Science and technology willnever solve all of the problemsassociated with the inadequate

food and care and the lack of healthservices and sanitation that lead tochildhood malnutrition. But the suc-cesses stemming from breakthroughsbeing made and insights reached havestirred new hope for healthier, moreproductive lives for both children andadults. This section describes some ofthe crucial scientific advances that arehelping to shape specific interven-tions to reduce malnutrition or thatmay do so in the future.

Some of this knowledge, such asthe strengthening effect of vitamin Aon the immune system, is well estab-lished; other knowledge is just emerg-ing and is worth watching. Some ofthe new science is likely to accelerateefforts to reduce malnutrition, and atthe same time generate new under-standing of how reducing malnutritionin childhood or during the prenatalperiod may lessen chronic disease inadulthood and the onerous public healthburden it causes. There are also new

The ‘cure’ for immunedeficiency due tomalnutrition has beenknown for centuries:It is achieved by ensuringan adequate dietary intakecontaining all essentialnutrients.

71

Photo: Over a million pre-school-agechildren suffer from vitamin A deficiency,which affects immune-system functioning.Vitamin A supplementation is estimated tolower a child’s risk of dying by 23 per cent.In Bangladesh, a boy receives a vitamin Acapsule.

UNIC

EF/2

064/

Zam

an

Bringing science to bear

tools to tackle the essential task of nu-tritional assessment and new waysthat agricultural science can bebrought to bear on the problem.

Nutritionally acquiredimmune deficiency

It is estimated that the immune sys-tems of some 23 million peopleworldwide have been damaged byHIV.1 It is less well known that mal-nutrition impairs the immune systemsof at least 100 million young childrenand several million pregnant women,none of them infected by HIV. But un-like the situation with AIDS, the‘cure’ for immune deficiency due tomalnutrition has been known for cen-turies: It is achieved by ensuring anadequate dietary intake containing allessential nutrients. Today, more isbeing learned about the specific roleof individual nutrients in the function-ing of the immune system, knowledgethat will help in the design of inter-ventions that can improve the situationin the near future. This knowledgealso reinforces the importance of striv-ing to ensure that everyone in theworld has access to a diet that is ade-quate in both quality as well as quantity.

Scientists have known for sometime that malnutrition and infectionare connected. A 1968 monograph byWHO, entitled ‘Interactions of Nutri-

tion and Infection’, was one of the firstcomprehensive statements of some ofthese links.

The threat that vitamin A defi-ciency poses to the lives of youngchildren has already been described.Within a few years, the scientific com-munity went from calling the fact thatvitamin A supplements could reducechild mortality “too good to be true”to calling it “too good not to be true.”But the many ways vitamin A defi-ciency increases child deaths were notwell understood until recently. Nowthe results of a dozen field studies,conducted in Brazil, Ghana, India,Indonesia, Nepal and elsewhere, indi-cate that supplementing the diets ofchildren who are at risk of vitamin Adeficiency can reduce deaths fromdiarrhoea. Four of the studies that fo-cused on diarrhoea showed that deathswere reduced by 35-50 per cent. Thevitamin can also halve the number ofdeaths due to measles2 (Fig. 11).

In Bangladesh, breastfed infantswhose mothers were given a single oralhigh-dose supplement of vitamin Ashortly after giving birth had signifi-cantly fewer days of sickness becauseof respiratory infections and febrileillnesses during the first six months oflife than did infants born to unsupple-mented mothers from the same socio-economic group in the same area.3

Zinc is another micronutrient thathas long been known to be essentialfor the growth and development ofcells and for the functioning of theimmune system. However, becausezinc deficiency is extremely difficultto measure, little attention was paiduntil recently to the possibility that itmight impair child health and devel-opment (Fig. 12).

Trials in Bangladesh, India andIndonesia have already shown reduc-tions of about one third in the durationand severity of diarrhoea in childrenreceiving zinc supplements and a

median 12 per cent decline in the inci-dence of pneumonia.4 In these investi-gations, zinc supplements did themost good for those children whostarted out the most malnourished.

