc survey of Zizyphus mauritania fruits, and of Amaranthus viridis (borronboulou) and Adansonia digitata (baobab) leaves is planned for the 1999 season. Plant materials will be gathered from a large number of individual plants sampled from several diverse agroecological zones. In order to respect full comparability of results, the analyses will be carried out at Waite Analytical Services in Adelaide, Australia.


Graph: Baobab leaf content of pro-vitamin A carotenoids as retinol equivalent (RE)

Lessons Learned

Experience in the measurement of nutrients from local plant species has brought to light three findings worth sharing with others seeking to undertake similar efforts:

1. Genetic diversity. The reporting of mean values of numerous samples, or the values of bulked samples, can mask the enormous diversity that may exist between individual plants. In the Malian studies, the baobab fruit measurements of bulked samples from many frees consistently resulted in vitamin C values of around 220 mg/100g. It was only when researchers measured bulked fruit from individual frees that a threefold range of values from 150 to 500 mg/100g vitamin C was discovered.

2. Distinguishing between sun and shade drying. Pro-vitamin A is very sensitive to sunlight. With baobab leaves, it was found that shade drying can double the RE values compared to sun drying, even though sun drying is the common local practice. It is important to at least report how plant samples are dried, and where possible, to compare pro-vitamin A or RE values from sun-dried versus shade-dried plant samples.

3. Beware of market samples. We have measured many market samples of baobab leaves and fruits, b-carotene and vitamin C levels were far inferior to any samples that were gathered directly from frees. We have been repeatedly told that market samples are commonly extended with innocuous material such as cereal stalk pulp. However, in the literature, nutrient levels are commonly reported from plant samples obtained in local markets rather than directly from original plant sources.

Since 1979, the Malian agronomic research institute (IER), through the continued support of the Novartis Foundation for Sustainable Development, has been addressing various aspects of child nutrition through agronomics, grain storage technology, food technology, and agroforestry. Locally available technologies have been developed to enrich the amino acid quality of millet foods with cowpea, to increase caloric density of infant gruels with malt, and most recently - as described in this article - to obtain high levels of vitamin A and C from baobab leaves and fruit. It is now time to put all this research into action. In 1999, village-level feeding programmes are planned. These will combine increased caloric density and protein quality in children’s foods, as well as increase intake of vitamins A and C from Baobab sources. This work will involve the active inputs from agronomists, nutritionists, and anthropologists.


The Baobab Tree - J. Scheuring

References

1. Sidib, Scheming JF, Kon, Hofman P and Frigg M. (1998a) More on baobab’s homegrown vitamin C. Some trees have more than others - consistently. Agroforestry Today. IN PRESS.

2. Sidib, Scheuring J.F, Tembely D, Sidib.M, Hofman P, and Frigg M. (1996). Baobab - homegrown vitamin C for Africa. Agroforestry Today. 8:(2), 13-15.

3. Sidib, Scheuring JF, Tembely D, SidibM, Hofman P, and Frigg M. (1998b) A for Africa - the leaves of the baobab tree as a source of vitamin A. Agroforestry Today. IN PRESS.

4. Noreide MB, Hatloy A, Foiling M, Lied E and Oshang A. (1996) Nutrient composition and nutritional importance of green leaves and wild food resources in an agricultural district in Kovtiala, Southern Mali. International Journal of Food Sciences and Nutrition. 47:6, 455-468.

Submitted by JF Scheuring and M SidibJF Scheuring is Director of Product Development, Novartis Seeds AG and Scientific Advisor to the Novartis Foundation for Sustainable Development, Basel 4002, Switzerland. Tel: 41 61 697 46 11 Fax: 41 61 697 52 34 Email: john.scheuring@seeds.novartis.com M Sidibis Deputy Director General of IER (Institut d’Economie Rurale), BP 258, Bamako, Mali, and former head of Agroforestry Research in Mali. Tel: 223-23-19-05 Fax: 223-22-37-75 Email: alpha.maiga@

Nutrition Activities in Micronesia

The Federated States of Micronesia (FSM) is located in the North Pacific and is made up of four states - Pohnpei, Chuuk, Kosrae, and Yap. Evolving from the U.S. Trust Territories, FSM became a new nation in 1986. The population is estimated at 111,000. Difficulties involved in nutrition programmes there, include the dispersed location of the four island states, the eight different languages, different cultures, as well as changes in the diet that have evolved in recent years. However, some exciting progress has been made, including projects supported by UNICEF, in conjunction with the FSM Department of Health, Education and Social Affairs.

