|New and Noteworthy in Nutrition (WB)|
|No. 18, September 11, 1992|
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. From Platitudes to Practice, a splendid new two-volume work on targeting nutrition and other social programs in Latin America by Margaret Grosh for Latin America and the Caribbean Department (LAC), will be available later this month. Based on 30 case studies, the volumes come to three main conclusions: Targeting works, albeit imperfectly. The median share of benefits reaching the poorest 40 percent of households is 72 percent for targeted food programs, compared to 31 percent for general food subsidies, 51 percent for primary health care and 62 percent for primary education. Administrative costs for moderately well-targeted programs are not prohibitive. Only a part of total administrative costs are due to targeting or screening devices; in cases where such costs could be separated, the median was one percent of program expenditures or $1.36 per beneficiary. And there is no correlation between the type of targeting and outcome, so it is not possible to rank targeting mechanisms. Details of circumstance and implementation contribute as much to the success and costs as the basic mechanism selected.
2. Nutrition and School Enrollment. A just-completed piece of research on Ghana by Paul Glewwe, World Bank, and Hanan Jacoby of the University of Rochester points up the economic importance of delayed primary school enrollment, and finds such delay a "consequence of nutritional deficiencies." The soon-to-be- published study, "An Economic Analysis of Delayed Primary School Enrollment and Childhood Malnutrition in a Low Income Country," finds no support for alternative explanations including family income, measured by per capita expenditures, or school fees.
3. Crediting Women. Last year's Population and Human Resources nutrition seminar by Freedom from Hunger President Christopher Dunford (on innovative community nutrition projects that require participation by women's groups in nutrition/health education activities to be eligible for credit from a revolving fund) piqued a lot of interest, but quantitative evidence was not in hand. Now, encouraging reports are in. An impact survey was conducted among a sample of randomly selected program participants and non-participants in West Africa and Central America. In Mali, for instance, 86 percent of Credit Association members reported more income (compared to 27 percent of controls), 90 percent reported more savings (compared to 27 percent), 65 percent of members were knowledgeable about specific nutrition messages presented, such as the proper age to introduce solid food to an infant (compared to 20 percent) and 85 percent of the members felt that health and nutrition of their pre-school children had improved (compared to 40 percent). Similar evidence was found in Honduras.
4. Suffer the Children. Are inadequate amounts of food the major cause of child malnutrition? A study recently completed in Zimbabwe (by Anna Ferro-Luzzi of Italy's National Institute of Nutrition and her associates), comparing the nutrition status of children and their parents in one of the poorest sections of the country, often finds parents with satisfactory weight (in many cases, overweight) but their children with poor nutrition. The conclusion: lack of food cannot be the major factor for much of the malnutrition, especially when considering the small quantities required by the very young.
5. Better Indicator. How to identify pregnant women at risk of delivering low birthweight infants? Although earlier research elsewhere had identified arm circumference and height as optimal indicators, recent research by the Institute of Nutrition for Central America and Panama (INCAP) found that, for Central America at least, calf circumference worked better than either.
6. Breastfeeding Discrimination. In rural India, "significant differences in male and female children in the extent of malnutrition pointed towards discrimination against girls, even in respect of exclusive breastfeeding," reported S. Rao and A.N. Kanade of the MACS Research Institute, in the most recent issue of The European Journal of Clinical Nutrition. The July newsletter of India's National Institute of Nutrition reports that a higher proportion of boys (51 percent) were being breastfed at the time of a survey than girls (30 percent) and that prolonged breastfeeding of boys was more common.
7. How Important Schooling? Conventional wisdom holds that mothers' schooling is critical to nutrition and health outcomes for children. Professor Jere Berhman of the University of Pennsylvania has begun to question whether education or cognitive capabilities before the schooling matters more. That question is being answered by Professor Ernesto Pollitt of University of California/Davis, using data from Guatemala. By testing cognitive capacity of girls before schooling, he shows that it may be those cognitive abilities, not just schooling, that make the difference. (The Bank's operational work in Indonesia shows that women's lack of schooling need not pose the insurmountable constraint to improving nutrition that it is widely believed to pose. Although formal education for women, of course, has many important benefits, the Indonesian experience demonstrated that education level does not define how much women are able to safeguard or improve their children's nutrition, if women receive highly specific messages, appropriately tailored and delivered.)
8. Overemphasizing MCH? Are we in nutrition and health so MCH-oriented we are over-concentrating on the mother/child dyad? In a just-completed dissertation at the London School of Hygiene and Tropical Medicine, Sarah Castle found in rural Mali that 33 percent of children under five are not living with their biological mothers and 52 percent of ten-year old girls are not. One distinction is important. Some youngsters are "dumped," while others are requested to help, an elderly relative, for example, by living together. So, thinking beyond the MCH concept, strategies to improve nutrition would differ, depending on category.
