NEWS AND VIEWS

Combatting Iron Deficiency: Can Weekly Supplementation be Effective?/Bioavailability of Vitamin A in Vegetables/Uses of Anthropometry in Infancy/Immunization of Children/Pneumonia in Malnourished Children/Breastfeeding and Morbidity in Affluent Populations/Bangladesh Integrated Nutrition Project/Multiple-Indicator Cluster Surveys/New Chair of the SCN/Meetings, Conferences, and Courses/Sources of Nutrition Training Materials.

Combatting Iron Deficiency: Can Weekly Supplementation be Effective?

Iron deficiency is the commonest nutritional disorder in the world, affecting over two billion people, most of them living in developing countries. Infants, small children, adolescents, and fertile-age and pregnant women are particularly vulnerable.

Although iron deficiency is often assumed to be synonymous with anaemia, only about 50% of people with deficiency develop this condition, which is in fact a manifestation of prolonged or severe deficiency.

Currently most programmes for the control of iron deficiency in the developing world, where iron fortification of foods has not been widely implemented, take the form of daily supplementation of the diets of anaemic pregnant women, mainly in the last trimester of pregnancy. Critics of this method argue that clearly this does not address the problem of the lower level iron deficiency that precedes the onset of anaemia, and in any case this type of programme is often ineffective for several reasons. One reason for the failure of such a programme to alleviate iron deficiency and anaemia is that many women suffer undesirable side-effects from daily dosage (it is estimated that 20% or more of women receiving 60mg of iron daily are affected) which leads to an understandable reluctance of women to continue taking the supplements. Providing supplements daily is also time-consuming and costly to administer.

It has been suspected for some time that weekly iron supplementation could provide a solution to the problem of compliance due to undesirable side-effects, and that it could be feasible to use this strategy in a preventative as well as therapeutic way. As noted by participants at the 1995 Annual Session of the SCN “evidence from studies in China, Malaysia, Indonesia, Guatemala, and the United States of America indicated that weekly doses of ferrous sulphate were as effective as daily doses in improving haemoglobin status, without producing side-effects”.

A Symposium on “Selected Strategies for the Control of Nutritional Anaemia” was held recently at the 7th Asian Congress of Nutrition, which took place in Beijing, China, from October 7-11, and amongst the topics discussed was the weekly dosage strategy. The results of two new studies were presented. The first, which took place in Malaysia, looked at the effectiveness of weekly iron supplementation in adolescent secondary school girls. According to the researchers “iron and probably folate deficiencies were found in 611 Sarawakian schoolgirls with initial haemoglobin from 8.0 to 13.0 g/dL. Weekly supplements of 60, or 120mg of iron with 3.5 mg of folate, obtained highly significant increments in haemoglobin in 12 weeks, with further improvements in the ensuing 10 weeks, and boosted iron stores”. They concluded that “the use of weekly iron and folate supplements is a promising new approach in the control of nutritional anaemia in adolescent girls”. In the second study, 405 pregnant Chinese women were randomly divided into four groups and given iron supplements either weekly, daily, or a placebo as a control. The researchers concluded from their results that “there was no significant difference between iron supplementation weekly and daily. Weekly iron supplementation is efficient and safe in controlling iron deficiency in moderately anaemic women.”

Providing weekly doses of iron might well be a safe and effective way to prevent and alleviate iron deficiency and anaemia. Studies are ongoing and are beginning to reach conclusions. A sound scientific basis on which to formulate policy is almost in place.

(Source: Viteri, F.E. (1995) A New Concept in the Control of Iron Deficiency (ID): Community-Based Preventive Supplementation (PS) of At-Risk Groups by Weekly Intake of Iron Supplements, Tee, E.S., Cavalli-Sforza, L.T., Kandiah, M., Harimah, A., Chong, S.M., Satgunasingam, N. & Kamarudin, L. (1995). A Study of the Effectiveness of Weekly Iron Supplementation in Adolescent Secondary School Girls in Malaysia: Preliminary Findings; Liu, X.N., Zhang, J.L., Yen, H.L. & Viteri, F. (1995). Haemoglobin and Serum Ferritin Levels in Pregnant Chinese Women in Response to Weekly Iron Supplements. Abstracts of papers presented at the Symposium on Selected Strategies for the Control of Nutritional Anaemia held at the 7th Asian Congress of Nutrition, Beijing, China, October 7-11, 1995.)

Bioavailability of Vitamin A in Vegetables (Was Popeye Wrong Again?)

Spinach was popularly regarded - thanks to Popeye - as good for you, especially for iron; but this has been known to be wrong for many decades now. Surprisingly, results show there may be similar doubts in relation to vitamin A. The low availability of iron from plant sources - particularly “green leafy vegetables” - has been known for some time. For example, the FAO/WHO report on iron requirements¹ noted that “a low bio-availability diet (iron absorption about 5%)... is dominant in many developing countries, particularly among lower socioeconomic groups”, and goes on to note that the estimated dietary requirements for iron from low bioavailability diets, for reproductive aged women “.. represent levels of intake that are deemed to be very unlikely on usual dietary patterns”. Some have suggested that only by adding bioavailable iron to the diet (through supplementation or fortification) can anaemia be prevented among reproductive-aged women in poor societies with a primarily plant-based diet.

1. FAO/WHO (1988). Requirements of Vitamin A, Iron, Folate and Vitamin B₁₂. Report of Joint FAO/WHO Expert Consultation. FAO, Rome.

Green leafy vegetables provide many micronutrients. Of major importance are carotenes, potential precursors of vitamin A. The consequences of deficiency in the intake or absorption of vitamin A are well known - the most evident being progressive damage to the eye or “xerophthalmia”. Symptoms range from night blindness, through reversible signs in the eye, to ulceration and destruction of the cornea leading to blindness. Increased ill health and mortality have long been associated with vitamin A deficiency, and in recent years intervention trials have established with increasing certainty that providing vitamin A to young children in areas where the deficiency exists has a significant effect on mortality, of around 25% reduction.

In developing countries, strategies for combatting vitamin A deficiency have included: (i) the fortification of food; (ii) pharmaceutical supplementation; and (iii) dietary change - encouraging the consumption of dark-green leafy vegetables, yellow and red fruits and vegetables, and red palm oil which are all rich in vitamin A precursors and which may be available but underutilized by the deficient population. Of these alternatives dietary change is advocated as sustainable, providing nutrients other than vitamin A, and adding variety to the diet.

A recent study conducted by researchers working in West Java, Indonesia, and published in The Lancet², has examined the extent to which an additional daily portion of local vegetables can improve vitamin A status in anaemic breastfeeding women. The study was carried out from September 1993 to January 1994 in two neighbouring villages in Bogor district, West Java. Here, a large variety of fruits, vegetables and staples are available all year. Women who were breastfeeding a child younger than 18 months who were anaemic (haemoglobin <130g/L) were screened out for eligibility for inclusion in the study (women with anaemia were selected because they were more likely to have low serum retinol concentrations). 191 women were enrolled in the study in 3 groups - women were matched in each of these groups for age of the breastfed child (many breastfeeding women do not eat fruits for 6 months after delivery, believing them to be harmful to their health). One group received a daily supplement of 100-150g of locally available vegetables (cassava leaves, water spinach, kartuk, spinach, or carrots). A second group received a wafer enriched with beta-carotene, iron, vitamin C, and folic acid - containing a similar amount of these micronutrients in a simpler matrix with better bioavailability. The third group received a non-enriched (control) wafer to allow for any possible effects associated with additional energy intake with the wafer. The supplements were provided 5 days per week for 12 weeks.

2. de Pee, S., West, C., Muhilal, Karyadi, D. & Hautvast, J. (1995). Lack of Improvement in Vitamin A Status with Increased Consumption of Dark-Green Leafy Vegetables. The Lancet, 346, 75-81.)

In the enriched wafer group there were increases in serum retinol, breastmilk retinol, and serum beta-carotene. These changes differed significantly from those in the other two groups. Serum retinol and breastmilk retinol did not increase significantly in the vegetable group and serum beta-carotene showed only a very small increase, much less than in the enriched wafer group. Therefore it was concluded that the additional daily portion of vegetables did not improve vitamin A status at all, whereas the beta-carotene provided in the enriched wafer did.

Results were interpreted as showing that beta-carotene is very poorly absorbed from vegetables. This may he due to several factors, for example, physical inaccessibility of carotenoids in plant tissues may reduce their bioavailability - perhaps beta-carotene in fruits is more bioavailable. Other factors that might affect bioavailability, such as parasitic infestation, infection with bacteria, viruses, or protozoa, and intestinal malabsorption, were not different between the groups.

The authors conclude that the findings do not support the long-standing assumption that vitamin A deficiency can be combatted by increasing the intake of dark-green leafy vegetables. Red or yellow vegetables and fruits may be more effective. Red palm oil also remains a potentially important source. Their results need to be confirmed and more work needs to be done on factors influencing the bioavailability of carotenoids from different foods. Use of foods naturally rich in retinol (eggs, whole fish, and liver) and fortified foods should be developed further for overcoming vitamin A deficiency.

The conclusions may be in line with other findings, where behavioural change interventions on a large scale, although shown to improve consumption of vitamin A precursors, had provided scarce evidence of biological impact³. Among these, one of the best known projects succeeded in substantially improving the intake of ivy gourd in Thailand (a green-leafy vegetable)⁴, but did not show biological impact in terms of changing serum retinol (with similar levels of deficiency to the Indonesia study cited above).

3. Gillespie, S. & Mason, J. (1994). Controlling Vitamin A Deficiency. State-of-The-Art Nutrition Report No. 14. ACC/SCN, Geneva.

4. Smitasiri, S. (1994) Nutri-Action Analysis: Going Beyond Good People and Adequate Resources. Institute of Nutrition, Mahidol University, Salaya, Thailand/Smitasiri, S. (1993) Social Marketing Vitamin A-Rich Foods in Thailand: A Model Nutrition Communication for Behavior Change Process. UNICEF, Bangkok, Institute of Nutrition, Mahidol University, Salaya, Thailand.

