No. 23, April 25, 1994

The following excerpts are selected from the quarterly newsletter, "New & Noteworthy in Nutrition," produced by Alan Berg, the Senior Nutrition Adviser at the World Bank. The objective of the newsletter is to inform Bank staff of nutrition- related projects and activities in the Bank as well as recent advances in international and domestic clinical and applied nutrition research. We regret that constraints on staff time make it impossible to respond individually to inquiries regarding citations or documents mentioned in these excerpts.

1. Stunted Growth = Stunted Growth. Before the outline for the 1995 World Development Report on productivity gets set in concrete, it is important to note that nutritional stunting amounts to an annual loss in productivity on the order of $8.7 billion --this nugget buried 400 pages deep in the Bank s recently published Disease Control Priorities in Developing Countries. This finding, based on a composite look at four recent studies, conveys for the first time a reasonably accurate estimation of economic losses associated with malnutrition. (Methodological flaws in numerous earlier studies made interpretation of their findings difficult.) Stunting during childhood appears to translate into equal height deficiencies in adulthood. The elasticity of height on productivity --as measured by wage -- was estimated in one study to be 1.38, implying that a difference of 1 percent in the height of adult workers is associated with a 1.38 difference in their wages. Calculations for the $8.7 billion estimate are in the Priorities Protein-Energy Malnutrition chapter by Per Pinstrup-Andersen, Susan Burger, Jean-Pierre Habicht, and Karen Peterson.

2. Poor Because They re Lazy or Lazy Because They re Poor? Bank-financed research on Rwanda (by Alok Bhargava and Jiang Yu, University of Houston) provides evidence that poor nutrition status forces adults to take more rest between work episodes. The data, says the green cover Poverty Reduction and Sustainable Growth (by Qaiser Khan) that summarizes the research, show that were they not forced to take the rest they could have done more work to improve productivity on their holdings; in short, they rest not because they have nothing to do.

3. They re Not Playing Hooky. Why do children in poor countries so often defer enrollment into primary school, despite the costs of delay, including significant costs on subsequent productivity? The delay is the consequence of nutrition deficiencies in early childhood, according to evidence cited by Paul Glewwe and Hanan Jacoby (University of Rochester). Our robust finding that better nourished children tend to start school earlier and thereby enter the labor force earlier, all else equal, they write in Delayed Primary School Enrollment and Childhood Malnutrition in Ghana, has potentially important implications for policy. They find no support for alternative explanations of putting off enrollment. Conditional on height-for-age, family income has no significant impact on delays. In addition, school fees have virtually no effect. Their calculations show that childhood nutrition interventions can lead to substantial increases in lifetime wealth.

4. Labor-Saving Tips. From work on the determinants of the nutrition status of adult women in Ghana, Harold Alderman and Paul Higgens (Tulane) conclude that the impact of heavy work (i.e., energy expenditure) on their nutrition condition is significant. In fact, lack of calorie availability seems to count for less than overwork.... By way of remedy, the introduction of labor-saving devices may have a direct impact on nutrition similar to the increase of food consumption. The authors also call for consideration by program designers of the negative impacts of public work projects involving physical labor on women, especially when designed in response to food shortages. Their report, Labor and Women s Nutrition: A Study of Energy Expenditure, Fertility, and Nutritional Status in Ghana, a Cornell University publication, gives weight to the nutrition components providing labor-saving devices to women --such as in the Malawi and Lesotho Population, Health, and Nutrition Projects --which were designed to reduce calorie (energy) expenditure.

5. A Greener Revolution. Promising news from a recent meeting in Annapolis that brought together some of the best and brightest plant breeders, plant physiologists, and agronomists from the Consultative Group on International Agricultural Research Centers and nutritionists and nutrition economists: gaining micronutrient efficiency through plant breeding IS feasible and could easily increase plant productivity and, at the same time, nutrition value. To get new breeds could take from 10-15 years, however, concluded the International Food Policy Research Institute (IFPRI)-sponsored meeting. So, staying the course on micronutrient supplementation, fortification, and dietary diversification is necessary while awaiting this magic bullet from agricultural technology.

6. Swing of the Pendulum? The Administrative Committee on Coordination-Sub-Committee on Nutrition (ACC/SCN), at its annual meeting last month in New York, expressed unusually strong concern about possible changes it detects in current thinking on food supply and food security/distribution issues. Supply historically dominated attention and resources, but access to food has been a major focus for the last decade or so. New concerns, however, such as doubts about the sustainability of intensive farming and irrigation systems and an apparent slowdown in the rate of increase of yields of the major food staples, have led to a re-emergence of arguments favoring greater emphasis on increasing food supply. Where does the SCN sit on this debate? At the moment, there is no question. Although it is imperative to assure a sustainable future world food supply and it is necessary to keep the situation under continuous review, in our analysis, problems of access to food remain the most urgent priority for the foreseeable future. The key concerns should be who is hungry and why. And resources directed to solutions.

