|New and Noteworthy in Nutrition (World Bank, 150 pages)|
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. The New Nutrition. An initiative that eventually could lead to a monumental turnaround in the way donor agencies and other institutions help countries improve nutrition was launched at a November conference at the Rockefeller Foundation's facility in Bellagio. The starting point for the conference was the recognition that, first, few countries had people experienced in managing, designing, and evaluating large-scale nutrition operations (although many countries do have people with graduate degrees in biochemistry and other biomedical aspects of nutrition) and, second, although sizable resources go into other aspects of nutrition research, the lack of work on and answers to simple practical field problems often limit the accomplishments of existing programs. In short, there was increasing uneasiness about the disconnect between existing research and training efforts and operations. What emerged was a consensus about the need to change substantially the emphasis in research and training -- to focus attention on the identification and solution of operational problems. The conferees adopted a Bellagio Declaration that spells this out, established a steering committee to shepherd the initiative, and set in motion a process designed to lead to an entity with regional orientation that will foster and finance such an approach.
2. Prophet --and Loss. If ever anyone could prophesy what it would take to make a serious impact on the nutrition and health problems of poor children of the world, and then push to fulfill that prophecy, it was Jim Grant, UNICEF's Executive Director of 15 years, who died January 28th. He not only had a vision, but conveyed it in a way that put the subject on national agendas -- and, in the process, redefined those agendas. He believed the only way to get countries to do better was to involve their top people and, as The Economist said, "bullied heads of states and other VIPs remorselessly." His personal enthusiasm for such interventions as salt iodization, oral rehydration, breastfeeding, and immunization was famous. When he lunched with presidents, he would take a pinch of salt, pull testing equipment from his pocket, and berate his host if the salt was not iodized. (Not by coincidence, UNICEF is well on track toward meeting his ambitious mid-decade goals for salt iodization.) Our sympathies to our colleagues in UNICEF on their loss. A memorial service will be held in Washington, on a yet-to-be-announced date in late March.
3. Mental Defector. Enough studies on the relationship of iodine to cognitive development have now been conducted for a meta-analysis of what they add up to. Such an examination of 18 studies by two Dutch scientists, Nico Bleichrodt and Marise Born (in a new book, The Damaged Brain of Iodine Deficiency, by John Stanbury), shows that iodine-deficient and non-iodine-deficient groups are 13.5 IQ points apart. ("Average" intelligence is 100.)
4. Dumb Bell Curve. Major attention has been given in the mass media to The Bell Curve: Intelligence and Class Structure in American Life, by Richard Herrnstein and Charles Murray. Its implication that interventions to raise intelligence are futile rubbed many raw nerves because of perceived racial overtones. This study ignores a long history of research and programs which show definitively that interventions with micronutrients can substantially improve intelligence and school performance. "Shifting the Bell Curve With a Grain of Salt," a new Human Resources Development and Operations Policy Dissemination Note by Judy McGuire, points out that even moderate iodine deficiency compromises intelligence. Citing the 13.5 IQ points mentioned above, she notes that "the intelligence curve of non-cretinous iodine-deficient population is shifted downward...so that the average falls within the range referred to as dull in The Bell Curve.")
5. Life in the Slow Lane. We know that early iodine treatment can prevent or limit childhood mental retardation -- but how early the treatment? As a result of research published in The New England Journal of Medicine, we now have a better idea. A group of Chinese researchers, working with others from Duke University, gave iodinated oil orally to nearly 1,000 people in eight villages where iodine levels are extremely low -- and the resulting rate of cretinism high. Nine percent of the babies who got the iodine after birth or whose mothers received the supplements only during the final three months of pregnancy showed moderate or severe brain or behavior problems, compared with only 2 percent of the infants whose mothers received iodine during the first six months of pregnancy. In another test, the same researchers found that 27 percent of children not treated for iodine had unusually small heads, compared to 11 percent who had received iodine.
6. Youth Movement. Another recent meta-analysis --conducted in nutritionally at-risk populations in Colombia, Guatemala, Indonesia, Jamaica, Taiwan, and the U.S. --shows that early high-energy and protein food supplements have a beneficial effect on motor development in infants (8-to-15 months old) and on both motor and mental development in older infants (18-24 months) who are nutritionally at risk. These findings, say Ernest Pollitt and Se-Yong Ho of the University of California/Davis in Food and Nutrition Bulletin, "provide justification for food assistance programs targeted to young at-risk children."