The possibility is thus raised that variable bioavailability amongst fruit and vegetables may contribute to inconsistent findings of biological impact. While it has been credibly argued that if plant sources of vitamin A precursors were generally not available, vitamin A deficiency would be much more widespread, it has also been intriguing that significant amounts of the deficiency have been observed among traditional societies, like Indonesia, where there is plentiful carotene in the food supply. Possibly bioavailability varies, between sources and with other dietary components, notably fat. As the authors of the Indonesia study stress, there is an urgent need for well-designed studies to clarify the present situation, and especially to show which sources of vitamin A precursors, under what circumstances, are effective in preventing vitamin A deficiency. With this information, programmes aimed at behavioural change (see Features) can be expected to have greater biological impact.

China: Rising Living Standards hit Cabbage Consumption

Rising living standards in China are leading to dietary changes including decreased consumption of vegetables and increased consumption of meat and eggs, and the types of vegetables eaten are getting more diverse, helped by the increasing use of greenhouses.

One notable victim of these changes has been the cabbage. Each year, in early November, Chinese families have traditionally bought a supply of cabbage sufficient to last through the winter months for consumption on its own, or for addition to dumplings, bread, soup, and rice dishes. Now, however, less cabbage is being bought in favour of a wider variety of vegetables including spinach, garlic shoots, broccoli, egg plant, cauliflower, and tomatoes. As Han Yiwen, a store manager in Beijing put it “cabbage is no longer a main dish, it’s a side dish” - a fact that has generated feelings of loss amongst older Beijing residents who feel a certain sentimental attachment to the vegetable.

All may not be lost, however. Cabbage is still substantially cheaper than any of the newly available vegetables, and the Beijing Evening News reported that on the opening day of cabbage selling season, Beijing residents bought 25.3 million pounds of cabbage, more than three quarters of the amount dumped into the markets.

(Source: Passing of a Rite in China: Cabbage is a Casualty of Better Times by Steven Mufson writing in the International Herald Tribune, 7 November 1995)

Uses of Anthropometry in Infancy

The important findings of a comprehensive inquiry into the use and interpretation of anthropometry in infants have been published in the Bulletin of the World Health Organization. The study, carried out by a WHO Working Group on Infant Growth, focussed mainly on the recently reported discrepancies between the growth patterns of infants as reflected in the current National Center for Health Statistics - World Health Organization (NCHS-WHO) growth reference, and those of infants fed according to current WHO recommendations. The discrepancies have raised questions, addressed in this study, about how such references are employed in anthropometric assessments, and how they should be designed in the future.

During infancy, anthropometric indicators, such as weight-for-age, length-for-age, and weight-for-length, are often used in individuals to assess whether growth is below or in excess of what is considered a normal healthy range. In order to draw conclusions about the growth of a particular infant, a representation of what is considered normal, healthy growth, against which to compare the observed growth is needed. Currently, as mentioned above, the NCHS-WHO growth reference for infants is used for this purpose.

Recently, however, it has been reported that the growth of infants fed according to current WHO recommendations, and living under favourable conditions in various geographical areas, has been less than expected on the basis of the current NCHS-WHO growth reference - especially during the latter half of the recommended exclusive breastfeeding period (i.e. after the age of 3 months), and so much so that health care workers have reached faulty decisions regarding the feeding of infants. Exclusive breastfeeding is recommended by WHO from birth to 4-6 months of age, after which the child should continue to be breastfed, while receiving appropriate and adequate complementary foods for up to 2 years of age or beyond.

The kind of feeding method used has been thought to be largely responsible for the observed variations in growth. The NCHS-WHO reference for infants is based on the Fels Longitudinal Study, conducted in Yellow Springs, Ohio, from 1929 to 1975. Most of the infants in the Fels study were bottle-fed, and of those who were breastfed, very few were breastfed for more than three months. The limitation of the sample to Caucasian infants from predominantly middle-class families, and the taking of measurements every 3 months rather than every month, which is not ideal for characterizing the shape of the growth curve, are also thought to play a part in the observed discrepancies.

In exploring the discrepancies, the Working Group recognized that the NCHS-WHO reference was never intended or designed to be put to use, as it often is, as a “standard” or “absolute diagnostic criterion to define malnutrition or pathology”, but rather it was meant to be a “general guide for screening and monitoring purposes”. This was recognized as an important consideration in the future construction of growth ‘references’ for use in anthropometric assessments.

In order to verify the reported inconsistencies in growth patterns, the Working Group reviewed, between April and June 1992, data sets on the growth of breastfed infants. The criteria for inclusion of a data set in the initial review were: (a) data available on growth during the first 12 months of life for a sample of at least 20 infants fully breastfed for at least 4 months; (b) measurement intervals no greater than 2 months in the first 6 months and no greater than 3 months in the second 6 months of life; (c) information available on the duration of breastfeeding, use of supplemental milk, formulas, and solid foods, and the timing of their introduction; and (d) documentation of socioeconomic conditions consistent with the likely achievement of the growth potential. Seven data sets fulfilled these criteria and were examined in detail: one each from Canada, Denmark, Finland, Sweden, and the United Kingdom, and two from the USA.

Of the 453 infants followed in the seven studies, 226 were breastfed for at least 12 months and not given solids, formula or other milk until after the age of 4 months. These infants are referred to as the “12-month breastfed pooled data set”. The growth of infants in the “ 12-month breastfed pooled data set” was compared with the growth patterns of the NCHS-WHO reference with the following results. Figure 1, taken from the report of the study, shows the mean z-score patterns of infants in the “12-month breastfed pooled data set”, relative to the NCHS-WHO reference. It shows that, for the three anthropometric indicators used, the nutritional status of the breastfed group appears to be declining relative to expected growth according to the NCHS-WHO reference. As reported in the study findings “mean weight-for-age declined continuously from 2 to 12 months to a low of almost -0.6 standard deviations at 12 months. The magnitude of the decline in length-for-age was not as great, with the mean z-score tending to stabilize or increase after 8 months: the mean value at 12 months was approximately -0.3 standard deviations. Mean weight-for-length at 12 months was also below the NCHS-WHO reference mean (approximately -0.3 standard deviations)”. In simple terms what this means is that the “breastfed pooled data set” babies grew at a different rate than the mainly bottle-fed NCHS-WHO reference population.

Figure 1. Mean z-score of infants in the “breast-fed pooled data set”, relative to the NCHS-WHO reference

The Working Group found that there was a return towards the current NCHS-WHO reference means for weight-forage, length-for-age, and weight-for-length between 12 and 24 months in most of the studies available to the Working Group with data on this age range.

The practical implications of these findings were explored in the second part of the study. The working group compared data from several “test” populations with the “12-month breastfed pooled data set” and the current NCHS-WHO reference. One of the test populations came from a cross-sectional study of predominantly breast-fed infants under 6 months of age in India. The infants had very low z-scores at birth and thus it is not surprising that they had much lower z-scores when compared with the “12-month breastfed pooled data set” than with the NCHS-WHO reference. This was due to the higher medians of the pooled data set for all three indicators during approximately the first six months (as shown in figure 1, above). When compared with the current NCHS-WHO reference, the Indian infants’ mean weight-for-age z-score increased between birth and 3 months, but then declined between 3 and 6 months. In contrast, when compared against the “ 12-month breastfed pooled data set”, the Indian infants showed a slight decline in weight-for-age from birth to one month, but an increase in mean z-scores thereafter, which is sustained until 5 months. Therefore, declining status in weight-for-age is likely to be identified beginning at 3 months using the current NCHS-WHO reference, but not until 5 months using the “12-month breastfed pooled data set”. The results of a similar analysis conducted on subjects from a squatter community on the outskirts of Lima, Peru, yielded similar information.

The Working group concluded from its evaluation that the “present NCHS-WHO reference is not adequate” and recommended “the development of a new weight and length reference for all infants”.

The analysis also led the Working Group to conclude that “the present WHO feeding recommendations, as practised in well-off populations, did not result in maximum growth during the first year”. On this finding they commented “while an assumption of an equivalence of maximum with optimal growth underlies the rationale for the development of cut-offs based on the NCHS-WHO reference, this assumption has never been reviewed explicitly by an expert group” - on the other hand, present WHO feeding recommendations are based on an expert review. The Working Group recognized that future scientific information and worldwide improvements in sanitation may alter the present feeding recommendations, which are based on the best wisdom currently available to the global community. It therefore viewed as reasonable the selection of a population of infants fed according to WHO recommendations to evaluate the growth patterns of infants.

The Working Group concluded that a single growth reference would be preferable to separate charts for breastfed and formula-fed infants. Development of two separate charts is not practical and would create confusion when evaluating the growth of infants on mixed feeding. It also recommended that the practical utility of references based on infants breastfed for at least 12 months must be evaluated further. Growth curves based on the pooled analysis should be used in research settings to assess the growth of exclusively or partially breastfed infants and of infants fed formula alone. The proposed studies should include cohorts from both advantaged and disadvantaged populations. The objectives of the proposed research would be the identification of problems encountered by users (e.g. health care providers) in the interpretation of such curves and of the benefits or adverse consequences which may result from changes (relative to the current NCHS-WHO reference) in the proportions of infants classified as faltering, stunted, wasted, or obese or overweight, regardless of the mode of feeding.

Summary of Recommendations

The following recommendations (not listed in priority order) reflect the needs and gaps in knowledge identified during the Working Group’s deliberations.

1. A new reference is needed, which enhances the nutritional management of infants

2. The reference population should reflect current health and feeding recommendations because of the frequent use of such references as standards.

3. The practical utility of using reference data based on infants who are fed according to WHO feeding recommendations should be evaluated in a broad range of settings.

4. The effects of different complementary foods on the growth of infants following WHO feeding recommendations merit close investigation.

5. Research is needed for identifying proxy measures for length.

6. Criteria for the evaluation of abnormal growth are needed

7. An evaluation is needed of reference data based on other anthropometric measurements (e.g. skin-fold thickness and arm and head circumferences).