A study recently completed inLima (Peru) found that the benefits ofzinc supplementation on immunitycan begin even before birth. Re-searchers from the Johns HopkinsSchool of Public Health in Baltimore(US) and the Instituto de Investi-gación Nutricional in Lima have beenadding zinc to the iron and folatesupplements of pregnant women andtesting its impact on the health of theirnewborn children, including its effectson immune system activity. Initialanalysis shows that antibody levelsjust after birth are higher in the chil-dren of zinc-supplemented mothersthan in those receiving a placebo.

Zinc supplementation appears soeffective in reducing the incidence ofdiarrhoea and pneumonia in poorcountries that one scientist, RobertBlack of Johns Hopkins University,has suggested that zinc supplementsare as significant a public health inter-vention for diarrhoea reduction as im-provements in water and sanitation.And major new research indicates thateven the effects of malaria, a deadlyenemy of both children and adults, maybe lessened by zinc and vitamin A(Panel 18).

Iron deficiency can also damagethe immunity of a growing child,impairing the body’s ability to killinvading pathogens and leading toincreased illness in iron-deficientpopulations.5 In studies in Egypt,anaemic children had longer andmore severe episodes of diarrhoeathan did their iron-fortified peers.

Basic science is now able to ex-plain why these astonishing resultsoccur. Thus far, zinc and vitamin Aare the two micronutrients that haveproved to be the most closely linked

72

Fig. 11 Measles deaths and vitamin A supplementation

In three separate trials of children hospitalized with measles — one as early as 1932 — deaths among children given high-dose vitamin A supplements were significantly lower than among children not supplemented. The consistent results suggest that a change in vitamin A status can rapidly alter basic physiological functions concerned with cellular repair and resistance to infection, thereby saving lives.

16

14

12

10

8

6

4

2

01932 1987 1990United Kingdom Tanzania South Africa

Non-supplementedSupplemented

Source: Alfred Sommer and Keith P. West Jr., Vitamin A Deficiency: Health, survival and vision, Oxford University Press, New York, 1996.

Cas

e fa

talit

y ra

te (%

)

with the proper functioning of thebody’s front-line defences. These twomicronutrients help maintain thephysical barriers of skin and mucosathat prevent micro-organisms frominvading the body, as well as enhanc-ing the activity of leukocytes such asNK (natural killer) cells and macro-phages — scavenger cells that engulf,then destroy, foreign pathogens suchas bacteria throughout the body.

Equally important, low dietaryconsumption of zinc and vitamin Areduces the number and impairs thedevelopment and function of twotypes of B-cells — key players in‘acquired immunity’. These produceantibodies and T-cells that, in turn,are responsible for eliminating virus-infected host cells. They also producebiochemicals known as cytokines,which further promote B-cell andmacrophage activity. At the sametime, an adequate intake of zinc isnow understood to be necessary inorder for both vitamin A and iodine todo many of their vital jobs.

Nutrition and AIDS

The role of nutrition in preventing in-fection is now being investigated asone possible way to help reduce thetransmission of AIDS. Vitamin A mayform part of the arsenal needed tocombat HIV, which is expected to in-fect between 4 million and 5 millionchildren by early in the next century,most of them in sub-Saharan Africa.These children will mainly be in-fected by their mothers.

The routes of mother-to-childtransmission of HIV, also known asvertical transmission, are threefold:during pregnancy, during labour anddelivery, and through breastfeeding.

Scientists have been exploring thepossibility of reducing vertical trans-mission in all three routes since 1994.They have tried to block intrauterine

transmission by giving women dosesof the antiretroviral drug Zidovudineduring pregnancy. The drug has beenshown to reduce mother-to-child trans-mission of HIV — but at hundreds ofdollars per course, it is prohibitivelyexpensive for most people in the devel-oping world. Less expensive methodsof antiretroviral therapy during preg-nancy, such as administering Zido-vudine for shorter periods or usingcheaper drugs, are now being tested inHaiti, sub-Saharan Africa and South-East Asia.