7. More Than Keeping Up. Related to the above --a roundtable convened by IFPRI in February concluded that, for most parts of the world, grain production is growing faster than demand, leading to projections of a substantial fall in real prices of grain (the Bank s own estimate is for a 30 percent fall in prices), and related speculation by some that the current droop in investment in agricultural production is perhaps a sensible thing.

8. Cloudy Predictions. If the greenhouse effect raises global temperatures appreciably, what will happen to the world s food supply in the 21st century? According to Cynthia Rosenzweig of Columbia University and Martin Parry of Oxford University in a recent edition of Nature, total global food production would be only slightly reduced by the year 2060. But countries at lower latitudes would be hurt worst, aggravating the disparity between rich and poor nations. In a companion article, John Reilly of USDA s Economic Research Service argues that those predictions may be overly pessimistic because they assume only modest agricultural innovation and deal with crops typical of temperate farming rather than those better suited to warm climates.

9. Undertapped Fountain of Youth. Health officials in many countries are lax about promoting breastfeeding because they believe sizable percentages of mothers already are breastfeeding and enjoy its contraceptive protection. In fact, the full potential protection is not there unless the infants are breastfed exclusively or near-exclusively. Demographic and Health Surveys (DHS) show a startling range of breastfeeding practice: in Nigeria, for instance, only 2 percent of mothers exclusively breastfeed at four months, in Brazil 4 percent, in Thailand 5 percent, compared to 86 percent in Burundi, 64 percent in Uganda, 56 percent in Bolivia, and 39 percent in Indonesia. The DHS data also show a broad range in median duration of any breastfeeding -- from roughly half a year in Brazil, the Dominican Republic, and Trinidad and Tobago, for instance, to about two years in Burundi, Indonesia, and Togo.

10. Well-Connected. Mothers in Quebec who keep the baby to the breast are paid a cash allowance of Can$37.50 a month. In the U.S. now, breastfeeding women covered under the special supplemental food program for Women, Infants, and Children (WIC), wile not given a cash incentive to breastfeed, are given additional food for themselves.

11. Vice Precedent. Mothers are no longer breaking the indecent exposure law when they breastfeed in public in Virginia. Noteworthy about last week s new legislation is the speed in which it was passed. Supporters of the legislation appeared at Committee hearings in Richmond, nursing babies in tow. State legislators, said the Washington Post, were anxious to get them out of there.

12. Making a Clean Breast of It. One of the most widespread misconceptions in nutrition, according to Chloe O Gara, Director of Well start International s Expanded Promotion of Breastfeeding Program, is that cleaning the nipple before breastfeeding is important for the baby s health. Not so. Not only is it not important, but if the mother uses anything other than water, it is a bad idea. Using soap can dry and crack the nipple, she says. The nipple does the job itself, excreting all sorts of, essentially, cleansing oils. What is important for the breastfeeding mother concerned about hygiene is washing her hands --which touch both the nipples and the baby s mouth --and keeping her bra clean.

13. Lactating Males!!! Scientists working in dense forest canopies of Malaysia have, according to the journal Nature, discovered the first example of a wild male mammal that lactates. The species is a Dayak fruit bat, a large and poorly understood creature with an 18-inch wingspan, a dog-like face, and, it turns out, a touch of androgyny. Researchers were shocked to find the breasts of all adult males swollen with milk. The males have the plumbing and the physiological capability to lactate, said Dr. Thomas Kunz, a biologist at Boston University who is senior investigator. He and other scientists say the males could be producing milk as a result of eating estrogen-like compounds found in some plant leaves. But this is mere speculation. The notion of male bats doubling as wet nurses sparks the imagination.

14. A Okay. Although most studies on the effect of vitamin A supplementation have reported marked reductions in childhood mortality, its effects on morbidity were less clear. Now, the Lancet has published a study of 22,000 Ghanaian children who every four months got either a placebo or a large dose of vitamin A. Vitamin A-supplemented children had significantly fewer attendance's at clinics (0.88), hospital admissions (0.62), and deaths (0.81) than children who received the placebos. The extent of the effect on morbidity and mortality did not vary significantly with age (6-90 months) or sex. The study was undertaken by a group from the London School of Hygiene and Tropical Medicine, Ghana s University of Science and Technology, and the Institute of Child Health in London.