(Source: WHO Working Group on Infant Growth (1995). An Evaluation of Infant Growth: The Use and Interpretation of Anthropometry in Infants. Bulletin of the World Health Organization, 73(2); 165-174.)

Immunization of Children Increases Globally

Following a drop-off in 1991 and three subsequent years of flat growth, world-wide immunization of children is now increasing again, according to newly released figures from the World Health Organization (WHO).

Data collected by the WHO Global Programme on Vaccines and Immunization (GPV) show that global immunization coverage rates for childhood diseases rose to 80% or more during 1994, the sole exception being for measles. That is nearly the same level as in 1990, the year of the World Summit for Children, when immunization rates reached their all-time peak.

Significantly, the number of new polio cases reported to WHO in 1994 fell below 10,000 for the first time ever, to just over 7,500 cases. However, because the disease is under-reported WHO estimates the real number of cases may be as high as 90,000.

The biggest improvements during the past year were achieved in the African region, where immunization coverage rates increased by up to five percentage points for selected diseases to well over 50% overall. Coverage for measles vaccine is now higher on average in African countries than in Italy, and higher for DPT than in Germany.

As a result of world-wide effort to immunize children, WHO estimates that last year alone almost 3 million child deaths were prevented from tuberculosis, diphtheria, pertussis, tetanus (including neonatal tetanus), polio and measles. Dr Jong Wook Lee, the GPV director, called the latest figures encouraging. “Although these increases are modest, they show the trend is now upwards and that the target of 90% immunization coverage globally by the year 2000 can be met,” Dr Lee said.

(Source: WHO Press Release, 3 October 1995)

Pneumonia in Malnourished Children

contributed by Kim Mulholland, WHO

Whilst a number of immunological deficiencies have been described in malnourished children, particularly those with kwashiorkor, most of the published studies have included children who recently suffered from measles, and it is not clear to what extent the abnormalities described are due to measles or malnutrition (1-3). Whether there are specific immunological deficiencies associated with malnutrition, or whether the immunodeficiency is simply because thinning of the respiratory mucosa makes it easier for bacteria to enter the lung, children suffering from malnutrition are more likely than well nourished children to develop pneumonia and more likely to die from it (4). Pneumonia and other infections in children presenting with malnutrition are often clinically inapparent. In two studies of malnourished Gambian infants 20-25% of children had pulmonary consolidation at the time of presentation, often without symptoms or signs. Other infections such as urinary tract infections may also be present (5).

Aetiology of Pneumonia in Malnourished Children

In a recent study in The Gambia, the aetiology of community-acquired pneumonia was studied in well nourished and malnourished children (6). That study employed blood cultures and percutaneous lung aspirate to detect bacterial causes of pneumonia. Streptococcus pneumoniae and Haemophilus influenzae were the organisms isolated most frequently from both malnourished and well nourished children, although other causes, particularly tuberculosis, were found more frequently in malnourished children. It must be remembered though that in The Gambia kwashiorkor, which is usually regarded as the most immunosuppressive form of malnutrition, is uncommon, and during the course of the study there was very little measles.

In addition to infections which are present at the time malnourished children are first seen, those children who are hospitalized are particularly susceptible to serious nosocomial (hospital acquired) infections, usually caused by Staphylococcus aureus or gram negative organisms such as Klebsiella spp. and Escherichia coli. As these infections are often fatal, any unexpected deterioration or fever in a hospitalized, malnourished child usually prompts treatment with parenteral antibiotics such as gentamicin with ampicillin or cloxacillin.

Clinical Signs of Pneumonia in Malnourished Children

It is now well established that in a child presenting with cough, fast breathing, and lower chest wall indrawing are the best indicators of the presence of pneumonia. These signs are the basis of the standardized case management approach that is now used by national ARI control programmes in many parts of the world. Unfortunately they are less sensitive in children with malnutrition (7). In other words reliance on fast breathing and chest wall indrawing will miss more pneumonia cases amongst malnourished children than amongst well nourished children. Furthermore malnourished children with pneumonia are more likely to have a normal or low temperature. These findings are not surprising. Fast breathing, lower chest wall indrawing and fever are signs of a healthy body adapting to the presence of infection in the lungs. A weakened malnourished child may be less able to adapt in this way. A study from Papua New Guinea showed that amongst malnourished children admitted to hospital with pneumonia, those who were afebrile, and therefore not responding normally to the presence of infection, were more likely to die (8).

Effectiveness of Drugs

Children with malnutrition often have disturbed gut and liver function. Impaired gut function may interfere with absorption of oral antibiotics. This is particularly likely with oral chloramphenicol palmitate which must be de-esterified by pancreatic lipase prior to absorption by the small intestine. Decreased absorption may also be a problem with other oral antibiotics but few pharmacokinetic studies have been conducted in malnourished children. For these reasons one may be inclined to recommend parenteral antibiotics for malnourished children. However the injection route is not without its problems in these children. Intramuscular injections are painful and difficult in a severely malnourished child with virtually no muscle, while intravenous lines carry serious risks of infection and fluid overload.

Recommendations

Severely malnourished children often have pneumonia and/or urinary tract infection at the time of presentation. Many clinicians argue that all such children who are admitted should receive a course of antibiotics, while others believe that antibiotics should be reserved for proven infections only. If the latter course is followed, the attending physician must look carefully for infections and have a very low threshold for the treatment of pneumonia and other infections, bearing in mind the fact that malnourished children may not display the usual signs of infection. Significant cough, respiratory rate >40/minute, fever (or hypothermia), or chest wall indrawing (including intercostal indrawing) may each be the sole presenting sign of pneumonia in a malnourished child, and any of these signs should be regarded as an indication for antibiotics.

In malnourished children with radiological consolidation which fails to respond to appropriate antibiotics, the diagnosis of tuberculosis should be sought by whatever means are available. Many such children will eventually need a trial of antituberculous therapy but such decisions should not be taken too quickly.

Conclusion

Malnourished children are at greater risk of pneumonia than well nourished children. They may not show the same physical signs of pneumonia, so physicians caring for severely malnourished children should have a low threshold for the use of antibiotics for suspected pneumonia. Whilst the main bacteria responsible for pneumonia in malnourished children are the same for well nourished children, other organisms such as gram negative organisms and staphylococci may be responsible, particularly in those children who have kwashiorkor, those who have had measles, and those who became ill in hospital.

References

1. Smythe, P.M., Schonland, M., Brereton-Stiles, G. et al. (1971) Thymolymphatic Deficiency and Depression of Cell-Mediated Immunity in Protein-Calorie Malnutrition. Lancet, ii, 939-43.

2. McFarlane, H., Hamid, J. (1973). Cell-Mediated Immune Response in Malnutrition. Clin Exp Immunol, 13, 153-64.

3. Chandra, R.K. (1983). Nutrition, Immunity and Infection: Present Knowledge and Future Directions. Lancet, 1, 688-91.

4. Tupasi, T.E., Mangubat, N.V., Sunico, M.E.S. et al (1990). Malnutrition and Acute Respiratory Tract Infections in Filipino Children. Rev Infect Dis, 12(Suppl 8), S1047-1054.

5. Reed, R.P., Wegerhoff, F.O. (1995). Urinary Tract Infection in Malnourished Rural African Children. Ann Trop Paediatr, 15, 21-6.

6. Adegbola, R.A., Falade, A.G., Sam, B.E. et al. (1994). The Etiology of Pneumonia in Malnourished and Well Nourished Gambian Children. Pediatr Infect Dis J, 13, 975-82.

7. Falade, A.G., Tscheler, H., Greenwood, B.M., Mulholland, E.K. (1995). Use of Simple Clinical Signs to Predict Pneumonia in Young Gambian Children: The Influence of Malnutrition. Bull WHO, 73, 299-304.

8. Shann, F., Barker, J. & Poore, P. (1989). Clinical Signs that Predict Death in Children with Severe Pneumonia. Pediatr Infect Dis J, 8, 852-5.

Breastfeeding and Morbidity in Affluent Populations

Many studies have provided evidence of a protective effect of breastfeeding against infection in infants, but the question of whether or not the effect is sufficiently large to be of public health significance in affluent populations remains unresolved. A study in California has now gone one step further in providing an answer to this question.

Studies which have compared the morbidity of breastfed infants to that of formula fed infants have shown conflicting results. Some, but not all, have found reduced diarrhoeal morbidity in breastfed infants - and similarly, the evidence of protection against otitis media (middle-ear infection) and respiratory illnesses has been mixed.

Of particular importance in assessing the protective effect of breastfeeding is the recognition of, and accounting for, the many other factors which might be responsible for differing levels of morbidity in infants - such as birthweight, parental socio-economic status, and other environmental factors. It has been suggested that inability to control for such confounding variables may be one reason for the inconsistencies in results amongst studies.

The study in California, whose results were recently published in the Journal of Paediatrics, has attempted to overcome this problem by matching two groups of infants for as many potentially confounding variables as possible, attempting to leave the method of feeding (breastfed or formula fed until at least 12 months of age) as the only factor differing between them that is likely to affect morbidity (the only significant difference in characteristics other than method of feeding between the study groups was use of day care, and this was controlled for in the analysis).

Morbidity data on the two groups of children were collected weekly during the first two years of life. Analysis of the data revealed that in the first year of life, the incidence of diarrhoeal illness amongst breastfed infants was half that of formula-fed infants. The proportion with any middle-ear infection was 19% lower, and with prolonged episodes (greater than 10 days) was 80% lower in breastfed compared with formula fed infants. There were no significant differences in rates of respiratory illness - but as the authors point out “the vast majority of episodes were mild upper respiratory illnesses. Previous studies have indicated that the protective effect of breastfeeding is greatest for lower respiratory illnesses.” Morbidity did not differ significantly between groups in the second year of life.

The authors of the study conclude that “taken as a whole, the results of this and other studies indicate that the protective effect of breastfeeding against illness is of public health significance even in relatively affluent populations. This study evaluated differences in morbidity associated with breastfeeding during the first 12 months of life. Although nursing for this duration is at present uncommon in the United States, other studies have shown a substantial protective effect even with breastfeeding of shorter duration. In addition to reducing morbidity, the evidence suggests that the cost savings in health care from promoting breastfeeding could be large, given that more than $1 billion is spent each year on diagnosis and treatment of otitis media alone, and that gastro-intestinal illnesses are a major reason for hospitalization during the first year of life”.