Two other treatments during preg-nancy are also under investigation.These involve either intravenous therapywith purified anti-HIV antibodies, orsupplementation with vitamin A. In a1994 study of HIV-infected women inMalawi, it was found that 32 per centof those who were vitamin A deficientduring pregnancy had passed HIV onto their infants. In contrast, only 7 percent of HIV-infected women with suf-ficient levels of vitamin A did so. Thestudy concluded that vitamin A-deficient women were thus four and ahalf times more likely to infect theirchildren.6

Also, a 1995 study from Kenyareported that the concentration of HIVin breastmilk is higher in vitamin A-deficient mothers than in those withgood vitamin A status. Another study,also from Kenya, has shown that HIV-positive women who are also vitaminA deficient were five times morelikely than non-vitamin A-deficientwomen to shed HIV-infected cells intheir reproductive tracts, a factor thatmay be an important determinant ofboth sexual and vertical transmissionof AIDS. However, some experts havesuggested that these results may havecome about not because of the influ-ence of vitamin A on HIV transmis-sion, but because poor vitamin Astatus and high rates of infectionoccur together for other reasons.

73

0.3

0.2

0.1

0

(0.1)0 2 4 6 8 10 12 14 16

PlaceboZinc

Chan

ge in

hei

ght-f

or-a

ge Z

-sco

re

Months of study

Note: The height-for-age Z-scores in the chart refer to the number of standard deviations below or above the median height for healthy children in the same age group.

Source: H. Dirren et al., ‘Zinc supplementation and child growth in Ecuador’, in Nutrient Regulation during Pregnancy, Lactation and Infant Growth, Plenum Press, New York, 1994.

Fig. 12 Zinc supplementation and child growth (Ecuador, 1986)

Zinc’s importance in ensuring normal growth and development is underlined in a 1986 study of Ecuadorian pre-schoolers with low zinc intake. The children were paired by sex, age and height; one in each pair was given a zinc supplement, the other a placebo. The results over 15 months showed a slow, steady gain in the supplemented children's height as compared with the non-supplemented group.

Panel 18

74

Early evidence from a study inPapua New Guinea suggeststhat zinc and vitamin A sup-

plements may boost children’s resis-tance to one of the world’s mostinsidious infectious diseases: malaria.

Two fifths of the world’s popula-tion, in 90 countries across sub-Saharan Africa, Asia and Central andSouth America, is at risk of contract-ing malaria. At least 300 million peo-ple worldwide endure its recurrentfevers, malaise, anaemia and risk ofseizures or coma. Malaria kills from1.5 million to 2.7 million people an-nually. It is the sixth leading cause ofdisability among children under fouryears of age in the developing world.Some 600,000 young children die ofmalaria alone each year; over 1 mil-lion die of malaria in conjunctionwith other illnesses — a rate of onechild every 30 seconds.

Many approaches have alreadybeen tried to combat the disease.However, the parasite that causesmalaria is no longer vulnerable to

some of the most powerful anti-malarial compounds available. For atime, the widespread use of pesti-cides in the 1950s managed to sup-press the Anopheles mosquito thattransmits the parasite, but it, too, hasdeveloped resistance.

Arming the body to defend itselfthrough immunization is one ap-proach to preventing the disease.But vaccines are difficult to developsince the parasite moves betweenorgans, changing its appearancefrom stage to stage and hiding fromthe immune system in a place thatthe immune system doesn’t check:inside red blood cells. Consequently,the best vaccines to date have man-aged to protect only around 30 percent of test populations from infection.

However, naturally acquired resis-tance does develop over time as peo-ple are repeatedly exposed to theparasite. A recent study by the JohnsHopkins School of Public Health andthe Papua New Guinea Institute ofMedical Research investigated the

ability of vitamin A and zinc to helpboost such natural resistance.