Baby Friendly Hospital Initiative (BFHI)

The smallest state of Kosrae is preparing for external assessment for Baby-Friendly status. Its Breastfeeding Mothers Support Group, has been described as “the first of its kind in the Pacific” by the regional UNICEF breastfeeding officer, because of the group’s enthusiasm and determination to reach every mother on the island. In Kosrae’s internal BFHI assessment, it was revealed that the local hospital was denying the group the right to enter the delivery room for assistance to mothers. The Hospital Chief of Staff admitted that he had not realised how important the group was, and the hospital regulations were changed. New badges for the support group mothers provide identification, and the group will now be able to provide support to mothers. Chuuk and Pohnpei are also actively preparing for Baby Friendly status, and the National Congress is considering the first FSM legislation on the Code of Marketing of Breastmilk Substitutes.

Vitamin A Deficiency Programme

Prevalence rates of vitamin A deficiency (VAD) in FSM are among the highest in the world according to Alnwick’s 1998 review.1 A VAD programme was initiated in Chuuk in 1993, with bi-annual distribution of high dose vitamin A capsules and anti-helminth tablets given to children aged 1-12 years on special campaign days. The 1997 evaluation for the first five years of the programme showed coverage rates from 71-95%. Ad hoc studies showed that VAD-related hospital paediatric and out-patient cases have greatly decreased. However, the challenge remains to make significant dietary improvements. A similar vitamin A capsule distribution programme was initiated in September 1998 in Pohnpei.

1 Alnwick, D.J. (1998) Combating micronutrient deficiencies: problems and perspectives. Proceedings of the Nutrition Society 57:1-12.

Family Food Production and Nutrition (FFPN)

FFPN projects have been ongoing in FSM since 1986, focusing on community-based nutrition programmes and inter-agency collaboration. All states have inter-agency nutrition councils, which actively carry out nutrition activities. These include World Food Day, World Breastfeeding Week campaigns, nutrition awareness, home gardening, and food demonstration activities.

Teacher Child Parent Community (TCPC)

A Health/Nutrition/Agriculture curricula for primary schools has been introduced to all four states of FSM in a project which has been ongoing since 1992. The set of sixteen illustrated books including Teachers Guides and Student Workbooks for Grades 1 to 8 developed specifically for FSM, has recently been reviewed and revised. It is hoped that this project, which actively involves parents and the community in the education process, may have a significant effect on improvement of nutrition awareness and health practices.

Convention on the Rights of the Child

In 1996, FSM submitted its Report on Two Years Implementation on the United Nations Convention on the Rights of the Child, and defended the document at the United Nations in Geneva in 1998. The need continues for increased awareness of the Convention on the Rights of the Child and further promotion of the principles therein.

Submitted by Lois Englberger, UNICEF Health and Nutrition Advisor, and Jane Elymore, National Program Manager for Food and Nutrition. For more information contact Lois Englberger, P.O. Box 2299, Kolonia, Pohnpei 96941, Federated States of Micronesia. Tel: 691 320 7359 Fax: 691 320 5263 Email: nutrition@mail.fm

Child-to-Child Trust

The objective of the Child-to-Child Trust is to promote and preserve the health of communities worldwide by encouraging and enabling children and young people to play an active and responsible role in the health and development of themselves, other children and their families. Children can be partners in health promotion because they are able to understand and spread vital health messages. They can be fully involved in the planning, implementation and evaluation of health promoting activities.

The Child-to-Child Trust involves children in health promotion by performing three main functions:

à Designing and distributing health education materials for use by children, teachers and health workers

à Assisting health and education workers in planning, implementing and evaluating projects using the child-to-child approach

à Coordinating a worldwide information network for people and projects around the world who use the child-to-child approach

Child-to-Child in Action

The Health Action Schools project in Pakistan, described below, shows how the child-to-child approach helps primary school children in Karachi to promote better nutrition. The project was launched in April, 1998 to develop prototypes of Health Promoting Schools in Pakistan using the Comprehensive School Health Promotion model which integrates three elements now often provided by different agencies, namely:

1. The health education programme in the school
2. The school environment (including nutritional standards and attention to children’s safety)
3. The school health services.

Health is defined broadly to include physical, environmental, mental, social and emotional health. Health priorities are defined by the school communities which includes children themselves. In each of the Health Action Schools, the area of Food and Nutrition has been defined as an interest and a priority area of need for health education. Some of the initiatives that have been taken in the pilot schools use the child-to-child approach to involve children who then pass on nutrition messages to their families and communities.

Needs Analysis

Before launching the programme in the schools a study was conducted to assess the health interests, knowledge and needs of primary school children. Using the “draw and write” technique as well as essays and discussion, the health interests and knowledge of 740 Pakistani primary school children were assessed. In addition, through focus group discussions and questionnaires with teachers and parents, the health needs of primary school children were ascertained as shown below:

Table 1. Health Interests, Knowledge and Needs of

Class

Average age

Health Topics Highlighted

I

6

Personal hygiene·; Good and Bad Foods·

II

7

Food· Personal hygiene· Environmental hygiene (including clean drinking water)

III

8

Cleanliness (personal and environment)·; Exercise· Good Food·; Healthy lifestyle·

IV

9

The Environment· Cleanliness (personal and environment)· Preventing Disease·; Balanced Diet· Exercise·; Responsibility to others·

V

10

Cleanliness (personal and environment)· Responsibility to others·; Balanced Diet· Preventing disease·; Mental health; Exercise·

Key:

Italics = Common to all ages (Class I-V) i.e. hygiene/cleanliness and food/diet, · = Also identified by teachers and parents as important areas in health to cover at different ages. Bold = Nutrition related

The table above shows that primary school children of all ages in the sample were interested in ‘Nutrition’ as a subject. In addition, their parents and teachers felt that there was a need for children in primary school to learn about the subject, at all levels.