7. The Comeback Kid. Can a pre-term, low-birthweight infant catch up with the intrauterine growth it was denied? A study of 355 such South Indian infants by Ramasethu and others, reported in The Journal of Tropical Pediatrics, says yes. Exclusively breastfed pre-term infants with birthweights of 1.5-to-2 kilos doubled their birthweight by 10 weeks of age and tripled it by 18 weeks, growing 20-to-30 grams a day, up to 20 weeks of age.
8. Mothers of Invention. Breastfeeding often comes to an abrupt halt when a mother is ill or her infant is ill or there is some other emergency situation. Can it be reinstituted? A group of studies in Karnataka, reported in Indian Pediatrics, conclude that even surrogate mothers who had adopted babies were able to exclusively breastfeed their children at about six weeks through techniques developed for nipple stimulation and repeated suckling at the breast. One of the mothers had not breastfed for 16 years. Another study, by Virginia Phillips in The Journal of Tropical Pediatrics, reports that relaxation was possible for 12-to-48-month-old Australian children whose mothers had earlier ceased to breastfeed.
9. Any Differences in Breastfed Babies Once They Are Grown? A group from Groningen University in the Netherlands studied 135 breastfed and 390 formula-fed children born at term between 1975 and 1979. A reexamination of the children at nine years of age revealed, after adjusting for a host of medical and social differences, an advantageous effect of breastfeeding on neurological status, albeit a small one. The authors, in The Lancet, suggest that the beneficial effect of breastfeeding on post-natal neurological development is due to longer-chain polyunsaturated fatty acids --vital for brain development -- which are present in breast milk, but not in most formula milks.
10. Is Breastfeeding in Infancy Associated with Longer Life? Apparently not, according to a recent paper in The American Journal of Public Health by Deborah Wingard and others, mostly with the University of California. Neither cardiovascular disease nor cancer survival was significantly associated with duration of breastfeeding. There was reduced risk of death from injury, but this was significant only for men. Figure that one out.
11. Change in Nutritionists' Catechism. The long-held instruction that mothers should be encouraged to breastfeed their infants exclusively for the first four-to-six months seems to be shifting. UNICEF staff have been encouraged to promote exclusive breastfeeding in developing countries "for about six months" --in line with the resolution coming out of the 1994 World Health Assembly. The reason is the research showing that 90 percent of children exclusively breastfed for six months grow adequately. (A study in Honduras, recently reported by Roberta Cohen and others from UC/Davis in The Lancet, indicates that "Breastfed infants self-regulate their total energy intake when other foods are introduced. As a result, there is no advantage in introducing complementary foods before six months in this population, whereas there may be disadvantages if there is increased exposure to contaminated weaning foods.") The second reason is a new recognition that earlier diagnosis of frequent growth faltering was an artifact of NCHS reference data, based on American bottle-fed babies. A working group has now been established to redefine growth standards.
12. Tempering Iron. Unlike the other key micronutrient deficiencies --vitamin A and iodine --only limited headway has been made during the past decade in overcoming iron-deficiency anemia. One reason is the belief that iron needs to be taken on a daily basis. Now, two important new studies refute that assumption. In the most recent issue of The American Journal of Clinical Nutrition, Rainer Gross, Werner Schultnik, and others show that twice-weekly iron supplementation for Indonesian preschool-age children with low iron status is as effective as daily supplementation. Another study by these researchers (discussed in The Lancet) concludes that supplementation on a weekly basis with a relatively low dose of medicinal iron for moderately anemic, nonpregnant, female cigarette factory workers in Central Java is as effective as daily supplementation. Similar studies are needed among other anemic risk-groups, particularly pregnant women and school children.