Nearly 800 children under the ageof five were enrolled in the study. Allof the children lived in an area ofnorth-western Papua New Guineawhere malarial infection is common.The parasite that is responsible forthe disease can be found in the bloodof over 40 per cent of under-fives inthe region, and it is the major causeof death among children from theage of six months to four years.

In controlled trials, regular vita-min A and zinc supplementation ap-peared to be complementary indecreasing the burden of malaria inchildren. According to Dr. AnurajShankar of Johns Hopkins Univer-sity, chief researcher of the study,vitamin A reduced by more than athird the febrile illnesses due to mildto moderately high levels of malariaparasites in children and significantlyreduced spleen swelling, an indicatorof chronic malaria. However, it hadlittle influence on the worst cases,where children had a very high num-ber of parasites in their blood.

Zinc, on the other hand, helpedblunt the severity of the worst cases.As a result, there were over a thirdfewer malaria cases seen at healthcentres among those given zinc thanamong those given a placebo. In addi-tion, overall clinic visits by those chil-dren who had received zinc decreasedby a third, and signs of other infec-tions (cough and diarrhoea, for exam-ple) were reduced by 20–50 per cent.

The Papua New Guinea experi-ence shows that vitamin A and zincstatus in children may be as im-portant in reducing malaria as othercommonly used malaria-control tech-niques, such as insecticide sprayingand the use of insecticide-treatedbed nets. And the cost is minimal:

Zinc and vitamin A: Taking the sting out of malaria

UNIC

EF/9

7-05

58/C

laus

en

75

Photo: Women and their children waitoutside a UNICEF-assisted health centrein the Peruvian Amazon, where malaria isa major health concern.

A year’s supply of zinc supple-ments costs $1 per child, with anadditional 10 cents for vitamin Acapsules.

A second study is under way inthe Peruvian Amazon to measurethe effectiveness of vitamin A andzinc in boosting the efficacy ofantimalarial drugs. Peruvian sci-entists at the Loreto Departmentof Health and colleagues fromJohns Hopkins are studying morethan 1,000 children who are suf-fering from malaria to see if a short,five-day course of zinc or vitaminA in conjunction with antimalarialdrugs improves their health. Somechildren are receiving both themicronutrients, in the hope thatthe zinc-vitamin A combinationwill be more effective, as zinc isknown to promote vitamin A me-tabolism in the body.

Despite the surge of interna-tional interest in malaria fromboth the public sector and privateindustry and the promise that vit-amin A and zinc may hold, fund-ing for research into diseaseprevention and treatment unfortu-nately remains meagre. Currently,funding levels run at roughly $42per malaria death, compared with$3,274 for each AIDS fatality.

Based on the findings of the firststudies — and to demonstrate whetherthe connection between vitamin A andHIV transmission is causal — fourclinical trials were begun recently toexamine HIV transmission rates inwomen who have received vitamin Asupplements during the second or thirdtrimester of pregnancy. Results fromthese studies, conducted in Malawi,South Africa, Tanzania and Zimbabweon a total of nearly 3,000 HIV-infectedwomen, are expected soon.

Using nutrition toreduce maternaldeathsMaternal mortality is a tragedy insocial, economic and public healthterms. WHO and UNICEF have notedthat of the 585,000 yearly maternaldeaths around the world, the vast ma-jority are preventable. About 80 per centof these deaths are the result of fivedirect obstetric causes: haemorrhage,infection, obstructed labour, unsafeabortion and a convulsive disorder inlate pregnancy called eclampsia.7

As already noted, obstructedlabour is more likely to occur amongwomen who were stunted in child-hood (Fig. 13). It is estimated thatanaemia may be responsible for asmuch as 20 per cent of maternal mor-tality, particularly those deaths fromhaemorrhage and possibly infection.Anaemia also increases the risk ofmorbidity and mortality associatedwith any major surgical intervention,including Caesarean section.