A second study was conducted in the primary pilot school communities in Karachi. Using group interviews of children and adults in these communities, baseline information was collected to assess their traditional health beliefs and customs. The most common emerging themes from the data were food remedies and food taboos in relation to common ailments. Communities saw direct links with food and eating habits to disease prevention. This may explain the importance placed by them on nutrition education as part of the health education curricula.

School Health Action Plans

Based on the health priorities set by the children of the needs in their communities, all five pilot schools identified nutrition related topics to cover in their health lessons. This was often integrated into a carrier subject such as Science or Social Studies. Topics chosen include: good food; keeping food safe and clean; clean safe water; a balanced diet; feeding younger children; how much have I grown? and growing vegetables. Four to six lessons are spent on each of these topics using the child-to-child step approach. This is a participatory child-centred method that links learning with action. An example of one school’s plan on ‘Good Food’ using this approach is given below:

Class: 5
Age of children: 10-11 years
Number of lessons: 4
Length of each lesson: 40 mins.

By the end of the topic children should:

Know:

· Which foods provide energy
· Which foods are needed for growth and body building
· Which foods protect us from disease
· We need a mixed diet
· Younger children need to eat more frequently due to their smaller stomachs


Do:

· Recognise which foods are healthy
· Recognise nutritious, tasty, low cost foods
· Grow vegetables in containers in their homes


Feel:

· Responsible to make sure their younger siblings are eating enough.

Lesson 1: Step 1 ‘Study’ - Choose and Understand

Tell the story of a boy who only eats one type of food. What happens to him? Discuss the need for a mixed diet.

Homework: Step 2 - Find out More

Observe and talk to Mum about what she feeds the baby and how often.

Lesson 2: Step 3 ‘Recognise’ - Discuss what was found out

Discuss in groups what we observed at home. Present to the class. Are babies at home eating enough? Through picture discussion teacher discusses with the children the foods and their different functions i.e. Body building; Energy giving; Protects us from disease.

Lesson 3: Step 4 ‘Act’ - Plan and Take Action

Children make a list of their favourite foods. Which are expensive and which are not. Are the ‘healthy’ ones expensive? What are the functions of these foods?

Children decide to bring in ‘balanced’ lunch boxes and do role plays for assembly on ‘Good food and eating healthily’. They also grow vegetables in a garden box in the class room.

Lesson 4: Step 5 ‘Evaluate’ - (What did we do; could we do it better?)

In pairs children check each other’s lunch boxes. Do they contain healthy foods? Children ask other classes in the break time what they understood from the assembly role play? Did the message of ‘Good Food’ get across?

Home work: Step 6 - Do it better

Children grow vegetables in tins or boxes in their homes

Co-Curricular activities: Height and Weight checking - older classes to help younger ones; Open House - cooking competition on making home made nutritious foods for babies; Visit to the market place; Plantation day; checking lunch boxes.

Conclusions

Our study shows that children of all ages are interested in ‘Nutrition’ as a subject and adults (parents and teachers) feel that there is a need for children to learn about nutrition in schools. Using participatory methods that link learning with living, nutrition topics can be integrated into the primary curriculum in a way that promotes understanding, develops life skills and is fun!

_______________________________________

Some of the main Child-to Child publications in English are listed below. For publications in other languages, see the Directory below.

Child-to Child, A Resource Book. Part 1: Implementing the Child-to-Child Approach. Contains sections on the concept of Child-to-Child, teaching and learning methods, evaluation and running workshops, and examples of action taken around the world. Part 2: Child-to-Child Activity Sheets. Thirty-five activity sheets contain essential health information combined with exciting activities designed to reinforce and spread health knowledge and good practice. Subjects are grouped into eight categories: Child Growth and Development-Nutrition-Personal and Community Hygiene-Safety-Recognising and Helping the Disabled-Prevention and Cure of Disease-Safe Life Styles-Children in Difficult Circumstances.

Children for Health. Includes the practical, health promoting activities based on the Facts for Life messages.

Health into Science. Designed for primary school teachers and contains activities which can be used inside and outside the classroom where science and health education overlap.

Health Promotion in Our Schools. A book of ideas for those who plan, organise and promote health in schools.

Training pack. Designed to assist those who are conducting training workshops for teachers, health workers and others interested in using the Child-to-Child approach in their work.