15. OD-ing on Vitamin A. Are there dangers to a child who unintentionally receives mass doses of vitamin A from more than one program? The child will get a headache and vomit because there is vitamin A intolerance at some very high levels, but will recover. The downside is that mothers, seeing their children vomiting and suffering from headaches because of the capsules, will not be receptive to another capsule some months later. And they will tell their friends, possibly jeopardizing the program. The real health danger involves pregnant women. A 200,000 International Unit (IU) dose just before pregnancy, or at the very beginning of pregnancy, could produce developmental defects, and should not be given to women of reproductive age. A daily supplement of 10,000 IU is safe and advisable. However, three or four days after delivery a new mother should get a good megadose of vitamin A that then become available in breastmilk for the child.

16. Fetal Attraction. We generally think of the main effects of iodine deficiency on fetal development. Now, in an important controlled field trial on the cognitive effect of iodine and iron supplements on primary school children in Malawi, UNICEF's Ramesh Shresta (as part of his dissertation for Wageningen) was able to show a fairly demonstrable effect (in layman s language, on IQ points) from iodized oil capsules. He was also able to demonstrate important, although smaller, differences from iron; the effects of the two micronutrients were additive.

17. Vitamin E-Mail. The surprising findings in last week s New England Journal of Medicine that vitamin E might not be so miraculous after all, likely will put to rest, for the moment at least, the E-Mail traffic of project officers querying whether vitamin E and the other anti-oxidants, beta-carotene and vitamin C, about which so much had been written of late, should be included in micronutrient components of Bank projects. Much of the attention resulted from a lengthy study of 87,000 nurses, published last year by the Harvard School of Public Health, showing a significant reduction in risk of heart disease death among those taking supplements. Even before last week s findings were published, inquiring task managers were being advised against adding megadose anti-oxidants into Bank projects --if only because of cost. A typical anti-oxidant formula (400 IU of vitamin E, 10,000 IU of beta-carotene, and 500 mg of vitamin C) is likely to cost $60 a person a year. By comparison, the annual cost to meet total vitamin A, iron, and iodine needs --with demonstrated effect --is under three dollars.

18. Shake It. After years of much talk but little action by the nutrition community, the International Development Research Center-based Micronutrient Initiative, in which the Bank is an active partner, is giving a push to salt that is doubly-fortified with iron and iodine --one of the most attractive potential nutrition interventions around, in that two major public health problems are addressed with one shake.

19. Iron Stamp. Hidden Hunger III, one of a series of Human Resources Development and Operations Policy Dissemination Notes on micronutrients, suggests --where access to public health facilities is limited -- the use of stamps to enable poor consumers to obtain iron tablets from commercial sources, in the same way food stamps are used.

20. Credit Where Credit is Due. An important new collaborative study on the Effects of Credit Programs on Food Security and Nutrition in Ghana (by IFPRI and the Ministries of Agriculture and Health in Ghana) shows that microcredit for women for food processing enterprises, when combined with nutrition education, not only enhanced income but had positive outcome on child feeding, said principal investigator Eileen Kennedy at the annual SCN meeting. This success is attributed, in the draft report of the study, to a support group structure for the microcredit that emphasized income-generation and education; this being more successful in increasing caloric adequacy than a credit approach that concentrated on generating income alone. Women involved in the former had household diets 22 percent higher in caloric adequacy than other households. Interestingly, the 2-1/2 times difference in per capita income from the highest to the lowest income households in the sample (constituting both credit and non-credit users) accounted for only a 4 percent difference in caloric adequacy in the households.

21. Looking at Extremes. Practical application of epidemiological analysis for improved targeting criteria, based on the Tamil Nadu Integrated Nutrition Project (TINP), appears in the International Journal of Epidemiology. By looking separately at positive and negative deviants (those children growing best and worst, compared to median growers), Bank consultant Meera Shekar has come up with different sets of recommendations for targeting interventions. These are reflected in the design of the second TINP project, now underway.

22. Digging Up Those Old Recipes? For as long as can be remembered we have been told that the best way to get nutrition front and center on the policy agenda is to be clever enough to figure out a way to fortify the diet with a contraceptive. Turns out the ancient Greeks and Romans may have been there first. In a provocative article in the March/April issue of Archeology, history professor John Riddle of North Carolina State University contends that several foods were used in the ancient world to prevent pregnancies and induce abortions. Based on recent scientific studies, he writes, a good portion probably worked. The juice of a kind of giant fennel, for instance, contains a substance that in low doses is nearly 100 percent effective in preventing pregnancy in rats. Also, seeds of Queen Anne s lace, or wild carrot, were cited by Hippocrates as contraceptives, and he may have been right. Studies with rodents indicate that the seeds block the production of progesterone, a hormone necessary for pregnancy to be established. Queen Anne s lace is still used as a folk medicine. Some women in Appalachia drink a glass of water containing a teaspoonful of the seeds immediately after sexual intercourse to prevent contraception. And women in Rajasthan chew the plant s seeds for the same reason. Pomegranate seeds, Dr. Riddle says, also have been shown to reduce the fertility of laboratory animals. Others working in the field are less certain of Dr. Riddle s thesis, but several involved in related research find his observations tantalizing.

