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close this bookSCN News, Number 16 - Nutrition of the School-aged Child (ACC/SCN, 1998, 80 p.)
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Letters to the Editor

This section aims to encourage positive discussion and debate about current issues in the field of international nutrition, including reponses to articles published in SCN News. Your letters and comments would be most welcome.

Dear Editor,

We have read with interest the edited version published in SCN News No.15 of the Forman Memorial Lecture on 'How are we doing in international nutrition' which was delivered by F. James Levinson at the recent IVACG Meeting in Cairo. Mr. Levinson based his lecture on a questionnaire sent to persons he selected. None of these questionnaires were apparently sent to anyone at FAO or WHO, despite our work to provide member countries worldwide with authoritative normative information and policy guidance needed for better nutrition, food, agriculture and health programmes and our daily work with involved government agencies, the international community, academia, NGOs and others involved in nutrition improvement activities.

Although his lecture is concerned with international nutrition, Mr. Levinson does not mention the FAO/WHO sponsored December 1992 International Conference on Nutrition (ICN). The lCN was attended by over 2,000 persons interested in nutrition with delegations from 159 countries and was the first and only international and inter-governmental conference on nutrition. The ICN took a broad approach to nutritional improvement and its recommendations call for action in a coordinated and cooperative manner by all concerned. In addition, the ICN recommendations were fully endorsed and incorporated into the 1996 World Food Summit Declaration and Plan of Action.

FAO and WHO have worked closely together, and with other interested international organisations at the global, regional and national level to prepare and implement ICN mandated national plans of action for nutrition. These ICN follow-up activities have elevated nutrition to a much higher priority in many countries. This has attracted significant levels of government and other resources for preparing and implementing effective policies, programmes and activities devoted to better food supplies, household food security, improved health care and education, poverty alleviation and improved overall development. In fact, in FAO Governing Body meetings, the member governments of FAO have regularly given strong support to our nutrition-related activities, particularly in regard to our ICN follow-up work. In addition, FAO has over many years played a major role in promoting better agriculture, food supplies, gender equality in agriculture, environmental protection and rational use of re sources, improved access to good quality and safe food, and better overall development and improved incomes and employment. This FAO work is essential to the programmes of all countries in attacking the basic causes of hunger and malnutrition.

Mr. Levinson's paper includes a ranking of a list of entities working in nutrition on the basis of his questionnaire. The list in itself is curious since it omits several ACC/SCN members with broad or specific interests in nutrition, such as UNESCO, IFAD, IAEA, UNHCR, the World Food Programme, UNFPA and UNDP. Although FAO has been working on international nutrition and nutrition improvement for more than 50 years, we note that we have finished last in the questionnaire results which indicates somewhat of a bias among those polled and a definite failure to appreciate the critical nature of access to adequate supplies of good quality and safe food as the first and foremost requisite for good nutrition.

Certainly the ICN brought the topic of improved nutrition and reduction of malnutrition to centre stage and prepared a very clear plan of action showing all the things that need to be done, The heads of state and government and high level ministers from 180 countries who attended the World Food Summit renewed the commitment of all countries to ICN goals and emphasised the need for access by all to adequate supplies of good quality and safe foods as essential to assuring food security and eliminating hunger and malnutrition. All involved in international nutrition should do their best to implement all of its recommendations and work together on the basis of our different mandates to cooperatively address all of the ICN concerns. While there was little appreciation of FAO work over the years by those polled, we at FAO will continue our efforts to implement the ICN recommendations to improve the nutritional status of all, and to continue to do our best to actively cooperate with all.

By John R. Lupien, Director, Food and Nutrition Division, FAO. Via delle Terme di Caracalla, 00100 Rome, Italy. Tel: 396 5705 3330 Fax: 396 5705 4593 Email: john.lupien@fao.org

A Reaction to James Levinson's 10th Annual Martin Forman Memorial Lecture (SCN News No. 15), presented in the form of a letter to the student 'Erica'

Dear Erica,

You probably did not expect that a concerned question of yours to Professor Jim Levinson would propel you to some notoriety. Your question allowed Dr Levinson to go into some depth on something that has worried us for many years, namely how we are doing in international nutrition. Reading his response to you, I found much that I could identify with. But I also found things for which I have a slightly different view and that would help you even better judge what you are planning to get involved in your future career. That is why I am writing you this sequel letter.