Directory of Child-to Child Activities World wide. Provides brief summaries of known projects in many countries, names and addresses of contacts for further information, and details of materials in languages other than English.

Submitted by Tashmin Kassam-Khamis, Assistant Professor, The Aga Khan University, Institute for Educational Development, PO Box 13688, Karachi 75950, Pakistan. Tel: 9221-6347611-14 Fax: 9221-6347616 Email: tashmin.khamis@aku.edu

Complete lists of Child-to-Child publications, with details of prices and how to order are available from The Child-to-Child Trust, Institute of Education, 20 Bedford Way, London WC1HOAL, United Kingdom. Tel: +44 (0)171 612 6648 Fax: +44 (0)171 612 6645 Email: c.scotchmer@ioe.ac.uk An annual newsletter containing articles about selected projects and new publications is available free of charge.

Promoting Better Dietary Habits Through Nutrition Education in an Impoverished USA community: the PANA Programme and the ¡SALUD! Campaign

The University of Connecticut Department of Nutritional Sciences, the Hispanic Health Council and the Cooperative Extension System have recently launched the PANA programme (Programa para Aprender Nutrici Alimentaci(1) and ¡SALUD! Campaign (2). Using the motto ‘smart food choices for a healthy life’, PANA is a bilingual nutrition education programme that incorporates community-participatory research and evaluation for developing culturally appropriate nutrition education and services for food stamp recipients.

Since 1995, these three groups have partnered to:

à conduct needs assessments to understand the food and nutrition situation of low-income Latino children and their families in Hartford, Connecticut;

à develop, implement, and deliver culturally appropriate nutrition education services for this population;

à develop, implement, and deliver culturally appropriate nutrition information through social marketing approaches;

à conduct process and impact evaluations to understand the cost-effectiveness of programme activities;

à conduct research to develop culturally-appropriate innovative nutrition education activities and materials.

The PANA and ¡SALUD! Initiatives were developed on the basis of results from two needs assessments. The first needs assessment documented that low-income Latino children and their families were at risk of poor health and nutrition, including poor dietary quality, food insecurity, stunting, obesity, and anaemia (3). A subsequent baseline needs assessment documented the lack of nutrition knowledge, and sub-optimal nutrition attitudes and behaviours among the children’s primary caretakers (4). In addition, nutrition education materials were also developed, such as a colorful Puerto Rican Food Guide Pyramid, the nutrition jeopardy game, a color-coded bilingual food label, and a low-fat vegetable cookbook.


Figure

The PANA programme currently delivers bilingual nutrition education to thousands of children while at school through puppet shows and interactive games, and also provides nutrition education to children and their caretakers at agencies and community health fairs. The ¡SALUD! nutrition social marketing campaign features Latino youth and TV celebrities ‘toasting’ with nutritious foods including a variety of fresh fruits and vegetables. The campaign has been delivered for over a year now through mass transit billboards (buses, bus stations), street billboards, radio, TV, and newspaper/magazine advertisements commonly used by the target community. Preliminary results indicate that the campaign has been very successful reaching over 75% of the target population. The PANA programme and ¡SALUD! campaign are examples of how community agencies and academic institutions can collaborate to come up with creative and effective approaches to help low income groups improve their food choices in an industrialised nation conext.

The PANA and ¡SALUD! initiatives fall under the umbrella of the infant-toddler component of the University of Connecticut Family Nutrition Programme (FNP-IT) which represents a full partnership between The University of Connecticut, The Hispanic Health Council, and The Cooperative Extension System. FNP-IT is funded by the US Department of Agriculture Food Stamp Programme through the Connecticut Department of Social Services with the mission to provide nutrition education to food stamp households where children live. For more information access the website at http://www.hispanichealth.com/pana.htm

References

1. Himmelgreen DA, Pz-Escamilla R, Segura-MillS, Gonzz A, Mez I, Bonello H. The PANA programme: a community-participatory bilingual nutrition education initiative. Presented at the 31st Annual Meeting of the Society for Nutrition Education, July 18-22, 1998, Albuquerque, New Mexico.

2. Pz-Escamilla R, and Himmelgreen DA. Promoting better nutrition in inner-city Hartford through social marketing: The ¡SALUD! campaign. Connecticut Family Nutrition Programme Technical Report # 2, Storrs and Hartford, CT, 1998.

3. Pz-Escamilla R, Himmelgreen DA, and Ferns A. Community nutritional problems among Latino children in Hartford, CT. Connecticut Family Nutrition Programme Technical Report # 1, Storrs and Hartford, CT, 1997.

4. Pz-Escamilla R, Himmelgreen DA, Gonzz A, Segura-MillS, Mez I, Haldeman L. Nutrition knowledge, attitudes and practices among Latinos in Hartford, CT: Essential information for developing appropriate nutrition education initiatives. Presented at the 126th Annual Meeting of the American Public Health Association, Washington DC, November 15-19, 1998.