23. No Bones About It. What is a nutrition miscreant doing spending a sunny weekend at the Annual Meetings of Archaeological Association? The reason: some skeletal evidence from ancient times sheds unexpected light on nutrition. Physical anthropologist Della Collins Cook of Indiana University reports that certain nutrition deficiencies were less prevalent during Neolithic times (4,000 years ago) and even Mesolithic times (8,000-10,000 years ago) than now. Ancient bones show that iron- deficiency anemia was at much lower levels than today. Scurvy (vitamin C deficiency) was never known and rickets (vitamin D deficiency) rarely known. The explanation: prior to settled agriculture, diets on a whole were more varied. Another study, this by Susan Kirkpatrick Smith of the American School of Classical Studies in Athens, examined skeletal remains to explore whether social structure in Late Bronze Age Athens determined nutrition status. No question, the better off --reflected by fancier burial types and goods found in graves, reflecting wealth -- were significantly taller in stature.

24. New Theory of Relativity. One way to determine the appropriate program to overcome malnutrition in young children may be to look at the nutrition condition of the children s older immediate relatives. A particularly revealing insight emerged from a recent (but not-yet-published) meta-analysis of households in half-a-dozen developing countries by Anna Ferro-Luzzi of the National Nutrition Institute in Italy and Philip James of the Rowett Nutrition Research Institute in Scotland. They found that when both mothers and children in the family suffer from malnutrition, the likely cause is inadequate food in the household. But when adequately fed mothers co-exist with malnourished children, the likely cause of malnutrition is feeding practices or health environment. The implications? The researchers suggest that anthropometry of the household may offer a simple operational tool to decide the best type of intervention necessary to improve nutrition status of children. Also to better target communities eligible for food aid.

25. If You Can t Beat Em. Recognizing the difficulties of fighting junk foods and of changing food habits to more nutritious products, the Philippine Food and Nutrition Research Institute has come up with nutritious junk foods. The idea is to take extruded products, that are junk food in appearance, and smuggle into them legumes and other nutritious ingredients to give the products a much higher protein, vitamin, and mineral content.

26. Hypocritical Oath. A nationwide survey published in the American Journal of Clinical Nutrition found that doctors trained in American medical schools are much less likely to advise on nutrition in their practices -- even though they say they recognize the importance of good nutrition --than foreign-trained doctors who are practicing in the U.S. So much for the quality of nutrition in U.S. medical schools.

27. Grounds For Concern. With increased coffee consumption in urban areas in developing countries, it may be useful to bring the issue of caffeine in pregnancy to the attention of health ministry counterparts. Even modest doses of caffeine may lead to miscarriages, according to a report in the Journal of the American Medical Association. The study found that pregnant women who drink 1.5-3 cups of coffee a day doubled their chance of miscarriage. Pregnant women who drink more than three cups a day triple the risk.

28. Weighing In. Relatively small systematic errors in weight or age measurement can cause significant changes in the calculated rates of malnutrition in a country, according to the new LSMS working paper (No. 101), Assessing the Quality of Anthropometric Data, by Kees Kostermans. This illustrated guideline for survey managers summarize quality control methods, including new ones made possible with the use of personal computers during field work.

29. Up in Arms. For children, relative risks for mortality associated with small mid-upper arm circumference are greater than risks associated with low levels of weight-for-age, weight-for-height, and height-for-age, according to a paper by Venanzio Vella in the American Journal of Public Health. Arm measurement is not proposed as a substitute for growth monitoring, but as a useful way to screen for future risk of mortality.

30. More on Nutrition Engineers. The American Journal of Clinical Nutrition has included a rush of letters-to-the-editor about the Population, Health, and Nutrition Department proposal that a special effort be made to develop nutrition engineers capable of seeing a project through (with skills in project design, management, and evaluation) and bringing about a result. Interestingly, all letters having a critical tone come from university researchers, while all those from people in policy and program positions are supportive. Other exchanges on the subject appear in the Journal of International Health and in the recently published Annual Review of Nutrition.