(Source: Dewey, K., Heinig, M. & Nommsen-Rivers, L. (1995). Differences in Morbidity Between Breast-Fed and Formula-Fed Infants. Journal of Paediatrics, 126, 696-702.)

Multivitamins, Folic Acid, and Abnormalities of the Soft and Hard Palate in Infants

The results of research in California, published recently in The Lancet, have provided evidence to suggest that there may be a link between folic acid intake before and during pregnancy, and occurrence of orofacial clefts (such as cleft lip).

It is well documented that deficiency of folic acid, especially during the first weeks of pregnancy, is associated with an increased risk of foetal neural tube defects - and for this reason women are advised to take supplements of this nutrient before they conceive. Surprisingly little is known, however, about whether similar links exist between folic acid deficiency and other congenital anomalies.

In the California study, 731 mothers with infants born with orofacial clefts, and 734 mothers with non-malformed infants were assessed according to whether or not they had taken extra multivitamins containing folic acid during the period from one month before through two months after conception. Results showed that women who took multivitamins containing folic acid around the time of conception had a reduced risk of 25-50% of having children with orofacial clefts. Controlling for the potential influence of other variables did not substantially alter the results. The authors do point out that the results of their study may not have been attributable to folic acid specifically, but may be a consequence of other multivitamin supplement components, or behaviours, that are highly correlated with the use of multivitamins containing folic acid. They conclude “our results indicate a substantial risk reduction for orofacial clefts among pregnant women who used multivitamins containing folic acid periconceptionally. If this association proves causal, many of these anomalies will be preventable.”

(Source: Shaw, G., Lammer, E., Wasserman, C., O’Malley, C & Tolarova, M. (1995). Risks of Orofacial Clefts in Children Born to Women Using Multivitamins Containing Folic Acid Periconceptionally. The Lancet, 346, 393-96).

New Woman and Child Nutrition Improvement Project in India

Preparations are underway for new large-scale World Bank-assisted nutrition projects in five States of India - Maharasthra, Uttar Pradesh, Rajasthan, Tamil Nadu and Kerala. The “Woman and Child Nutrition Improvement Project” will aim to draw on the positive lessons from the Tamil Nadu Integrated Nutrition Project (TINP) and the Integrated Child Development Services (ICDS) while taking steps to deal with any identified shortcomings. The ICDS in particular has been frequently criticized in the past for its lack of focus on the youngest children (0-24 months), its lack of coordination with health services and its failure to become rooted in poor communities. These deficiencies will be systematically addressed in the preparation for the project, which also intends to break the inter-generational transmission of malnutrition whereby young malnourished mothers (often still in adolescence) give birth to low birth weight infants who, if they survive, become underweight children and later stunted adults.

The preparation process currently underway is supported technically and financially by UNICEF India, and has involved the convening of state and inter-state consensus-building workshops on nutrition problem assessment/analysis and strategy development, a World Bank Project Identification Mission and recently the initiation of a series of “social assessments”. These social assessments - which will ultimately drive the bottom-up design of the project - will comprise a series of participatory appraisals and focus group sessions among marginalised social groups, such as scheduled castes and tribes, in both rural and urban areas. The objective is firstly, to better understand local perceptions of malnutrition, its degree of priority with respect to other social problems and the existing constraints to remedial action, and secondly, to more directly involve stakeholders in project design. The first round of assessments are intended to be completed by April 1996.

(Source: Stuart Gillespie, UNICEF)

Bangladesh Integrated Nutrition Project

Malnutrition is a critically serious problem in Bangladesh. 54% of children under five years are severely or moderately malnourished. 35-50% of new-born babies are below normal weight (less than 2,500 gms.). About 70% of mothers and children suffer from iron-deficiency anaemia. The prevalence of night blindness due to vitamin A deficiency is 1.7%. Iodine deficiency disorders affect 68.9% of the population. These and other problems of malnutrition lead to great burden on the health of the people. Malnutrition adversely affects physical growth, mental capacity, learning ability and productivity costs.

The Government of Bangladesh, UNICEF, and the World Bank, are collaborating in starting a major project aimed at nutrition improvement in Bangladesh.

Objectives

Bangladesh is a signatory to the goals which were adopted at the International Conference on Nutrition (ICN) in Rome (December, 1992). Similarly, Bangladesh is also committed to the spirit of the declaration made by the World Summit for Children (WSC) in 1990. This project is the first major dynamic attempt by Bangladesh to translate the nutritional goals into reality. Therefore, the project goals and objectives are in line with ICN and WSC goals and targets. In addition to this the concept of this project is consistent with the draft National Nutrition Policy.

Ultimate Goal

The project aims to develop a comprehensive national nutrition program. The ultimate goal of the program will be to reduce malnutrition in Bangladesh, particularly in women and children. It also aims to bring sustainable behavioural changes in food intake patterns and caring practices.

The project will have the following major components:

A. National Level Nutrition Activities;
B. A Community-Based Nutrition Component; and
C. Project Management, Monitoring and Evaluation.

Core Component of the Project

The Community-Based Nutrition Component (CBNC) will be the core component of the project. It will develop a community capacity to diagnose its own problem(s) of malnutrition, identify population groups and households which require special attention and set up a mechanism to help themselves. Its central approach is community mobilization, followed by regular Growth Monitoring Promotion (GMP) with a strong element of IEC. This involves the regular (monthly) weighing of pregnant women and children to monitor their growth and using this process to counsel mothers by showing them when there is a growth faltering and explaining the causes and how to take remedial measures. It also involves very selective and targeted supplementary feeding of nutritionally vulnerable children and women. The strategy is to change feeding and eating behaviours at the household level, so that the benefits are sustainable.

The proposed project aims to use supplementary feeding as a tool to demonstrate, educate, and generate community participation for nutrition development. Although small, the supplementation of food will form the nucleus of this participatory action programme. Such community-based nutrition interventions have been shown to be effective in other parts of the world. Without this kind of intervention, all the efforts to ensure food security and good health care, even if very successful, could not fully address the problem of malnutrition.

Supplementary feeding will serve as a demonstration tool to the mothers - to show what some appropriate food can do for the improvement of the nutritional status. Selected children will be fed a ration of 300 kcal/day, six days a week for a period of 4 months and mothers will be fed a 600 kcal ration every day for 6 months during pregnancy and 6 months into lactation. In case of illness, the beneficiaries will be referred to the nearest health care delivery system.

Organizational Arrangements:

The project will be implemented through a Project Directorate at central level under administrative control of the Ministry of Health and Family Welfare (MOHFW). A national Steering Committee headed by the Secretary, MOHFW will be set up for policy guidelines and overall supervision of the project.

At village level female VDP members will be selected to work as Community Nutrition Promoters (CNP). Similarly at union level VDP leaders will work as Community Nutrition Organizers (CNOs). CNPs and CNOs will receive monthly honoraria amounting to taka 500.00 and 1000.00 respectively. If suitable candidates are not available, CNPs and CNOs chosen from the community could then join the VDP organization.

Community Mobilization

The project at community level will enhance community mobilization to share this programme as their own development activity. This will be enhanced by participation of village mothers, committee members, CNP and local personnel: this will be accelerated by the IEC components and other awareness creating programmes.

NGO Involvement

In view of the strong element of community mobilization in CBNC and the experience of several NGOs in similar nutrition activities in the country, it is proposed to involve selected NGOs substantially in the implementation of this component.

Information, Education and Communication (IEC)

Person-to-person IEC activities will be carried out under CBNC. Therefore the need for a separate component for IEC is mainly to provide for two distinct sets of activities: (i) development of appropriate IEC messages and production of IEC materials; and (ii) delivery of messages through mass media. Materials produced through the former process will be fed into CBNC as well as the media campaigns. Audience research would first be carried out to understand fully the cultural and behavioural aspects relevant to nutrition, to assess the exact IEC needs in this regard and subsequently to develop the messages. The production of IEC materials would follow. Mass Media will be used for awareness of BINP in general. An appropriate media-mix would also be introduced.

Project Management, Monitoring and Evaluation

Monitoring is a very important part of the proposed project, particularly for two reasons: (i) the project itself is new for Bangladesh and thus lessons need to be learnt as it progresses; and (ii) the activities (especially the inter-sectoral ones) will be carried out by various ministries/departments and some NGOs, thus making the importance of monitoring even greater. The monitoring process will help detect the achievement of the targeted outcomes and direct guidelines for necessary modification if needed. Continuous monitoring of the project as well as mid-term evaluation at the end of three years and final evaluation will be based on a predetermined set of indicators which measure inputs and process as well as outputs and outcomes.

Involvement of UNICEF

UNICEF has provided necessary technical assistance to the Government (Ministry of Health & Family Welfare) in conceptualization and preparation of the project. During the project implementation period UNICEF will provide assistance to the project in the field of Training, IEC/Social Mobilization, Monitoring, Evaluation etc.

Project Cost

Estimated project cost is US$67.3 million out of which the World Bank/IDA and the Government of Bangladesh will bear 59.8 and 7.5 million respectively.

(Source: UNICEF, Dhaka. December 1995)

MICS - An International Household Survey Initiative for Monitoring Progress Towards World Summit for Children Goals

Prompted by a commitment by the United Nations to report at mid-decade on progress toward achieving health, nutrition, education, and water and sanitation goals set at the 1990 World Summit for Children, and the paucity of reliable, current national data for goal-indicators, UNICEF, in collaboration with other agencies - including WHO, UN Statistical Office, and the US Centers for Disease Control - has for the last year been engaged in promoting national sample household surveys world-wide to collect the required data for a small number of internationally accepted Mid-Decade Goal indicators. These surveys, which have come to be known as Multiple-Indicator Cluster Surveys (MICS), are intended to produce nationally representative and statistically robust estimates, of sufficient quality to withstand international scientific scrutiny. They are designed as an integral component of national capacity building for programmatic action and policy review in each of the goal areas. They foster inter-sectoral collaboration in this process.