Submitted by Rafael Pz-Escamilla, UConn FNP-IT Principal Investigator, Assistant Professor of Nutritional Sciences, University of Connecticut (Tel: 1 860 486 5073 Fax: 1 860 486 3674 Email: rperez@canr1.cag.uconn.edu), David Himmelgreen, HHC FNP-IT PI (1995-1998), Senior FNP-IT Advisor, Department of Anthropology, University of South Florida, and Anir Gonzz, FNP-IT coordinator, Hispanic Health Council, Hartford, Connecticut, USA.

The Economic Costs of Iron Deficiency

New analysis to quantify the economic impact of iron deficiency has provided convincing evidence that preventative measures can be highly beneficial from an economic perspective. In a paper commissioned by the Micronutrient Initiative and funded by CIDA, Drs Jay Ross and Susan Norton examined the evidence for the functional consequences of iron deficiency on individuals through the life cycle and quantified the effects in economic terms. Motor and mental impairment in children, low work productivity in adults, poor pregnancy outcome and health effects on children were examined. Results from a number of countries showed that the median value of productivity losses as a result of iron deficiency is about US $4 per capita, or 0.9% of gross domestic product (GDP). On a per capita basis, losses are greatest in richer countries, where wages are highest. When calculated as a proportion of GDP, productivity losses are greatest in South Asia, where the prevalence of anaemia is highest. The absolute losses in South Asia are close to US $5 billion annually. The dominant effect for all countries was shown to be the loss associated with cognitive deficits in children.

In some cases, iron deficiency or anaemia may merely serve as an indicator of risk due to other causes, such as deficiencies in other nutrients. The authors therefore examined only the epidemiological evidence for causal relationships, and quantified only these effects in economic terms. Although anaemia is an important cause of maternal death in many countries, the authors did not attempt to estimate the economic impact associated with this. Furthermore, there is some evidence of economic losses because of the effect of iron deficiency on child growth, immunity and susceptibility to the toxic effect of heavy metals, but the authors did not consider it strong enough to permit quantitative estimates.

Because of the multi-causal nature of anaemia, reducing iron deficiency and iron deficiency anaemia poses special challenges. This new analysis highlights the huge economic costs of the problem as it affects survival, development and well-being of individuals throughout the life cycle.

This work has been completed and the publication is available from the Micronutrient Initiative, c/o International Development Research Centre, 250 Albert Street, Ottawa, Ontario, Canada, K1G 3H9. Tel: 1 613 236 6163 Ext 2482 Fax: 1 613 236 9579 Email: mi@idrc.ca

Guidelines for the Inpatient Treatment of Severely Malnourished Children

The development of a set of treatment guidelines (‘10 steps’) for the care of severely malnourished children was reported last year in SCN News No. 15 (December 1997, pp24). The finalised guidelines are now available on the web at: http://www.lshtm.ac.uk/eps/phnu/malnu.pdf

The guidelines, supported by CIDA, were developed by the London School of Hygiene and Tropical Medicine in collaboration with WHO/UNICEF and many other experts working for the IMCI1. The document provides simple and brief instructions for treating severe malnutrition with the aim of providing practical help for those responsible for the medical and dietary management of such children. The guidelines are organised into five sections:

à routine treatment: the ‘10 steps’;
à treatment of associated conditions;
à what to do if a child fails to respond;
à what to do when children have to be discharged early;
à emergency treatment of shock and severe anaemia.

1 IMCI: Integrated Management of Childhood Illness Programme

For further information, please contact Claire Schofield, Public Health Nutrition Unit, London School of Hygiene and Tropical Medicine, 49-51 Bedford Square, London WC1B 3DP, UK. Tel: 44171 299 4600 Fax: 44 171 299 4666 Email: claire.schofield@lshtm.ac.uk

A Positive Impact of Credit with Education in Ghana

The results of Freedom from Hunger’s three-year impact study of Credit with Education in Ghana, West Africa, indicate that women and their families are significantly better off financially, socially and nutritionally for having participated in the programme. By combining small-scale loans with education in nutrition, health, birth timing and small-business skills, the study showed that Credit with Education increased income and savings, improved health and nutrition knowledge and practice, empowered women and improved household food security and children’s nutritional status.

Relative to non-participants and controls, participants in the programme reported positive changes in a variety of breastfeeding practices including:

à giving newborns colostrum;
à introducing complementary food closer to the ideal age of about 6 months;
à not using feeding bottles;
à enriching koko (the traditional complementary food) with bean/cowpea, egg, fish, groundnut, milk and palm oil.

Despite involvement in their loan-financed activities, participants did not wean their children any earlier than non-participants, and were just as likely to breastfeed their babies into the child’s second year of life.

A positive impact on household food security - as assessed by degree of vulnerability to the ‘hungry season’ among participant and non-participant households was seen as a result of the programme. Furthermore, the nutritional status of participants’ children - in terms of mean height-for-age z scores and mean weight-for-age z scores - also improved relative to the non-participants and controls.