Judging the most important advances in nutrition in the last 10 years, the survey respondents chose advances in reverting micronutrient deficiencies. This came as no surprise. Most nutritionists still like 'silver bullet' fixes, primarily because they move within the technical realm. But, at its roots, PEM is more of a political problem; it is the biological translation of a social disease.

Of the four next choices for important advances that were chosen, I can agree with two: greater community involvement in programmes (not so much projects), and increased attention to care practices addressing women and children. But for the other two, I have slightly different interpretations: it is not that we now have a 'better' understanding of the causes of malnutrition; we have rather reached a point in which we have convinced more people about the 'correct' conceptual framework of the causality of malnutrition, one that considers the latter an outcome of those different levels of causality. Further, I take exception to the suggestion that having achieved better designs and management of nutrition interventions in the last 10 years, this has led us to significantly better resolve the problems of PEM - design and management are not the main constraints our nutrition interventions have had in the last 10 years. The main top-to-bottom, often palliative thrust of them has been (and still is) the main constraint. We have not started addressing all underlying and basic causes of malnutrition yet I was definitely surprised, Erica, to read the next major advance chosen by respondents: 'greater sensitivity to the importance of nutrition counselling'; this just shows the ethnocentric bias of the respondents.....as if 'counselling' would solve the problems of poverty and inequity...

The same bias can be found when respondents chose reduced funding as the major problem or constraint to achieving better results in the battle against PEM. If additional funding is used for the wrong priorities and interventions, we might as well not have it! As pertains to available funding going more for field operations than for research, this is a shift that may be pointing to the fact that we do know what to do, we just have to apply it rationally and courageously, even against the opposition of the powers that be.

I propose that we - once and for all - have the courage to separate PEM from micronutrients interventions as two completely different entities, two different universes and two totally different challenges. Only then will we avoid nutritionists running away from the more difficult choices and challenges in the battle against (the real) malnutrition.

I am sorry, Erica, to disagree not only with the respondents, but also with Dr Levinson on the centrality of the issue of intera-gency infighting. It exists, and it is a disappointment, granted, But it is not the main obstacle to a faster progress. The issue of a lack of commitment by governments to meaningful nutrition interventions was chosen as another major obstacle. But this argument has been made too often, always keeping it as a blanket statement, almost as a slogan. It is time we must analyse this in more depth; only then will we learn how to tackle it better. The frequent absence of project evaluation, also cited as a constraint, I am convinced is on purpose; this allows agencies to continue pouring money into actions that do not much alter the balance of power at the base of the disempower-ment that breeds malnutrition. Further, I do agree that bureaucratic problems in getting things done are a great burden.

Jim Levinson concludes from these responses above something that I cannot agree with. He says that this shows that 'the major negative factors faced in international nutrition are not...structural... constraints, but rather problems that the nutrition community.... can...control'. I could not disagree more. The major negative factors I think are indeed structural and related to the basic causes of malnutrition. Most is ultimately a matter of empowerment. In the years to come, it will take a more sustained (and sustainable) bottom-up activism to revert malnutrition on the scale that is needed.

The respondents were also asked to rank international agencies in terms of how they had served the field of international nutrition. Low rankings received by agencies we thought major nutrition actors do not necessarily reflect them having lost their funding or commitment to international nutrition; it rather reflects that they probably embraced the wrong approaches to solve malnutrition in the last 10 years (perhaps those that were too sectoral?). Lower current funding, in my view, reflects nothing more than one more swing of the pendulum that has affected international nutrition funding following the fashion swings in the thinking of the international community. (Or is it that we have little to show for the increased funding we enjoyed in the last few years,..?).

The politics of it all is at the very centre of international nutrition. With this fait accompli, it should be clear that you cannot escape the responsibility of taking a political stand on nutrition yourself. This will help you to question your own current education, as well as all that you see out there in the job market that is waiting for you shortly.

Dr Levinson is right, Erica, when he tells you that the current state of affairs in international nutrition 'will pose increasing frustrations' and challenges for you and your generation. My doubts though come from looking at how politically uninterested your generation of students in America and Western Europe has become. If you are one of them, don't worry, you will not face increasing frustrations and malnutrition will continue to plague this world in the years to come.

In closing, Erica, Jim Levinson conveys to you his confidence and optimism that our work has the ability to make a difference. The question is which difference. It is not a matter of an increasing number of activities in international nutrition taking place in developing countries; it is a matter of what kind or type of activities. Issues of inequity are at the base of the problems at hand, and if nutrition is used as a port of entry to revert such inequity I would share his optimism. But we need your upcoming generation, Erica, to get the job done.