Programmes already exist toreduce anaemia in pregnant women.More work is needed, however, notonly to make iron/folate supplementa-tion programmes more effective, butalso to improve the treatment and pre-vention of malaria and hookworm.Both of these are conditions that alsocontribute to maternal anaemia.

125 135 145 155 165 175 185

100

80

60

40

20

0Inci

denc

e of

intra

partu

m C

aesa

rean

del

iver

y (%

)

Maternal height (cm)

Fig. 13 Maternal height and Caesarean delivery (Guatemala, 1984-1986)

The importance of good nutrition for girls and women is affirmed in a mid-1980s' study of pregnant Guatemalan women, which found that the risk of having an intrapartum Caesarean delivery was 2.5 times higher in short mothers than in tall mothers. Short stature in women is often a consequence of poor growth in early childhood.

Source: Kathleen M. Merchant and José Villar, ‘How do maternal and newborn size affect risk of foetal distressand intrapartum Caesarean delivery?’ (draft).

With foetal distress

Without foetal distress

Even if an adequate nutritional sta-tus were achieved in adolescent girlsand women before their first preg-nancy, this would never eliminate theneed for good medical care in preg-nancy and childbirth. But some day itmay help reduce the tragic burden ofmaternal mortality and the need forcertain medical interventions. Someof the connections between nutritionand maternal mortality suggestedbelow are not yet definitively demon-strated or part of programme activi-ties, but they hold great promise forthe future. A few are especially worthmentioning:t Even given the many known bene-fits of good vitamin A status, it isnonetheless remarkable to find thatimproving the vitamin A status ofpregnant women whose intake of thevitamin is low also dramatically re-duces maternal mortality (Panel 1).Deadly infections in pregnancy, as inchildhood, find a formidable adver-sary in vitamin A. The use of low-cost, low-dose vitamin A capsules aswell as improvements in diet make ithighly probable that this new re-search will be easily incorporated intoprogrammes.t Zinc deficiency, increasingly rec-ognized as widespread among womenin developing countries, is associatedwith long labour, which increases therisk of death. Severe zinc deficiencyis also believed to impair foetal devel-opment in a number of ways. Zinc isimportant for the synthesis of hor-mones and enzymes essential tochildbirth — especially estrogen-dependent functions such as expulsionof the placenta and proper contractionof uterine muscles during birth — aswell as for immune-system develop-ment. A number of studies around theworld have found that zinc supple-mentation has reduced complicationsof pregnancy. Several studies areunder way that will soon help define

the impact of improved zinc status onpregnant women.t It has long been known that iodinedeficiency in women increases therisk of stillbirths and miscarriages.And there is evidence that, in highlyiodine-deficient areas, another resultof this deficiency may be increasedmaternal mortality through severehypothyroidism.t A recent study in the United Statesshowed that calcium supplementationdid not reduce the risk of hyperten-sion in pregnancy that could result indeath, but a number of experts havesuggested that supplementation mightreduce this risk in areas where womenare especially calcium deficient.t Folate deficiency, now well knownto induce neural-tube birth defects ifit is present during the first month ofpregnancy, may also represent a riskfor maternal morbidity and mortality,as well as increase the risk of lowbirthweight.

The clear message emerging fromthese connections is that improvingwomen’s nutritional status — by in-creasing their intake of micronutrientsas well as their overall food consump-tion, and by taking steps to reducetheir workload and improve theiraccess to health care — may offerconsiderable, low-cost benefits in re-ducing maternal deaths. But there isstill no international consensus on thebenefits to be gained by supplementa-tion during pregnancy with nutrientsother than iron and folate.

The real challenge is to reachwomen well before they becomepregnant — indeed, to help adoles-cent girls achieve the best nutritionalstatus possible before they enter theirreproductive years. This would notonly help reduce maternal mortalitybut would also reduce the prevalenceof low birthweight, the risk of birthdefects and the rates of stillbirths andearly infant mortality. All of these re-

Impact of deficiency

Vitamin A deficiency makes children es-pecially vulnerable to infection and wors-ens the course of many infections.Supplementation with vitamin A is esti-mated to lower a child’s risk of dying byapproximately 23 per cent. The deficiencyis also the single most important cause ofblindness among children in developingcountries.