Freedom From Hunger

With 81% of the operating costs recovered by the interest paid by borrowers, the Ghana Credit with Education programme offers a higher level of cost recovery than many income-generation interventions and traditional health and nutrition education programmes. The authors of the study argue that this financial sustainability, combined with positive impact, makes the Credit with Education strategy an attractive intervention with potential for widespread impact on nutrition and food security.

The Executive Summary of the Ghana study is available on the Freedom from Hunger website at http://www.freefromhunger.org/study.htm Copies of the full Ghana study results are available for US$15 (plus shipping costs) from Freedom from Hunger, 1644 DaVinci Court, Davis, CA 95616, USA. Tel: 1 800 708 2555 or 1 530 758 6200 Fax: 1 530 758 6241 Email: info@freefromhunger.org Results from a parallel study of Credit with Education in Bolivia will be available January 1999.

Source: ‘Impact of Credit with Education on Mothers’ and Their Young Children’s Nutrition: Lower Pra Rural Bank Credit with Education Program in Ghana,’ by Barbara MkNelly and Christopher Dunford in collaboration with the Program in International Nutrition, University of California, Davis. Freedom from Hunger. Research Paper No. 4 March 1998.

Micronutrient Initiative

Flour fortification in the Middle East and North Africa

MI has recently cosponsored (with WHO, UNICEF and ILSI), a follow-up meeting (to the 1996 meeting in Oman) on flour fortification in Beirut, Lebanon, July 13-16, 1998. Government and industry representatives from 15 countries participated. The region is making rapid progress with flour fortification. As a result, MI is supporting a regional flour fortification fund of US $1 million with WHO and UNICEF collaboration.

For more information: email: mi@idrc.ca Tel: 613-236-6163, Fax (613) 236-9579 The mailing address is Micronutrient Initiative. PO Box 8500, Ottawa, ON, Canada K1G 3H9 Web site: http://www.idrc.ca/mi

Preventing Iron Deficiency in Women and Children: Technical Consensus on Key Issues and Resources for Programme Advocacy, Planning, and Implementation

At the SCN meeting in Oslo in March 1998 it was emphasised that the level of national and international commitments and of national activities and international support directed toward programmes to reduce iron deficiency among vulnerable population groups have been seriously out of balance with the prevalence, seriousness, and consequences of this public health problem. To build stronger consensus the SCN called for “a technical workshop to resolve issues using a practical, field-oriented, science-based approach be held before the next meeting of the SCN Working Group.”

Thirty specialists convened by the International Nutrition Foundation on behalf of WHO, UNICEF, UNU, and MI met at UNICEF headquarters in New York October 7-9, 1998. Consensus on a number of issues on which there have been technical disputes was reached. The executive summary emphasises that iron deficiency anaemia steals vitality from billions of men and women around the world and impairs the cognitive development of young children. A World Health Organization (WHO) report states that iron deficiency anaemia affects over 3.5 billion individuals in the developing world compared with 834 million for iodine deficiency and 300 million for vitamin A deficiency.1 Yet iodine and vitamin A deficiencies are receiving far greater attention and support for their prevention, and the current availability of effective solutions for the prevention of iron deficiency is not sufficiently recognised.

1 “Life in the 21st Century: A Vision for All.” Report of the Director General of the World Health Organization (WHO), Geneva, Switzerland. 1998, p. 133.

Despite promising new intervention trials, little progress has been made towards the global elimination of iron deficiency. One reason is that it is a hidden deficiency with few recognizable overt symptoms. There is a lack of widespread knowledge of the serious and often permanent consequences of iron deficiency anaemia on the cognitive development of young children and its negative impact on the health of all people. Advocacy and national scale programmes have also been constrained by the erroneous perception that effective, practical interventions are not available.

The report draws together information published in guidelines developed at several recent workshops as well as from the scientific and field programme experience of many organisations. The document provides references and sources of relevant research, technical information, and the major organisations and networks supporting efforts to prevent iron deficiency. It also summarises a series of key issues and provides consensus statements that were endorsed by the experienced professionals convened from many different organisations and institutions. It outlines the major issues constraining stronger advocacy and accelerated planning and the implementation of programmes to prevent iron deficiency.

Strategies for prevention and control that include dietary change, food fortification, oral supplementation, and control of infection that contribute to anaemia are covered. It is unlikely that the problem will be solved for any country by just one of these interventions. Most countries need to introduce a combination of these interventions targeted toward those sectors of their population that are at risk. Dietary improvement should be part of an integrated strategy but cannot be expected to solve the problem. This is because the iron in vegetables is poorly available and increasing consumption of meat, with its better absorbed iron, often encounters severe economic and sometimes religious constraints.