9. Iron Surprise. A Wageningen (Netherlands) dissertation on micronutrients in Ethiopia found iodine and vitamin-A deficiencies to be very high, but iron deficiency surprisingly not. The explanation by author Z. Wolde-Gebriel, now Director of the Ethiopian Nutrition Institute, is in the way the food staple tef is threshed. "It comes in direct contact and is contaminated by the iron-rich soil." Meanwhile, vitamin-A deficiency was the highest ever recorded anywhere; 8 percent of children had the serious clinical symptom, Bitot Spots. One reason given is the inadequate vitamin A in food aid. The village with the highest incidence had been dependent on food aid for six years.
10. Breastfeeding Benefits of Rooming-in. The bottom line of a recent doctoral thesis by Rafael Perez-Escamilla for the University of California/ Davis is that a Mexican maternity ward system with rooming-in led to as much as 30 percent exclusive breastfeeding at the end of four months, compared to virtually none for babies who remained in the nursery. Also, from interviews within 10 hours of childbirth, mothers who expressed less confidence in being able to fully breastfeed were, in fact, those who later reported being unable to provide enough milk for exclusive breastfeeding. With social support for breastfeeding from the family, women were three times more likely to breastfeed exclusively for an extended period.
11. Activity and Milk Production. Another study at Davis, this by Cheryl Lovelady, compared nursing women who had high physical activity levels during and after pregnancy to nursing women who did not. Compared to their sedentary counterparts, the active group tended to produce more milk, delivering an average of nine percent more calories to their babies each day.
12. Cost of Worms. Deworming significantly improves the nutrient intake of Indonesian preschoolers (by as much as 16.3 percent protein, and 13.3 percent energy or, put differently, the value of nearly one-sixth of food intake is lost because of worms) according to a recent Cornell doctoral investigation by Fasli Jalal, now Deputy Chief of the Bureau of Health and Nutrition for Indonesia's planning agency BAPPENAS. Among children with heavy worm loads, deworming also improved vitamin-A levels when combined with fat supplements which enhance the vitamin's absorption. The author's recommendation: include deworming in all primary health care strategies.
13. Unusual for that part of Africa, a recently-completed Bank-financed study on food security and nutrition in Chad found that child malnutrition is more widespread in urban than in rural areas. Interestingly child malnutrition in a good production year was only 20 percent below the level of a poor year. It appears that either chronic food insecurity grips as many as 80 percent of urban households or something else is causing the malnutrition.
14. From the new Population, Health and Nutrition Sector Review for Vietnam, data show quite high malnutrition rates relative to infant mortality; also an inverse relationship between adult and young child energy intakes, with increased food allocation to children at the expense of adults -- not usually the case. Still, overall, the malnutrition rates are surprisingly high, comparable to Bangladesh. Food production is adequate, but uneven geographical patterns and poor distribution systems take their toll. The rice-dominated diet results in pervasive micronutrient deficiencies. Recommendations are for a national child nutrition program.
15. Since surprisingly substantial levels of malnutrition have been found in Zimbabwean school-aged children, there may actually be a decline in nutrition status once children begin attending school -- this according to a new Bank Nutrition Sector Study. Authors Julia Tagwireyi and Ted Greiner say this brings into question whether the policy of targeting nutrition program resources almost exclusively to pre-school aged children is still appropriate in Zimbabwe.
16. Iron. Under the micronutrient component of the Tanzania Health and Nutrition Project, Donald McLarty of the Muhimbili Medical School found the anemia in men in five rural areas to be as bad as in women, and in some cases worse. The result was so unexpected that the Tanzania Food and Nutrition Center repeated the survey -- only to confirm the results. One possible explanation is that males who do not migrate to cities for work are weaker (for instance, more loaded with parasitic infections). Another, more intriguing, possibility is that iron supplements for women over the years are paying off. If the latter is true, this and the unexpected school-age problems in Zimbabwe point to the need from time to time for a country's nutrition priorities and targeting goals to be revisited.
17. The May 26 issue of New & Noteworthy noted that the color of iron pills influences their acceptability. In Indonesia, for example, a red pill --a color associated with good blood -- is more readily valued. By coincidence, a few days later the June issue of Pediatrics published a study showing that in the United States brightly colored iron supplement pills are the biggest cause of accidental poisoning deaths in children under six. The reason: children mistake the brightly colored pills for candy.
18. Vitamin A. Until now, all vitamin A studies showing high impact on reducing mortality have been on children under five. A study in Nepal, undertaken by the University of Michigan, also looks at five-to-ten year olds. The unexpected outcome: almost double the impact of vitamin A deficiency on mortality of the five-to-ten year olds than those under five, and more reduction associated with treatment.
19. What is probably a first-ever program to increase the vitamin A content of foods through genetic manipulation is now underway at the Asian Vegetable Research Development Center in Taiwan. Early screening of sweet potatoes, green leafy vegetables and tomatoes finds great variations in the levels and bio-availability of vitamin A. The aim of the undertaking: to attain the maximum amount of vitamin A in a food, when combining yield multiplied by the vitamin A content.