13. More On Nutrition vs AIDS. One puzzle of the AIDS epidemic is why the disease has spread so much more extensively in many African countries than in North America and Europe. Important findings reported at a meeting sponsored by the American Society for Microbiology may shed light on the reasons. A large group of HIV-infected pregnant Malawian women have been followed by Dr. Richard Semba and colleagues of the Johns Hopkins School of Medicine, along with counterparts at the Malawi Medical College -- and (as reported in the last issue of New & Noteworthy in Nutrition) those with the most severe lack of vitamin A had a 32 percent chance of transmitting HIV to their infants, as against a 7 percent chance for women with healthy amounts of vitamin A. These findings led Dr. Semba's team to further analyze data in the study. This showed that of the infants born to mothers with the most-severe vitamin A deficiency, 93 percent died in the first year of life, as compared with 14 percent of those born to mothers with healthy levels of vitamin A. About 14 percent of the most severely deficient mothers died in the first year, compared with 5 percent of those who had healthy amounts of vitamin A. These findings will be published soon in Clinical Infectious Diseases.
14. Enriching Our Knowledge. "The control of vitamin and mineral deficiencies is one of the most extraordinary development-related scientific advances of recent years. No other technology in the world today offers as large an opportunity to improve lives and accelerate development at such low cost and in such a short time." So begins Judy McGuire's new Enriching Lives: Overcoming Vitamin and Mineral Malnutrition in Developing Countries. To fulfill the promise of such a bold beginning is a challenge. But the small book delivers. The study demonstrates that the social and economic consequences of neglecting these deficiencies could cost as much as 5 percent of a country's GDP in lost lives, disability, and productivity, while addressing these problems would cost less than 0.3 percent of GDP. This is also the first time that the three key micronutrients are examined jointly and from several different professional perspectives. Emphasis is given to ways to develop and improve programs that deliver the micronutrients.
15. Man Does Not Live By Income Alone. Enriching Lives makes clear that "micronutrient intake does not necessarily improve in step with income, because the micronutrient content of foods is a hidden quality to the uninformed consumer. People know when they are hungry and when they have had enough to eat. They have no natural hunger, however, for vitamin A, iodine, iron, or other micronutrients...." Just by eating more or having a more varied diet will not necessarily increase the intake of these micro-nutrients.... Task managers may want to consider providing copies of Enriching Lives to their counterparts, with a cover note highlighting the cost-effectiveness features. (French and Spanish versions soon will be available.) In the book's forward, HRO Vice President Armeane Choksi says that micronutrient components will be encouraged in countries "where micronutrient malnutrition exists and is not being addressed by other means." Currently, micronutrients are included in World Bank-assisted projects in 38 countries.
16. The Worm Turns. At a January 17 Bank seminar, Rebecca Stolzfus of Johns Hopkins, speaking on the Impact of Helminth Treatment on Nutritional Status in Zanzibar, said that preliminary results of a school-based project there show positive effects on growth and iron status from interventions of the deworming drug Mebendazole. The cost is three cents a dose, three times a year. Deworming, she said, can take care of a quarter of the iron deficiency; the attributable risk of anemia from hookworm is very high. Importantly, adolescent girls were not being reached; they were not in school.
17. With the Grain. The most important news coming out of the Consultative Group on International Agricultural Research (CGIAR) International Centers Week at the Bank was the announcement that a new breed of super rice has been developed that can produce 25 percent more grain on the same amount of land than today's best varieties. The new strain, developed by agronomists at the International Rice Research Institute in the Philippines, also requires significantly less fertilizer and water than today's varieties. The new rice, if widely planted, could produce 100 million more tons per year; enough for 450 million people. The new variety will probably be commercially available in five years.
18. Taking the Heat. Even in the rice-eating world, wheat is becoming more important because bread is such a convenient food in an increasingly urban, industrial life-style. Wheat production, however, is not suited to the tropics. Now, agronomists at the International Center for Maize and Wheat Improvement in Mexico have developed heat-tolerant varieties as a possible second crop during the cooler season in the tropics. Amid predictions that global warming could spell disaster for world agriculture, the benefits of such varieties are obvious.
19. Garlic Press. We all know the effect of garlic in keeping other people at bay. It turns out garlic has the same effect on ergot, that deadly fungal disease that wreaks havoc on sorghum crops in India and Africa. Until now, plant breeders have had little success in developing cultivars resistant to ergot, but now researchers at the International Crops Research Institute for the Semi-Arid Tropics in India have had what they call astounding success in greenhouse and field experiments using a spray made of garlic extract. The main problem is that the garlic extract is washed off by rain. A second is that technology needs to be better developed to reduce the labor of preparing the extract.