By Claudio Schuftan, MD, IPO Box 369, Hanoi, Vietnam. Tel/Fax: 84 4 8260780 Email: aviva@netnam.org.vn

A response by Jim Levinson...

Dear Editor,

I am delighted that my Forman Lecture has generated so much discussion. In my invitation to deliver the Lecture I was asked by Dr. Horwitz to be 'original, stimulating and even provocative¹. One measure of success on the last of these was the comment made by one listener who came up to me after the Lecture and said jocularly, "I hope you have tenure!"

As mentioned in the Lecture, I grew up with the greatest respect for both FAO and WHO, and continue to believe that both provide important services. I utilise many of them myself on a regular basis. As indicated, I am genuinely saddened to see that these UN technical agencies do not elicit the same level of confidence, at least within the nutrition community that they once did. Rather than responding defensively, I would hope that these organisations would view the Lecture as an invitation to recapture that confidence.

I should correct a few factual errors in the letters. First, re John Lupien's comment about the questionnaire, it was, in fact, sent to a considerable number of FAO and WHO officials, John included. Many of these persons have acknowledged to me personally both that they received it, and that they completed and returned it. Additionally, rather than ignoring the FAO/WHO sponsored International Conference on Nutrition (ICN), I specifically included it together with the development of country plans of action on a list from which respondents were invited to select the four most important advances in international nutrition over the past 10 years. Nineteen percent of respondents included the ICN and country plans as one of their choices in the 'most important advances' category.

But, let me be clear. The data I presented in the lecture was a summation of responses from a large number of individuals around the world. A 50% response rate is remarkably high for an internationally mailed questionnaire of this sort. I was able to assure that the information was accurately analysed and tabulated. To say that the material is 'inaccurate' is only to question the judgements of the respondents.

John Lupien may be correct in chiding me for excluding from the organisation/agency rankings a number of other UN organisations which do have some nutrition involvement. The desire here was only to make the questionnaire manageable - as it was, there were 16 organisations or groups or organisations to rank. I took my cues on which to include from several international colleagues and two major international figures, one each from Africa and Asia.

I won't try to respond to all of Claudio Schuftan's interesting remarks, but will comment briefly on a few. First, I think Claudio is correct about underlying structural and political problems which deserve more attention from the development community as a whole. Second, I'm in complete agreement with Claudio's contention with respect to the micronutrients/PEM imbalance. In fact, his letter to the SCN News, which he copied to me earlier, generated considerable correspondence and an eventual letter from the two of us and V. Ramalingaswami which will be published in The Lancet this summer.

Claudio and I may agree to disagree on the importance of the 'infighting' issue which was identified by respondents as such a major negative factor in international nutrition. But I should mention that, since presenting the Lecture, I've been absolutely swamped with messages from individuals around the world confirming the insidious effect that such infighting has had on our community. Several individuals even have asked that the issue be placed formally on the agenda of the SCN.

What pleases me most is that the Lecture and SCN's publication of it, have served the purpose of presenting these important issues to the nutrition community at large for our common consideration.

By Jim Levinson, Director, International Food and Nutrition Center, School of Nutrition Science and Policy, Tufts University, Medford MA. 02155, USA. Tel: 1 617 627 3223 x2284 Fax: 1 6176273887 Email: jlevinson@emerald.tufts.edu

Dear Editor,

Claudio Schuftan's review of Werner and Sanders' new book 'Questioning the Solution' (SCN News No.15 p58) cannot go unchallenged. David Sanders kindly gave me a copy of the book on his recent visit to Darwin, so I certainly bear him no malice, but this book is too far from evidence-based medicine for my approval. Indeed, the science is used too selectively to justify a political perspective. Many important claims are made with no data to support them. In the end, it is political rhetoric instead of good medicine. This is especially disappointing as a sequel to 'Where there is no doctor', which deserved its good reputation.

The basic argument is for salt-sugar solution (SSS) which can be made up at home instead of ORS in packets, which has been a recurring theme of public health debate, and I am not unsympathetic to that argument. But there have been so few sustainable SSS projects in which families have been shown to remember the formula of the safe solution when children have diarrhoea that this book's argument is unsustainable. ORS has been an important advance for health facilities, so it is a pity this book appears to discredit it without making a convincing case from an evidence perspective. However, it is true that the emphasis on oral rehydration ignored (until recently) the importance of persistent diarrhoea and malnutrition. I would favour home-based programmes under circumstances where health facilities were inadequate, but not as a universal programme for diarrhoea, and certainly not always instead of ORS in packets.