In general, where populations are iron deficient, iron fortification of food staples (such as wheat and maize flour) or condiments (such as soy sauce and fish sauce) to improve the overall iron intake is desirable. In addition, iron status and needs at various phases of the human life cycle require special consideration. Teenage girls and women of childbearing age should be targeted for interventions that prevent them from entering pregnancy with anaemia. Similarly the prevention and treatment of anaemia in pregnancy and infancy need to be made effective.

Weekly administration of an iron tablet has been shown to be effective in pilot studies in children and women of child-bearing age. Where compliance can be assured, as in school children and factory workers, programmes can be effective. However, it has not yet been adequately tested for compliance in large scale programmes where ingestion of the weekly iron tablets cannot be individually supervised. For pregnancy, it is recommended that daily dosage of iron supplements be continued until current studies determine whether or not a weekly dose can be effectively employed under some programme conditions.

All intervention programmes need quality evaluation that measures and improves both their process and impact. Components of national programmes to prevent iron deficiency can often be integrated and add beneficial impact to other public health programmes. This applies especially to those addressing other nutritional deficiencies and to the control of infections such as hookworm and schistosomiasis that cause blood loss, malaria that is another cause of anaemia, and increased child spacing that reduces the burden of pregnancy on iron status.

Iron deficiency has a massive but almost totally unrecognised economic cost, by adding to the burden on health systems, affecting learning in schools, and reducing adult productivity. Iron deficiency anaemia can usually be prevented at low cost. The benefit/cost ratio of implementing preventive programmes is recognised as one of the highest in the realm of public health.

Submitted by Nevin Scrimshaw, Senior Advisor, UNU Food and Nutrition Program for Human and Social Development, International Nutrition Foundation for Developing Countries, United Nations University, Charles Street Stations, PO Box 500, Boston MA 02114-0500 USA. Fax: 617 227 9405 Phone: 617 227 8747 Email: nevin@cyberportal.bet/uncpo@zork.tiac.net

Vitamin A Fortification Survives a Scare in Guatemala

After an unsuccessful attempt at vitamin A fortification of sugar in the 1970s, by the late 1980s all sugar in Guatemala was fortified. The target concentration was 15 mg/kg; however, spot checks of the sugar in the market in the early years showed vitamin A levels to be far below the target because of poor stability of the added vitamin A. By 1993 a new decree from the Guatemalan government indicated that all sugar produced in Guatemala would contain vitamin A at a concentration of 10-20 mg/kg and any sugar found not to contain this level would be confiscated. The National Micronutrient Survey of 1995 reported that, although 99% of sugar was fortified, only 14-49% contained the mandatory concentrations. Despite the low concentration of vitamin A in sugar, dietary studies documented an important contribution from this source to the total intake of vitamin A. When the recently discovered low efficiency of bioconversion of provitamin A in plants is taken into consideration it is evident that sugar fortification contributes significantly to overall vitamin A intake. For example elderly subjects in a central highlands hamlet of Guatemala had a median total vitamin A intake of 847 retinol equivalents (RE) with 45% coming from sugar; preschool age children in outlying communities around Guatemala City had a median total vitamin A intake of 809 RE with 56% from table sugar. Additionally breast milk concentrations of 18 lactating mothers were adequate and estimated liver values were in the acceptable range for 17 older Guatemalans.

In December 1997, the Guatemalan Association of Sugar Refiners announced a 10% increase in the price of sugar. The government, fearing that this price increase could set off a spiral of inflation, announced in early January that vitamin A fortification was no longer obligatory and that up to 50,000 metric tons of sugar (not fortified) could be imported annually. This measure was conceived as leverage to reduce the price of sugar. An outcry arose from several sectors including the legislative and judicial branches of the same government and from both national and international civilian groups. They all realised the potentially devastating effect this could have on a population at risk of endemic hypovitaminosis. Nine days after the initial announcement to curtail fortification the government revised its decision and restored fortification to its previous level.

The events in Guatemala indicate how precarious the health of a population can be when a country is so dependent on one food source of a nutrient. A diversified approach to food fortification would lessen the national vulnerability to vitamin A deficiency. Fortification of other food products, supplementation of lactating mothers and increased consumption of animal protein sources rich in preformed vitamin A have been suggested to protect the Guatemalan population. The unexpected shake-up of the policy on vitamin A fortification in Guatemala serves as a reminder of the fragility of political will and the resilience of a populations committed to vital food fortification programs.

This is a summary of a report written by Noel Solomons and Jesus Bulux (Centre for Studies of Sensory Impairment, Aging and Metabolism (CeSSIAM), Guatemala City, Guatemala) that first appeared in the SIGHT AND LIGHT Newsletter, 2/1998 p 26.

Anthropometric Evaluation of Schoolchildren in La Union, El Salvador

In 1993, the Salvadoran Ministry of Public Health conducted a nation-wide family health survey with technical support provided by the Centres for Disease Control (CDC, Atlanta, USA). This study showed that nationally 11.2% of children under five years are underweight (< 2 SD below the NCHS median). Stunting was even more prevalent, as nearly one-quarter (22.8%) of the 3,483 under-5 children were < 2 SD below the reference.