A standardized questionnaire and survey methodology - including sampling guidelines - were developed in late 1994 and are documented in A Practical Handbook for Multiple Indicator Surveys (Monitoring Progress Toward the Goals of the World Summit for Children). The Handbook, along with data entry and analysis software, was distributed to all UNICEF country offices in January 1995. UNICEF offices were directed to assess local data availability and where necessary, to initiate plans for MICS, in collaboration with appropriate government agencies, and in the framework of National Plans of Action for Children and Women. Technical assistance, coordinated internationally by UNICEF’s Planning Office, has been provided to many countries through international and regional training workshops and country missions.

The core questionnaire collects information on the quality and accessibility of drinking water and the adequacy of sanitation facilities; child education; immunization of children and, in the case of tetanus toxoid, mothers; and diarrhoea incidence and treatment. Of particular interest to the SCN News readership, the questionnaire also covers salt iodization, anthropometry, and vitamin A supplementation. Salt used in the household is tested with standard kits by the interviewers. The anthropometry module focuses on child weight and follows procedures described in the booklet How to Weigh and Measure Children (UN Statistical Office, 1986). Questions on vitamin A focus on household exposure to particular programmatic initiatives (whether the household has received supplement capsules, or has fortified food products, or has been exposed to public health messages).

Table 1. Countries with Populations of 1 Million or more doing a MICS by Indicator and Region

Region	# of surveys	Underweight	Vitamin A	IDD	Total Countries
West Africa	20	19	14	17	21
East Africa	16	14	14	15	19
MENA	14	13	8	9	17
S. Asia	6	6	5	6	6
E. Asia	10	8	9	10	15
LA & Carib	18	13	14	12	22
CEE-NIS	7	2	3	3	24
Total	91	75	67	72	124

The guidelines in the Handbook are flexible and framed in a way to be relevant to a range of country situations: but they are only guidelines. Thus there will be a local flavour to each survey, with respect to sample size and design, the number of modules included, and other areas of inquiry. What has been stressed, however, is the importance of adhering to the wording of questions and of having a sample size sufficiently large to produce good national estimates. As of now, of 124 developing countries with populations of 1 million or more - including the countries of Central and Eastern Europe and the Newly Independent States of the former Soviet Union - 91 have either completed a survey or are committed to completing a survey by early 1996. Of the 91, 56 involve stand-alone MICS, while 35 entail appending MICS modules, or their substance, to other national surveys. Some countries, such as China and India have implemented these surveys at the sub-national level. In India, some 200 MICS have been conducted at the state level.

Not all surveys collect data on every indicator. The anthropometry module has been excluded in several instances due to cost considerations. Therefore, data on underweight children will be available for only 75 of the 91 countries referred to above; on salt iodization for 72; and on vitamin A for 67 countries. Table 1 gives the regional breakdown of survey activity. The level of activity in Africa is particularly notable.

Few results in final report form are as yet available. It is reasonably hoped that data from all surveys will be available at least in preliminary form by May 1996. For the purpose of National reviews that take stock at mid-decade it is essential to have up-to-date readings. The Secretary-General is expected to present his own report on progress since the World Summit for Children in September 1996.

The level of survey activity indicated by the table is a good indication of the poverty of current data on these important indicators. The MICS initiative should go a long way toward redressing this problem. Quite apart from international goal-monitoring, and probably more important, the survey results are expected to be extremely useful at the level of national policy reviews, mobilization of action and national capacity building in programme monitoring.

(Source: Planning Office, UNICEF, 3 United Nations Plaza, New York NY 10017, USA, 5 January 1996)

Progress in Micronutrients in Africa

The first meeting of the Eastern and Southern African Sub-Region of the OAU/UNICEF/WHO/FAO African Micronutrient Task Force was held at the Red Cross Training Institute, Addis Ababa, Ethiopia, for three days, 28-30th August 1995. Participation was also invited from English speaking West African countries, Egypt and Sudan.

The meeting was convened and jointly organized by OAU and UNICEF ESARO and financially supported by UNICEF, WHO and the Micronutrient Initiative (MI). There were 50 participants from 18 countries and 6 agencies.

The objectives of the meeting were: (1) to take stock of progress made in the achievement of the mid and end of decade goals for micronutrients and identify critical constraints and support needed in accelerating their achievement; (2) to continue with advocacy in order to maintain and sustain high level commitment for the elimination of micronutrient deficiencies; and (3) to assist governments to plan and implement national micronutrient programmes using an integrated combination of high dose supplementation, food fortification, dietary approaches and public health measures to achieve sustainable elimination of micronutrient deficiencies

Main Issues

Based on the four main areas discussed in group work (intervention strategies, food fortification and role of industry, training and networking), participants identified the following main issues which were considered to be critical for accelerating action and ensuring large scale impact of micronutrient programmes.

Intervention Strategies

1. Although there has been commendable progress in action with regard to the control of IDD and recently vitamin A deficiency, there is very little progress in controlling iron deficiency anaemia.

2. There is need to integrate the long-term food based and public health measures with short term and medium term strategies of supplementation and fortification.

3. There is need for an integrated approach e.g., EPI, EPD, MCH-FP, Primary health care and deworming.

4. There is a lack of nutrition education which emphasizes the local availability of micronutrient rich foods.

Actions at Community Level

1. Develop country specific guidelines that empower communities to distribute low dose vitamin A supplements (e.g. 10,000 IU).

2. Promote the production and use of “drought resistant” crops rich in micronutrients.

3. Empower communities to be able carry-out (appropriate) household or village level food fortification, processing and preservation.

4. Empower communities to demand for foods fortified with essential micronutrients (through IEC).

5. Mobilize and support communities/households to fortify local staples (i.e. food to food complementation).

6. Train extension and community level change agents in the use of the Assessment, Analysis and Action (Triple A) and community animation approaches in order to ensure sustainability of programmes.

Actions at National Level

1. Use supplements but emphasize food based strategies at all levels (community, district levels).

2. Lack of up-to-date and quantitative data on Micronutrient deficiency should not delay action in carrying-out interventions in micronutrient deficiency areas.

3. Other programmes like EPI, MCH, EDP and infectious disease control can be used to improve the coverage of the supplementation programs in the countries.

4. Develop a National Strategy for combating micro-nutrient deficiency at community level.

5. Targeted intervention should be undertaken where necessary.

6. Micronutrient programs should be integrated in other nutrition-relevant projects.

7. Identify focal institutions or persons who should serve as co-ordinators for micronutrient malnutrition control.

8. Continue Advocacy to industrial producers, decision makers, other actors and to communities on food fortification.

9. Carry-out food consumption surveys to enable better planning of fortification (i.e., the foods, the levels, etc.).

10. Need to evaluate the needs and the opportunities for fortification in the country (which foods, where is the fortification, by who, at what cost, etc.).

11. Analyze existing information that can be useful for planning and management of food fortification.

12. Training should be tailored to specific tasks.

13. Plan for building in micronutrients issues into ongoing educational systems (primary, secondary and professional schools).

14. Need to develop a training policy/strategy for micronutrients.

15. Need to train district level cadres on micronutrient, management and programming.

(Source: Communication with Dr F. Kavishe, September 1995)

ICCIDD Communication Focal Point

The International Council for the Control of Iodine Deficiency Disorders (ICCIDD) has established its Communication Focal Point in the International Communication Enhancement Center at Tulane University’s School of Public Health and Tropical Medicine.

Among the activities of the Communication Focal Point is the ICCIDD Clearinghouse, mandated to collect and classify all types of materials related to IDD and its control such as Books, Reports, Videos, Slides, Manuals, Posters, Brochures, Evaluations, Articles, etc. Some materials, such as published journal articles, are included but they are not a priority because the assumption is that information about their content and how to acquire these are available through other channels. We do not assume, however, that information about the content of all published materials is widely available. In this regard, we try to present the contents in an alternative manner which can be quickly reviewed.

The ICCIDD Focal Point is also charged with the dissemination of information about the material in the Clearinghouse and how these may be obtained. There are three ways in which information on the content of the ICCIDD Clearinghouse is disseminated:

1. Through a publication of the contents called NOTES.

2. Through response to specific queries by searching the database by authors, subjects, keywords, titles, etc. The results of the query are then sent to the interested party.

3. By providing our entire database (database files and the software with a user’s guide) which allows anyone to perform their own searches on any author, title, subject, date, key word, or material classification which is of interest to them. Data file updates will be provided semi-annually. If anyone would like a copy of this database on diskette, please contact:

Tulane University SPHTM
ICCIDD Communication Focal Point
1501 Canal Street, Suite 1304
New Orleans, LA 7011
Telephone/Fax: (USA) 504-585-4090

Internet address:
[email protected]

In addition to the Clearinghouse, the ICCIDD Communication Focal Point has developed a Universal Iodized Salt Logo and “visiting-card” size IDD Fact & Figures cards in English, Spanish and French. It also played a key role in introducing IDD Day on October 21, jointly sponsored by ICCIDD, UNICEF and the Kiwanis International, the service organization committed to raise $75 million for UNICEF to eliminate this scourge.

(Source: Communication with Thomas E Scialfa, Coordinator ICEC, November 1995)

Fourth Executive Director of UNICEF - Carol Bellamy

On 1 May, 1995, Carol Bellamy took up office as the fourth Executive Director of the United Nations Children’s Fund (UNICEF). Ms Bellamy joined UNICEF from her post as Director of the US Peace Corps, a service organization which has 6,500 volunteers in more than 90 countries. Ms Bellamy has a distinguished career in law and finance, and has worked extensively in the public sector, including five years in the New York State Senate (1973-1977). In 1978 she became the first woman President of the New York City Council, a position she held until 1985. She was a member of the Statewide Coalition to Fight Infant Mortality, and chaired the New York City Task Force on Adolescent Pregnancy.