20. Iodine. The AIDS scare apparently is partly responsible for what is a distinct move away from the use of injected iodized oil (effective for up to three years) to an oral dose (good for one). Even though the wallop is not as great, the latter is so much easier to administer that in most situations it is the most cost- effective approach. Teachers, for instance, can give the oral dose. In Bolivia, 1.5 million doses have been effectively provided by responsible non-health professionals. In difficult-to-reach areas, the longer lasting injection has cost advantages.
21. Polygamy and the Contraceptive Effects of Breastfeeding. Discussion of contraceptive effects of exclusive breastfeeding in the last issue of New & Noteworthy prompted Michael Azefor, to note breastfeeding's greater effect among the polygamous. A widespread cultural taboo in much of Sub-Saharan Africa is to avoid sexual intercourse during the months the baby is supposed to be on the breast. The tradition of his tribe in Cameroon: "Don't feed (satisfy) baby and daddy at the same time." If one or the other is given up, it is less likely in polygamous families that it will be the former, he says. The extensiveness of polygamous cultures in West Africa is one reason that breastfeeding goes on longer there than, say, southern African countries.
22. Breastfeeding Promotion Revisited. From Brazil, a new evaluation of an early 1980s breastfeeding program that found that, five years after it was over, the duration of breastfeeding had still doubled (to 120 days). There was remarkable memory of specific TV clips, for instance, of on-the-screen nursing by a novella (soap opera) heroine and by the wife of a football hero.
23. Price-fixing. The ongoing battle between infant formula manufacturers and their critics, especially NGOs, reached another milestone in mid-June when the U.S. Government charged the three largest manufacturers with price fixing of formula being provided to public nutrition programs. Two of the three, American Home Products and Mead Johnson settled out of court -- the latter, for instance, agreeing to deliver 3.6 million pounds of infant formula (worth $25 million) to the government's WIC (Women, Infants and Children) program. The largest manufacturer, Abbott Laboratories, did not join the consent decree and court charges have been filed. Similar allegations have long been voiced by critics regarding international marketing of infant formula.
24. New Bank Book. The research in Northeast Brazil by Ralph Harbison, World Bank, and Eric Hanushek, University of Rochester, that concluded "Failure to provide adequate food for children has an insidious and cumulative negative effect on their school performance" has now been published for the Bank (Oxford University Press) under the title Educational Performance of the Poor.
25. Sustaining Sustainability. With "sustainability" the buzz word in development these days, it is difficult to imagine sustainability without behavioral change, the Society of Nutrition Education was told at its 25th Anniversary Conference in Washington last month. If development agencies are serious about self-sustaining measures, the starting point is whether people can be taught to do it for themselves.
26. Mixed Messages. The importance of pre-testing nutrition messages in Bank projects was brought home by a poster in Yemen with pictures of a machine gun, a dagger and a baby bottle with infant formula --and the caption "all these can kill." Pre- testing found that, to illiterate Yemeni, the poster meant strength and protection, according to Ted Greiner, now nutrition advisor to (Swedish International Development Agency (SIDA), who served in Yemen to help implement the nutrition component of the Bank's first Health Project there.
27. Double Duty. Nutrition education messages aimed at Asian-Americans in the U.S. Government's WIC program are based on the research and messages developed for Indonesia (with the help of consultant Marcia Griffiths) by the Bank's first Nutrition Project there, according to a talk by Claudia Fishman (formerly of WIC, now of The Academy for Educational Development) at a Social Marketing Workshop held in Washington in July.
28. Eating the Cure. On July 1 the U.S. Government announced what may be the largest-ever nutrition education effort: a $93 million "Five-a-Day" Program, financed by the National Cancer Institute and the food industry, to encourage consumption of fresh fruits and vegetables (at least five servings a day) to lessen cancer risk. NIH says that approximately 35 percent of cancers are diet-related.
29. Food Outlook. FAO reports that although cereal production in 1991 fell below consumption for the fourth time in the last five years, the cereal crop is expected to recover some this year.... World Food Program colleagues reported this week that the Somalia famine is far worse than previously believed -- and present efforts fall far short of need.... In the southern Africa drought, Mozambique and Malawi are facing greater problems than Zambia and Zimbabwe with internal food distribution, according to Africa Department, drought coordinator Judith Edstrom.... An inter-agency team just back from Bosnia- Hercegovina and other hot spots of the former Yugoslavia confirms, in the words of Carl Taylor for UNICEF, "the malnutrition there is every bit as bad as the media portray." Its country-by- country assessment, for the UN High Commissioner for Refugees, is available for those interested.
30. Infectious Malnutrition? Amartya Sen is at it again. In his June 17 keynote speech to the Bank's conference on "Public Expenditure and the Poor: Incidence and Targeting," the Harvard food scholar noted that "generally infectious diseases receive much greater attention than other type of maladies do, and they tend to get eliminated with remarkable efficiency. In part, Dr. Sen said, "this is because a poor person with infectious disease is a source of infection for others. Ailments and deprivations that are not infectious --including undernourishment -- do not get comprehensive attention." He went on to wonder whether there is any way of making poverty and malnutrition infectious. "If that were to happen," he said, "its general elimination would be, I am certain, remarkably rapid."