Within El Salvador, notable socio-economic disparities are present across the 14 departments that comprise the country. La Unithe eastern-most department in El Salvador, is characterised by a dominant rural population with a majority of its inhabitants (in excess of 65%) living below the poverty line; as well, more than 40% of adults are illiterate. Given the conditions in La Union, concern arose as to the extent to which schoolchildren in the area between 5 and 9 years of age are malnourished.

This survey coincided with a related objective, namely, that of identifying the potential benefit of a school-based health education/promotion programme. Since 1995, in hundreds of primary schools throughout the country, a school-based health promotion initiative entitled Escuela Saludable (Healthy Schools Programme) was implemented collaboratively by the Ministries of Education and Health in El Salvador. The programme consisted of complementary actions, which together aimed to improve the overall health status of Salvadoran schoolchildren. These components included nutritional supplementation (provision of food, such as rice, cooking oil, and tinned pork meat), vitamin A and ferrous sulphate administration, treatment for intestinal parasites and basic dental treatment.

Although a significant level of funding of the Healthy Schools programme had been received by 1997 no systematic evaluation of the programme’s impact had been conducted. When at the beginning of January 1997, the Healthy School programme was introduced into five adjacent primary schools in the southern part of the department of La Union, a quasi-experimental study was conducted. Baseline data were collected on 196 school children in February 1997 with subsequent follow-up evaluation in September 1997, using standardised anthropometric measures. Comparison of baseline and follow-up anthropometric indices indicated some improvement in the nutritional status of the children; specifically low weight-for-age decreased from 18.3% to 10.2% while low weight-for-height decreased from 5.9% to 1.7%. However, low height-for-age remained high (25.5% initially v. 24.2% at follow-up).

According to the author, improvements may be the result of:

à increased access to food items over the eight month period,
à increased energy intake,
à improved absorption in the gut following treatment for parasites,
à iron and Vitamin A supplementation.

Given that nutritional stunting occurs early in life by the time a child reaches the age of 5 years, his/her growth potential may already be adversely affected. Secondly, while the combined impact of the actions of the Healthy Schools programme may have been beneficial amongst this group, the sustainability of this initiative is questionable, as it is dependent upon future government expenditure commitments. Making additional food supplies available at the local level is unquestionably a critical step forward, particularly amongst the more vulnerable segments of populations such as that of El Salvador. Nevertheless the underlying causes of malnutrition in such settings are inextricably linked with more structural factors, especially poverty and the lack of sustainable local income opportunities. Therefore, to substantially reduce malnutrition amongst young children, it is necessary to address the basic and underlying factors - both direct and indirect - principal among these being poverty.

Submitted by Brendan Dineen and William Gonzalez. Brendan Dineen is with the Department of Health Promotion, Medical Faculty, National University of Ireland, Galway, Ireland. Email: brendan.dineen@nuigalway.ie William Gonzalez is with the Instituto Salvadoreno de Seguridad Social (ISSS), San Salvador, El Salvador.

IUNS

At the 16th International Congress on Nutrition in Montreal, the International Union of Nutritional Sciences (IUNS) General Assembly called for a review of the structure and functioning of the IUNS including funding. The President was instructed to select a small representative group independent of the current IUNS Council to conduct the review and submit a report to the IUNS Council in two years. This will allow time for review by the Adhering Bodies before final consideration by the Council at the 2001 General Assembly meeting in Vienna. Professor M. Gabr, Professor of Paediatrics at Cairo University will chair the committee.

Two new task forces have been established within the IUNS:

à Nutrition Transition, and
à Nutrition and Electronic Communication

The Nutrition Transition Committee, chaired by Dr. B. Popkin is working on understanding the dynamic patterns of dietary change, physical activity, and body composition and their health implications for transitional economies. It is also exploring the underlying socio-demographic, economic and technological factors responsible for the accelerated transitions. The committee is developing an understanding of public health and other national programs and policies that can reduce the negative components of nutrition transition while enhancing the more positive elements.

The new task force on Nutrition and Electronic Communication, Chaired by Dr. B. Hsu-Hage, is charged with developing electronic communication mechanisms in less technologically advanced countries. The committee will find ways to encourage electronic communication within and between Adhering and Affiliated IUNS Bodies and international organizations that deal with nutrition.

Additionally a Steering/Advisory Committee for the 3rd International Food Data Conference (Joint IUNS/UNU), chaired by Dr. B. Burlingame, has reviewed requests for hosting the conference. A theme for the conference will be selected and, if appropriate, advice on financial and organisational aspects will be given. The committee will review and monitor progress of organisational aspects, as well as assist with conference promotion. The site of the conference has been selected: FAO, Rome, July 5-7, 1999.

Submitted by Osman Galal, IUNS Secretary General. Email ogalal@ucla.edu