Ms Bellamy was a member of the New York State Commission on Judicial Nomination, the New York City Commission to Review Health and Hospitals Corporation, the Executive Committee of the Citizens Budget Commission, and co-chair of the New York Public Transportation Improvement Coalition. She also served as a member of New York State’s Blue Ribbon Commission on State Legislative Practices and Ethics, as chair of the Congressional Office of Technology Assessment’s Advisory Panel on Public Works Technologies, Management, and Finance and on the Peace Corps Advisory Council. Ms Bellamy graduated in law from New York University in 1968. She is a former Fellow of the Institute of Politics of the Kennedy School of Government at Harvard University and an honorary member of the Phi Alpha Alpha, the US National Honor Society for Accomplishment and Scholarship in Public Affairs and Administration. Ms Bellamy graduated with honours from Gettysburg College in 1963. She was born in Plainfield, New Jersey, on 14 January 1942.

(Source: UNICEF Biographical Information Note, May 1995)

Richard Jolly, New Chair of the SCN

UNICEF/95-0103/John Isaac

Dr Richard Jolly of UNICEF was nominated as Chair of the ACC/SCN at the recent Session, held in PAHO in June. The appointment was endorsed by the ACC system in September, for a two year period.

From 1982-1995 Richard Jolly was deputy to UNICEF’s Executive Director, James P. Grant, and took part in all UNICEF major programme developments, during that time, including the initial formulation of the Child Survival and Development Strategy, the emergency response to the African drought in the mid 1980s and the acceleration of immunization and ORT towards the 1990 goals. Following the World Summit for Children, he ensured UNICEF’s full support to help countries implement the goals agreed at the summit, especially in the areas of health, nutrition, water, education and family planning.

In the early 1980s, with the study “Adjustment with a Human Face”, Dr Jolly spearheaded efforts to direct attention to the needs of children, women and the poor, in the making of economic adjustment policies. Under his direction, UNICEF’s programme concerns shifted from an almost exclusive focus on women as mothers to support for women as women.

During the 1980s, Dr Jolly was Chair of the Steering Committee of the Joint Nutrition Support Programme (JNSP). This programme, funded by the government of Italy, at a level of more than US$80m, supported innovative nutrition projects in nearly 20 countries. These included the Iringa project in Tanzania, which contributed greatly to the current emphasis on community-based programmes; and the goitre control programme in Bolivia, a forerunner of the worldwide campaign to end IDD.

Dr Jolly maintains a special concern for Africa. From 1987 to 1991 he was Vice Chairman of the interagency task force chaired by Professor Adedeji which followed up the UN Programme of Action for African Economic Recovery and Development (UNPAAERD). In 1992 he led UNICEF’s Programme preparations for the OAU/UNICEF International Conference for Assistance to African Children (ICAAC).

Earlier, after graduating from the University of Cambridge in 1956, he spent two years as a Community Development Officer in Baringo District, Kenya, concerned with literacy, women’s activities, village water supplies, and other community action. He then studied economics at Yale University (gaining his doctorate for a study later published as “Planning Education for African Development”. After a year in Makerere College, Uganda, he worked from 1964-66 and again in 1970 in the Office of National Development and Planning of the Government of Zambia, concerned with the economic framework of Zambia’s First and Second National Development Plans and with the sections on human resources.

Dr Jolly is committed to interagency collaboration to strengthen the whole UN effort in development. For three years, he chaired CCSQ (Ops), the most senior committee which brings together all UN agencies involved in development. For three separate years he chaired the Joint Consultative Group on Policy. During this time the UN agencies identified common objectives, took major steps towards agreeing guidelines for strengthening the Resident Coordinator system, agreed methods on harmonized cycles and common premises, and established the first interagency mechanism for training senior level field personnel.

Richard Jolly is a member of the Governing Council of the Society for International Development and was Vice President from 1982-1985. In 1987 he became Chairman of SID’s North South Roundtable. Recent meetings from the North South Roundtable under his chairmanship have led to reports on Reform and Strengthening of the United Nations (including presentations in ECOSOC) and to reports and meetings on The Economics of Peace, Mass Movements of People (organized as part of the 40th anniversary of UNHCR) and The Challenge of Africa and Southern Africa. A recent series of meetings of the North South Roundtable (1993) was on “The Bretton Woods Institutions and the United Nations: challenges for the 21st century”.

Richard Jolly gave the third Barbara Ward Lecture at the SID World Conference in Amsterdam in 1985 on “Adjustment with a Human Face”, which drew on the study he directed for UNICEF on “The Impact of World Recession on Children” (published a year earlier). This set forth specific actions which could be taken to protect children, and other vulnerable groups in the course of adjustment policy. He was co-editor and author with Andrea Cornia and Frances Stewart of UNICEF’s study on this theme, also entitled “Adjustment with a Human Face” (published in 1987).

“I am pleased and honoured to take on the Chairmanship of the SCN, which I have long considered one of the most creative of the interagency bodies. I am excited to come to the job to play my part in facilitating interagency action, especially to accelerate the rate of improvement in nutrition worldwide. In this I give particular importance to Africa, where there has be so little improvement in recent years and where challenges are so enormous.” Richard Jolly said of his new appointment.

Starting January 1996, Richard Jolly will be Special Advisor to the Administrator of UNDP and architect of UNDP’s Human Development Report.

XVII International Vitamin A Consultative Group Meeting

The above meeting, scheduled to take place in Guatemala City from 18-22 March, 1996, will take the theme of “Virtual Elimination of Vitamin A Deficiency: Obstacles and Solutions for the Year 2000”. Invited presentations on this theme will be included in the programme together with oral, poster, and video presentations to be selected from submitted abstracts on the following topics: population assessment of vitamin A deficiency and marginal vitamin A deficiency; biologic significance of vitamin A deficiency and marginal vitamin A deficiency; and appropriate interventions, especially food-based approaches and highlighting food fortification.

Policy makers, implementors, and scientists in health, nutrition, biochemistry, agriculture, horticulture, and development are expected to be amongst the more than 300 participants attending the meeting, which is sponsored by IVACG and a local organizing committee coordinated by the Instituto de Nutricie Centro America y Panama (INCAP).

For farther information please contact: IVACG Secretariat, ILSI Research Foundation, 1126 Sixteenth Street, N.W., Washington, D.C. 20036, USA. Phone: (202) 659 9024 Fax: (202) 659 3617 Email: [email protected].

(Source: IVACG Press Release, April 1995)

Diet, Nutrition & Chronic Disease - Lessons from Contrasting Worlds, London School of Hygiene and Tropical Medicine Sixth Annual Public Health Forum

The above Forum will take place from 31 March - 3 April 1996 in the Goldsmiths’ Lecture Theatre in the London School of Hygiene & Tropical Medicine (LSHTM) in central London.

The aims of the Forum are to: bring together scientists, policy makers and those working in public health from both developing and developed countries to share knowledge and experiences of the growing problem of chronic non-communicable diseases; increase international awareness, by describing the global burden of chronic non-communicable diseases, and predicting the likely trends, particularly in developing countries; evaluate the impact of changes in diet, nutrition and lifestyle that predispose to chronic non-communicable diseases in modern societies; identify and prioritize major research issues; suggest strategies to enable health policy makers, particularly from developing countries, to obtain information on the burden of chronic non-communicable diseases and to plan effective counter-measures; and produce a major publication summarizing the current state of research into chronic non-communicable diseases and strategies for prevention worldwide.

For further information please contact: Alice Dickens, Conference Organizer, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom. Phone: (44 171) 927 2314 Fax: (44 171) 580 7593 Telex: 8953474 Email: [email protected].

(Source: LSH&TM Booklet, undated)

The Second European Congress on Nutrition and Health in the Elderly, Hotel Marienlyst, Elsinore, Denmark, May 9-12, 1996

The elderly constitute an increasing proportion of the population. Nutrition has an important impact on the maintenance of health and quality of life, and the prevention of illness, in the elderly. The importance of optimal nutrition for the elderly is now recognized and the above congress has been organized for the sharing of experience and research results in age, nutrition and function of the elderly with a broad scientific audience.

The 1st European Congress on Nutrition and Health in the Elderly was arranged to present the Euronut, SENECA study, in 1991 in the Netherlands. It was decided to continue European congresses on nutrition and health in the elderly. The main theme of the Second European Congress will be: ageing, nutrition and body composition. The main sponsor of the Congress is the Danish Dairy Board.

For farther information, please contact the Congress Secretariat, Conventum Congress Service, Hauchsvej 14, DK-1825, Frederiksberg C, Denmark. Phone: 45 31 31 08 47 Fax: 45 31 31 06 14.

(Source: Congress 1st Announcement, undated)

28th International Geographical Congress

The Hague, August 5-10, 1996, are the location and dates of the 28th International Geographical Congress. The Congress will take the theme of “Land, Sea and Human Effort”, and promises to offer something for everyone who is engaged, either scientifically or professionally, with the issues of people in the environment. The extensive schedule will include general sessions, symposia, state-of-the-art lectures, commission/study group sessions, joint sessions, day trips, scientific field trips, and business meetings.

For farther information please contact: Congress Secretariat, 28th IGC, Faculteit Ruimtelijke Wetenschappen Universiteit Utrecht, Postbus 80.115, 3508 TC Utrecht, The Netherlands. Phone: 31 30 532044 Fax: 31 30 540604 Email: [email protected].

(Source: Congress Preliminary Program, undated)

XII International Congress of Dietetics

The above Congress, hosted by the Nutritionist-Dieticians’ Association of the Philippines, under the auspices of the International Committee of Dietetic Associations, will take place from 18-23 February 1996 at the Philippine International Convention Center. For further information please contact: Congress Secretariat, XIIth ICD, c/o Nutritionist-Dietician’s Association of the Philippines, PO Box 4486, Manila, The Philippines or Prince Tower Condominium, 14 Tordesillas Street, Makati, Metro Manila, Philippines 1200. Fax: (63-2) 815 1935; 522 1090 Phone: (63-2) 810 5034; 521 4884.

(Source: Congress Final Announcement and Call for Abstracts, undated)

International Conference on Health Promotion and Nutrition

Wageningen, the Netherlands, January 25-26, 1996. Organized by the European SUPER project team.