20. Seed Money. Well-publicized worries about meeting CGIAR's $60 million financing gap have been lessened with the launching of a new stabilization program. This was made possible by the Bank's approval of up to $20 million, to match (at a 1:2 ratio) additional contributions from other donors. The additional funds thus raised made it possible for the Centers to implement fully their 1994 work programs. And prospects for this year are equally positive, with total support of $270 million projected.
21. Smart Alec. "Capacity is needed to analyze the impact of agricultural policy and rural development programs on national food supplies and on the food consumption of the poor," said Agriculture and Natural Resources Director Alec McCalla at the 15th Annual Agricultural Symposium for Bank staff on January 6th. "This is an area where the welfare of both the urban and rural poor has to guide our work. Countries continue to use inappropriate policies and institutions to ensure their food supply. They also mistarget their food consumption budgets, that is, food aid, food subsidies, and nutrition programs.... Excellent models of better targeting are available, but require coordination between ministries and within our institution." (See his lecture, "Agriculture and Food Needs to 2025: Why We Should Be Concerned," the annual Sir John Crawford Memorial Lecture, presented at International Centers Week.)
22. The Outer Banks. The Inter-American Development Bank, under the impetus of executive vice president Nancy Birdsall, intends to give major push to a social agenda, including nutrition. (Of particular interest to her are early childhood development programs; a day-long seminar on these was held with IDB and World Bank staff on February 16.) IDB pledged $20 million to help Honduras extend both the coverage and time period of the effective food coupon project, which the World Bank pilot tested and then helped initiate under the current Nutrition and Health Project.... The Asian Development Bank's first major project involving nutrition interventions will be the Early Childhood Development Project in the Philippines, collaborating with the World Bank. ADB also has a policy paper underway, highlighting the macro/micro nutrition interface.
23. Nuclear Reaction. An unlikely U.N. agency, the International Atomic Energy Agency, is now involved in human nutrition, and representatives met here last month to discuss its work. Among its projects is the testing of non-radioactive stable isotopes in food as a means of monitoring whether people have eaten specific foods given to them. No information on costs.
24. More Condolences. This has been a bad month for UNICEF. In addition to the loss of its executive director, UNICEF also lost its former nutrition adviser, Lukas Hendratta, whose contributions to nutrition, particularly in his home country of Indonesia, are legion. He died of a heart attack the day before Christmas, while on a mission for the Asian Development Bank in the Solomon Islands. He also was a World Bank consultant over the years. (Also lost last year was another long-time UNICEF nutrition adviser, Les Tepley, a stalwart in the international nutrition community.)
25. NEWTrition. Much nervousness these days among those in the U.S. domestic nutrition community. The "Contract with America" would slash the current funding for U.S. feeding and nutrition programs and would return what's left to the states under what are called block grants. The food-stamp, school lunch and breakfast, and WIC (Women, Infants, and Children) programs began or were dramatically increased during the Nixon administration to combat hunger in the United States. The decline in hunger since then has been in large part attributed to these safety-net programs, which are budgeted at $40 billion a year. Fiscal conservatives suggest that any new gap in meeting serious needs can be made up from private sources -- but a 10 percent cut in federal spending will take a 150 percent increase in private giving just to make up the difference. Meanwhile, President Clinton's newly released budget calls for a $1.3 billion increase for other nutrition programs. Drama ahead....
26. Second Opinion. It has become common public practice to consider the nutrition status of children under five years old (as measured by anthropometry) as a barometer for the population as a whole. Now, Nancy Mock of Tulane University, and others, investigate the relationship between maternal and child anthropometry, using data from a regional cross-sectional survey recently undertaken as part of a Bank-supported project in Guinea. The study, published in a recent issue of Ecology of Food and Nutrition, finds that although maternal and child anthropometric indices are correlated, the magnitude of the correlation is modest. "More importantly, maternal malnutrition exists in many households where children are free of malnutrition and vice-versa." The researchers, therefore, suggest that the common practice of limiting nutrition assessment to under-5s may result in important inaccuracies in evaluating community nutrition problems.