As a paediatrician treating children with diarrhoea, I am too aware of the need for potassium in rehydration solutions and the dangers of incorrect sodium concentrations in home-based solutions, Of course mistakes can be made with packets going into a glass of water instead of a litre, but health facilities need to use the best solution and that means with potassium. Of course, empowering people to manage their children's diarrhoea without the need for health workers is fine, but not in order to deny them optimal treatment which is still accessible to most populations even in very poor countries like Malawi and Zimbabwe (where I have worked). This book does not provide any evidence that home-based solutions are more accessible as a sustainable and effective intervention than ORS made widely available through all levels of health facilities. Successful home-based SSS projects have needed enormous educational and promotional activities, which are excellent but expensive and difficult to sustain.

Cereal-based ORS does seem to have marginal benefits in some of the studies, but not in all. However, the nutritional benefits do not seem to be greater than with early refeeding of malnourished children. The work of Nichols, Lunn, Pappen-heimer, Wright and others (see references) on the intestinal mucosa now allow us for the first time to design appropriate diets for malnourished children during early rehabilitation which will be tolerated and lead to faster transition to a high energy rehabilitation diet and recovery. So it is improved diets rather than just cereal-based ORS which are needed.

I feel that Werner and Sander's arguments would have been better supported with more focus on issues such as abuse of medical treatment of diarrhoea (antidiarrhoeals or antibiotics), poor motivation and supervision of health workers, etc., but applied to ORS, I found it unconvincing because ORS has been one of the great successes of diarrhoeal management upon which we need to build.

References:

1. Morales E, Craig LD, MacLean WC, Jr. (1991) Dietary management of malnourished children with a new enteral feeding. J. Am. Diet. Assoc. 91(10)1233-8.

2. Nichols BL, Dudley MA, Nichols VN, Putman M, Avery SE, Fraley JK, Quaroni A, Shiner M, Carrazza FR. (1997) Effects of malnutrition on expression and activity of lactase in children. Gastroenterology 112(3)742-51.

3. Wright EM, Hirsch JR, Loo DD, Zampighi GA. (1997) Regulation of Na+/glucose cotransporters. J. Exp. Biol. 200(Pt 2) 287-93.

4. Pappenheimer JR, Kamovsky ML, Maggio JE. Absorption and excretion of undegradable peptides: role of lipid solubility and net charge (1997). J. Pharmacol. Exp. Ther. 280(1) 292-300.

5. Mazumder RN, Kabir I, Rahman MM, Khatun M, Mahalanabis D. (1996) Absorption of macronutrients from a calorie-dense diet in malnourished children during acute shigellosis. J. Pediatr. Gastroenterol. Nutr. 23(1)24-8.

6. Northrop Clewes CA, Lunn PG, Downes RM. (1997) Lactose maldigestion in breast-feeding Gambian infants. J Pediatr Gastroenterol Nutr 24(3) 257-63.

7. Brewster DR, Manary MJ, Graham SM. (1997) Case management of kwashiorkor: an intervention project at 7 Nutritional Rehabilitation Centres in Malawi. Eur J Clin Nutr 51 139-47.

By David Brewster, Head of Paediatrics & Clinical Dean, Northern Territory Clinical School, PO Box 41326, Casuarina, Darwin, Australia. Tel: 61 8 89228765 Fax: 61 8 89228286 Email: david. brewster@health. nt.gov.au

Corrigendum. Guiding principles for feeding infants and young children during emergencies (SCN News No.15 p. 37). Copies of the final version of the Guiding Principles will be available for general distribution only later in 1998. In addition, our footnote at the bottom of the 2nd column should have read: Editor's note: World Health Assembly resolution WHA45.34 reaffirmed 'that during the first four to six months of life no food or liquid other than breastmilk, not even water, is required to meet the normal infant's nutritional requirements, and that from the age of about six months infants should begin to receive a variety of locally available and safely prepared foods rich in energy, in addition to breastmilk, to meet their changing nutritional requirements'. The complementary feeding portion of this resolution was reiterated in resolution WHA 47.5, which urged 'fostering appropriate complementary feeding practices from the age of about six months, emphasising continued breastfeeding and frequent feeding with safe and adequate amounts of local foods'. The scientific basis for these recommendations is the 1995 report of the WHO Expert Committee on 'Physical Status: the use and interpretation of anthropometry¹.