In 1996 the European SUPER project will celebrate its fifth anniversary. With the recognition that nutrition-related diseases are one of the main causes of premature death in Europe, the project, also known as the Nutrition Multi-City-Action-Plan, began in 1990 with the objectives of: fostering a positive change in knowledge and attitudes regarding healthy diets and a change in dietary behaviour to improve public nutrition as a contributing factor to the long-term reduction of nutrition-related diseases (cardio-vascular disease, cancer, etc.); bringing about a positive change in environmental factors which influence public nutrition; and incorporating the programme into local structures. The project is coordinated by the Department of Communication and Innovation Studies of the Wageningen Agricultural University, and currently eight European cities are involved (all cities are members of the Healthy Cities Project of the World Health Organization).

To celebrate the anniversary and to share experience from the project with others the project team has decided to organize an International Conference on Health Promotion and Nutrition on the 25th and 26th January 1996, in Wageningen, the Netherlands. The conference aims to bring together professionals from the field of health promotion and nutrition who have a commitment to the WHO principles of Health for All and Health Promotion. The purpose is to share scientific and practical experiences gained from the SUPER programme to help illustrate how to achieve the goals of equity, participation and collaboration in practice.

The conference is aimed at assembling all persons actively involved in the promotion of health and nutrition, e.g. health promotion professionals, public health researchers, nutritionists, community dieticians and community workers.

The conference will be held at the Wageningen International Conference Centre (WICC-IAC).

For further information please contact: Lenneke Vaandrager, Department of Communication and Innovation Studies, De Leeuwenborch, Hollandseweg 1, 6706 KN Wageningen, The Netherlands. Phone: 31 317 490287 Fax: 31 317 418552.

(Source: Conference Information Folder, undated)

Second International Congress of Food and Cancer Prevention

The elderly are constituting an ever increasing proportion of the population and there is growing interest amongst the general public, industry, and policy-makers in improving health and quality of life during old-age, including the prevention of age-related cancers. Results of scientific research over the past few decades have clearly shown that nutrition can play an important role in the prevention of cancer, and the aim of the International Congress for Food and Cancer Prevention II is to discuss scientific developments in this field.

The Congress, to be held in Ede, The Netherlands, from May 19-22, 1996, is directed towards research into nutritional factors involved in the primary prevention of cancer. The title “Food and Cancer Prevention” implies a broad approach, in which both vegetable and animal products will be included.

For further information please contact: Congress Office, Wageningen Agricultural University, FCP II Congress, c/o Joost Meulenbroek, PO Box 9101, 6700 HB Wageningen, The Netherlands. Phone: +31 317 482029 Fax: +31 317 484884 Internet: [email protected].

(Source: Conference First Circular and Pre-registration form, May 1995)

6th International Course on Food Processing

The International Agricultural Centre (IAC), based in Wageningen, The Netherlands, is organizing two course programmes on Quality Assurance and Marketing in Food Processing Enterprises, and on Food Fortification for the Elimination of Micronutrient Malnutrition as part of its International In-Service Training Course on Food Processing (ICFP) The following information about the courses is extracted from the course booklet.

The course on Quality Assurance and Marketing (ICFP-QAM) is intended for professionals from business advisory, training and support institutions and technical and technological services for formal small and medium scale food processing enterprises, and entrepreneurs in small and medium scale enterprises. This programme aims to broaden participants’ views on problems of small and medium scale food processing, to upgrade participants’ knowledge concerning the analysis of problems and the selection of appropriate technologies, and to impart techniques for the implementation of selected technologies, focusing on quality assurance and marketing. The course will take place from August 11 - November 16, 1996.

IAC participates in The Program Against Micronutrient Malnutrition (PAMM), a global network based in Atlanta, USA, that is working towards the virtual elimination of iodine and vitamin A deficiency disorders and a one-third reduction of iron deficiency anaemia by the year 2000. Assistance for the development of interventions includes support for dietary supplementation, food diversification and fortification of common foods with physiological amounts of micronutrients.

Food Fortification is the most sustainable long-term strategy to control iodine deficiency disorders (IDD). It is also an important short and medium-term strategy to combat vitamin A deficiency (VAD) and iron deficiency anaemia (IDA). A six week course programme on Food Fortification for the Elimination of Micronutrient Malnutrition is offered by IAC, Wageningen. It provides information on fortification technology and processes, appropriate food vehicles that may be fortified, and fortificants that convey micronutrients.

The programme is designed for those working in advisory positions for food fortification technology applications in national Micronutrient Malnutrition programmes such as: government employees with an advisory role to the food processing industry, industry employees, in-charge of food fortification processing; and private consultants, hired as advisors on technical and operational questions on food fortification by government and/or industry.

This programme aims to provide participants with insight and views on how to develop and refine the skills to promote and manage the fortification of strategic foods with micronutrients for national programmes and to create acceptance of food fortification among concerned groups, i.e. the government, private enterprises and consumers. The course will take place from October 6 to November 16, 1996.

For further information please contact: International Agricultural Centre (IAC), PO Box 88, 6700 AB Wageningen, The Netherlands, Lawickse Allee 11. Phone: 31 317 490111 Fax: 31 317 418552 Email: [email protected]. Telegrams INTAS Telex: 45888-INTAS NL.

(Source: Courses booklet, undated)

Refresher Courses in Human Nutrition in London, UK.

In 1996 the Human Nutrition Unit (Department of Public Health and Policy) of the London School of Hygiene and Tropical Medicine is offering a choice of seven Study Units from their MSc course on Human Nutrition which make ideal refresher courses for professionals and visiting scholars in the fields of nutrition and health.

Each course, which lasts for five weeks, comprises 2.5 days per week of timetabled teaching. The courses are as follows:

8 January - 9 February 1996
1. Nutritional Epidemiology in Public Health
2. Diet & Disease

19 February - 22 March 1996
3. Maternal & Child Nutrition
4. Nutritional Assessment & Malnutrition

22 April - 24 May 1996
5. Nutrition Programme
6. Policy in Food and Nutrition
7. Nutrition in Emergencies

The refresher courses are organised and taught by the staff of the Human Nutrition Unit, with the assistance of visiting lecturers for some specialist topics. Course activities will include integrated class teaching, group work, library work, computer-based exercises, discussions, role-play, and case-studies, using tutors’ and participants’ experience. Students will be encouraged to bring relevant material.

Course participants are expected to include middle and senior level professionals working in the areas of health and/or nutrition in government, non-government, and development agencies worldwide.

For further details please contact: Dr A Tedstone, Human Nutrition Unit, 2 Taviton Street. London WC1H 0BT, UK. Phone: 0171 927 2128 Fax: 0171 383 5859 Telex: 8953474 LSHTM Email: [email protected].

(Source: LSH&TM Leaflet, undated)

Courses at the Institute of Nutrition and Food Hygiene (INHA), Cuba in 1996

The Institute of Nutrition and Food Hygiene (INHA) of Havana, Cuba, was established in October 1984. It is a research center for the scientific study of problems of food and nutrition related to the promotion of human health, prevention of diseases associated with food quality or inadequate diets, and with the dietetic management of disease. The INHA is the National Reference Centre of the Ministry of Public Health in all aspects which relate nutrition to human health.

In 1991, INHA became a WHO Collaborating Center in Research and Training in Human Nutrition, especially in those aspects related with non-communicable diseases. Scientific links have been established with the Institute of Nutrition of Central America and Panama (INCAP), in Guatemala; the Institute of Nutrition and Food Technology (INTA), in Chile; the Caribbean Food and Nutrition Institute (CFNI) in Jamaica; several universities and research centres in Venezuela, Ecuador, Colombia, Argentina and Mexico; the Dunn Nutrition Centre in the United Kingdom; the German Institute of Nutrition in Potsdam, Germany; and the Agricultural University in Wageningen, the Netherlands.

INHA will be holding the following International Postgraduate Courses in 1996.

1. International Masters Degree in Nutrition in Public Health. September 9 1996 - July 18, 1997. Coordinator: Prof. Troadio Gonzalez. Fee US$ 7,800

2. Sanitary Control of Cosmetic Products. February 19-23,1996. Coordinator: Dr Lidia Altunaga. Fee US$ 365* or 315**

3. Risk Analysis and Critical Control Points in Foods. March 4-8, 1996. Coordinator: Dr Angel Caballero. Fee US$ 365* or 315**

4. Food-Borne Diseases. March 11-15, 1996. Coordinator: Dr Manuel Grillo. Fee US$ 350* or 245**

5. Food Toxicology. March 25-April 5, 1996. Coordinator: Lic. Miguel O. Garcia-Roche. Fee US$ 410* or 280**

6. Micotoxicology. April 8-19, 1996. Coordinator: Lic. Olga Sanchez. Fee US$ 400* or 280**

7. Food and Nutrition of the Healthy Man: Theory and Practice. May 20-31, 1996. Coordinator: Prof. Troadio Gonzalez. Fee US$ 600* or 420**

8. Mother and Child Nutrition in Primary Health Care. June 3 - July 12, 1996. Coordinator: Prof Manuel Amador. Fee US$ 1,650* or 1,155**

9. Anthropometric Indicators of Nutritional Status. July 15-30,1996. Coordinator: Lic. Armando Rodriguez. Fee US$ 715* or 615**

10. Quality Control in Food Assay Laboratories. September 2-13, 1996. Coordinator: Ing. Maria V. Luna. Fee US$ 400* or 280**

11. Physiological Requirements and Protein Quality. September 16-20, 1996. Coordinator: Lic. Mario Abreu. Fee US$ 400* or 280**

12. Fats in Human Diet: Effects on Health. October 14-18,1996. Coordinator: Dr Alaejandrina Cabrera. Fee US$ 330* or 210**

13. Food and Nutritional Surveillance. October 28-November 1, 1996. Coordinator: Prof John Gay. Fee US$ 300* or 210**

14. Computer Programs Applied to Dietary Assessment for Food and Nutrition Surveillance. November 4-22, 1996. Coordinator: Lic Armando Rodriguez, Fee US$ 1050* for three modules (US$ 350/module) or US$ 750** for three modules (US$ 250/module)

15. Food Security. November 25-29, 1996. Coordinator: Dr Santa Jimenez. Fee US$ 300* or 210**

16. Data Analysis in Nutritional Studies. December 2-13,1996. Coordinator: Lic Pedro Monterrey. Fee US$ 700* or 600**

* Price includes registration fees, printed materials, lodging, and meals in the Guest’s House of the Institute of Nutrition and Food Hygiene. Teaching activities take place in the same location.