27. Long-term Payoff. Last issue we noted the work on the relationship of nutrition to productivity by Nobel laureate Robert Fogel. Irwin Rosenberg, who heads nutrition at Tufts University and is a collaborator of Fogel's, says that we also need to look at the Fogel-cited benefits of improved nutrition in an expanded time frame --perhaps seven or eight decades -- to see all the real benefits.... Discussions are currently under way for a lecture on nutrition-productivity linkages by Fogel at the Bank in late April.
28. Small Things Considered. In a recent issue of the Bulletin of the World Health Organization, D.G. Schroeder of Emory University and Ken Brown of the University of California/Davis looked at five published prospective studies, estimating the relative risks of death among young children after they had been identified as having mild-to-moderate or severe malnutrition. These risk estimates, along with global malnutrition prevalence data, were then used to calculate the total number of young-childhood deaths "attributable" to malnutrition in developing countries. Young children (6-60 months of age) with mild-to-moderate malnutrition had 2.2 times the risk of dying during the follow-up period than their better-nourished counterparts. Severely malnourished young children had 6.8 times the risk. They estimate 41 percent of the total deaths of young children in developing countries are associated with malnutrition. The last New & Noteworthy in Nutrition discussed the important study by David Pelletier and others that estimated 56 percent. But the estimate in the World Development Report on health, just two years ago, was only 25 percent. Why the discrepancy? Philip Musgrove, the father of the WDR figures, says "this can be explained by my limitation to a short list of diseases instead of a prospective study of all mortality. The difference between starting at 0 months and starting at 6 months probably also contributes."... Relatedly, an important set of papers, edited by Ray Yip of CDC, on "The Relationship Between Child Anthropometry and Mortality in Developing Countries" appears as a special supplement to the October Journal of Nutrition.
29. Ground Work. A useful discussion of approaches linking agriculture and nutrition programs is found in Health Policy and Planning, 9(3), by Eileen Kennedy. (Also worth noting is her paper on the implications of the shift in Africa to nontraditional grains, in Food Policy, 19(1).) Kennedy was recently named executive director of a new USDA Center on Nutrition Policy and Education.... An excellent series of articles on food security and nutrition monitoring in Africa --reflecting an important body of work by IFPRI --also appears in Food Policy, 19(3). This includes a review of country experiences and lessons learned. Recommended for all task managers planning a component on nutrition monitoring and surveillance.... Also meriting note is "The Role of Information in the Planning, Management, and Evaluation of Community Nutrition Programs," by David Pelletier and Roger Shrimpton in Health Policy and Planning 9(2).
30. The Last Writes. Colleagues, when told, often are surprised to learn of the extent of contributions to the professional journal literature in nutrition being made by Bank staff. Examples of the plethora of analytic nutrition work coming out of the Bank these days are found in the following journal articles (written or co-authored by Bank Staff) that have come to our attention --apologies if there are others we have missed -- just since the last issue: By Judy McGuire and Rae Galloway, "Determinants of Compliance With Iron Supplementation: Supplies, Side Effects, or Psychology?," in Social Science and Medicine.... By Harold Alderman and Marito Garcia, "Food Security and Health Security: Explaining the Levels of Nutritional Status in Pakistan," in Economic Development and Cultural Change (see Alderman also in the February issue of The World Bank Research Observer).... By Venanzio Vella, "Determinants of Stunting and Recovery From Stunting in Northwest Uganda," in The International Journal of Epidemiology (also his "Anthropometry and Childhood Mortality" in The American Journal of Public Health).... By Jim Greene and John Kevany, "Projects to Programs: An International Perspective," in Food and Nutrition Bulletin.... By Peter Heywood, "Nutritional Effects of Export-Crop Production in Papua New Guinea: A Review of the Evidence," in Food and Nutrition Bulletin, (also his "Maternal Nutritional Depletion in a Rural Area of Papua New Guinea," in Tropical and Geographical Medicine).... And by Dick Seifman, both "A View From Washington" (an analysis of the International Conference on Nutrition) and a commentary on the Cairo Population Conference from a nutrition perspective, both in Ecology of Food and Nutrition.