** Price includes only registration fees and printed materials.

For further information please contact: Professor Mirta Hermelo, MD, PhD. Head, Dept. of Postgraduate Education, Institute of Nutrition and Food Hygiene, Calzada de Infanta 1158, La Habana 10300, Cuba. Phone: (537) 78 1835 or (537) 70 8947 Fax: (537) 33 3375.

(Source: Communication with Professor Manuel Amador, Deputy Director, INHA, September 1995)

SOURCES OF NUTRITION TRAINING MATERIALS

Compiled by the International Committee of the Nutrition Society, 10 Cambridge Court, 210 Shepherds Bush, London W6 7NJ, UK. Fax +44 171 602 1756.

The following organizations produce and/or distribute English-language materials useful to trainers in tropical low-income countries. Some have materials in French, Spanish and other languages. To obtain the materials please write directly to the organization not the Nutrition Society.

Prices for the materials listed are given where known but may change; they are in US$ or UK£ unless stated otherwise. If there are two prices the first is for low-income and the second for industrialized countries. Post and packing (p&p) is sometimes extra. We suggest you write for details of recent materials, prices and methods of payment before ordering. Single copies of priced items are sometimes sent free to low-income countries.

Inclusion of an item does not necessarily mean the Nutrition Society recommends it although we have tried to list the more useful materials available. We thank everyone who supplied information and would be pleased to receive corrections and additions for updating this list.

Academy for Educational Development, 1255 23rd St NW, Washington DC 20037, USA Fx +1 202 862 1947. Examples: Q/A on infant feeding 1991, Learning to listen to mothers 1993 Free/$4

African Medical & Research Foundation (AMREF), Publishing Department, Box 30125, Nairobi, Kenya Fx +254 2 506112. Some items also available (using local currency) through AMREF offices in Uganda, Tanzania, South Africa, USA & UK (TALC). Examples (prices dependent on exchange rates):

Distance learning for village educators Breastfeeding course £20

Books A guide for training teachers of health workers 1993 £3.50, Helping mothers to breastfeed 1992 £2.50 Community nutrition for eastern Africa 1994 £7.00

AHRTAG, Farringdon Point, 29-35 Farringdon Rd, London EC1M 3JB, UK Fx +44 171 242 0606. List of training materials Breastfeeding information resources Free/£5

Caribbean Food & Nutrition Institute, Box 140, Mona, Kingston 7, Jamaica Fx +809 927 2657. Examples: flash cards $4/$8/set, leaflets $3/$6/set, flipcharts $2.50/$5 each.

Centre for Health Education, Training & Nutrition Awareness (CHETNA), 2nd Floor, Drive-In Cinema Building, Thaltej Rd, Ahmedabad 380 054, Gujarat, India. Example: Chart/Booklet Anaemia Training Kit

Department of Health, Nutrition Unit, Room 501A, Skipton House, 80 London Rd, London SE1 6LW, UK Nutrition core curriculum for nutrition in the education of health professionals Free

Food & Agriculture Organization, Food Policy & Nutrition Division, 00100 Rome, Italy Fx +39 6 5225 3152. Example: Training pack Field programme management. Food & nutrition: population & nutrition 1988

Helen Keller International, 90 Washington St, New York NY 10006 USA Fx +1 212 943 1220. Examples:

Training guides Vitamin A training activities for community health & development 1993 $10, Ending hidden hunger 1993 $30

Cards Guidelines for prevention of blindness due to vitamin A deficiency 1988 $1 & poster $3, Health workers find, treat, prevent vitamin A deficiency 1988 $1, Know the signs & symptoms of xerophthalmia Undated $1

Brochures with slide strip or slides Vitamin A/Child Survival 1990 $6, Saving a child from xerophthalmia 1990 $4.50

ICCIDD Focal Point, Tulane University School of Public & Tropical Medicine, 1501 Canal St, Suite 1300, New Orleans, Louisiana 70112, USA. Sources of IDD materials ICCIDD Notes. Free

International Baby Food Action Network (IBFAN), c/o GIFA, Box 157, 1211 Geneva 19, Switzerland Fx +41 22 798 4443. Examples:

Information kit on breastfeeding Fighting for infant survival 1989 Free/Sfr5

Guide to code on marketing breastmilk substitutes Protecting infant health 1993 ed. Free/Sfr5

International Vitamin A Consultative Group, Nutrition Foundation, 1126 16th St NW, Washington DC 20036, USA Fx +1 202 659 3617. Example: Nutrition communications in vitamin A programs: resource book 1992?Free

London School of Hygiene & Tropical Medicine, Human Nutrition Unit, 2 Taviton St, London WC1H 0BT, UK Fx +44 171 383 5859. Prices UK/EU/other countries. Examples:

Manuals Statistical exercises in nutrition £10/$20/$25, Basic Nutrition £8/$ 16/$ 17, Assessment of nutritional status £12/$24/$30

Videos Techniques of anthropometric measurement, Interpretation of anthropometric measurements, Assessment of problems in the community £20/$40/$50 each

Liverpool School of Tropical Medicine, Liverpool Epidemiology Programme, School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK Fx +44 151 708 8733. Computer learning package Nutritional Surveillance Learning Module 1994 £25

Nurture, Center to Prevent Childhood Malnutrition, 3333 K St NW, Suite 101, Washington DC 20007, USA Fx +1 202 298 7988. Examples:

Leaflet First Foods 1992 Free
Slide sets on breastfeeding, birth spacing, child survival $25 each.

Task Force SIGHT & LIFE, Box 2116, 4002 Basel, Switzerland Fx +41 61 688 1910 (supported by Hoffmann-Roche). Example: Video The battle against nutritional blindness ?Free

Teaching Aids at Low Cost (TALC), Box 49, St Albans AL1 5TX, UK Fx +44 1727 846852. Examples:

Sets of 24 slides with text/tape. Iodine deficiency disorders 1995, Breastfeeding problems 1991, Protein Energy Deficiency - signs & causes 1990, Breastfeeding 1989, Anaemia - reporting blood films 1986 Weaning foods & energy 1985, Xerophthalmia 1985, £4.50-£16 + p&p

Flannelgraphs Nutrition & Child Health £21.50 +p&p

Sheets Child-to-child activity sheets 1990s £2 +p&p

Books Facts for life 1993 £2, Children for health 1993 £2, Communicating health 1993 £5.80, Helping mothers to breastfeed 1992 £2.50, Nutrition for developing countries 1992 £3.95, Protein energy malnutrition 1992 £5, Maternal & child health in practice 1988 £3.40, Teaching health care workers 1985 £5, Helping health workers learn 1982 £6, All + p&p

South Pacific Commission, Publications Section, BP D5, Noumea Cedex, New Caledonia Fx +687 263818. Prices for outside S. Pacific. Examples:

Colour posters Alcohol is dangerous, Atoll foods $5 each
Leaflets of South Pacific foods $2 each
Flipchart on baby’s health $ 10
Games Bingo, Snakes & Ladders $5-28
Videos First foods for my baby, Healthy food choices $20 each

University College, London, Department of Biochemistry & Molecular Biology, Gower St, London WC IE 6BT, UK; email [email protected]; Fx +44 181 907 9933. Computer programmes (IBM compatible PC) for nutrient analysis of 470 foods & activity diary/energy expenditure calculation £25 EU, £30 airmail outside EU

University of the South Pacific, Continuing Education, Box 1168, Suva, Fiji Fx +679 300 482. Nutrition community education books 1990 Family food supply, Preparation of Pacific Island foods; Food, drinks & life, Food, drinks & fitness, Food, drinks & non-infectious diseases, Food, drinks & infectious diseases, Preservation of Pacific Island foods, Food in schools, Assessing community food & nutrition needs, Food needs for family members, Teaching & learning, Making & using training materials Also available from SPC (see above). Approx $10 + p&p each.

UNICEF, Programme Publications, 3 UN Plaza, New York, NY 10017, USA Fx +1 212755 1449 or request free copies from your UNICEF Country Office. Examples:

Training guides: Breastfeeding management & promotion in a baby-friendly hospital - 18 hour course for maternity staff with 40 slides 1993 $40, Training guide to lactation management 1992 $20

Videos Hidden Hunger (micronutrient deficiencies) $20, The Silent Scourge (iodine deficiency). Feeding low birth-weight babies

Books Children for Health 1993 £2, Facts for life 1993 £1

Voluntary Health Association of India, Tong Swasthya Bhavan, 40 Institutional Area, South of IIT, New Delhi 110016, India Fx +91 11 6885377. Examples:

Flash cards Feeding your baby Rs20, Balanced diet for the family Rs25
Booklet Practical guide on supplementary feeding 1990 Rs5
Posters A sick child needs more nourishment Rs1.50
Kit Infant milkfood unsafe at any price Rs15

World Health Organization, Distribution & Sales, 1211 Geneva 27, Switzerland Fx +41 22 791 0746. Examples:

Manuals/Training guides Guidelines for training community health workers in nutrition 1986 $10/$14.40, Teaching for better learning: a guide to teachers of primary health care staff 1992 £17.50, Nutrition Learning Packages, 1989 $19/$27, Educational handbook for nutrition trainers, 1993 $35/$59

Leaflet Health workers Find, Treat, Prevent Vitamin A deficiency Free

World Health Organization, CDR, 1211 Geneva 27, Switzerland Breastfeeding counselling 5 day course includes training guides, participants’ manuals, checklists, overheads and slides. Limited supplies. Free to breastfeeding trainers in developing countries; $50 for pack with single copies of each item.