Who is affected

Over 100 million pre-school-age childrensuffer from vitamin A deficiency. VitaminA deficiency is also likely to be wide-spread among women in their reproduc-tive years in many countries.

What vitamin A does

Vitamin A, stored normally in the liver, iscrucial for effective immune-system func-tioning, protecting the integrity of epithe-lial cells lining the skin, the surface of theeyes, the inside of the mouth and thealimentary and respiratory tracts. Whenthis defence breaks down in a vitamin A-deficient child, the child is more likely todevelop infections, and the severity of aninfection is likely to be greater.

Depending on the degree of the defi-ciency, a range of abnormalities also ap-pears in the eyes of vitamin A-deficientchildren. In the mildest form, night-blindness occurs because the rods in theeye no longer produce rhodopsin, a pig-ment essential for seeing in the dark. Inmore severe forms, lesions occur on theconjunctiva and the cornea that if leftuntreated can cause irreversible damage,including partial or total blindness.

Sources

Vitamin A is found as retinol in breastmilk,liver, eggs, butter and whole cow’s milk.Carotene, a precursor of vitamin A that isconverted to retinol in the abdominalwalls, is found in green leafy vegetables,orange and yellow fruits, and red palm oil.

Spotlight: Vitamin A

76

main scientific and programmaticchallenges, along with the imperativeof ensuring that women’s health ispositioned high on the health anddevelopment agendas of all countries.

Breastfeeding:Good for mothers’health tooIn addition to the nutritional status ofadolescent girls and women, there isanother important connection betweennutrition and maternal mortality. Anumber of studies have shown a stronglink between the early initiation ofbreastfeeding and reduced risk ofpostpartum haemorrhage.

Initiating breastfeeding immedi-ately following birth, as most womendo in baby-friendly hospitals, stimu-lates the contraction of the uterus andreduces blood loss. For this reason,the continuing spread of the Baby-Friendly Hospital Initiative shouldalso contribute to the reduction ofmaternal mortality.

In recent years, research has alsodemonstrated that this immediatepost-partum benefit is by no meansthe only way in which breastfeedingcan improve women’s health. A re-cent large-sample study in the UnitedStates demonstrated that women whobreastfed their children had a lowerrisk of breast cancer in the pre-menopausal period, and the longerthey breastfed, the lower the risk.8

These results show that protecting,promoting and supporting breastfeed-ing has benefits for women that go be-yond the remarkable effects, alreadywell understood, that protect theirchildren from illness and death.

Prevention of chronicdiseases

Chronic degenerative diseases arelargely regarded as diseases of afflu-

ence. In industrialized countries, im-provements in living standards andhealth care have led to increased lifeexpectancy, allowing people to livelong enough to develop such chronicillnesses. Chronic diseases are alsoassociated with the sedentary lifestyleand over-abundant diet prevalent inmany industrialized nations.

Arguments are being made, how-ever, that these chronic diseases inlarge measure may also be diseases ofpoverty — particularly poverty earlyin life and during foetal development.The hypothesis is particularly intrigu-ing in light of the fact that ischaemicheart disease is projected to be theworld’s leading cause of death anddisability in the year 2020.9

Professor David Barker and hiscolleagues at the Medical ResearchCouncil (MRC) Environmental Epi-demiology Unit in Southampton (UK),first raised the “foetal origins of adultdisease” hypothesis over a decade ago,noting a link between low birthweightand the incidence of cardiovasculardisease among middle-aged men andwomen born in the United Kingdom.10

Since then, over 30 studies aroundthe world have indicated that low-birthweight babies who were not bornprematurely have a higher incidenceof hypertension later in life than thosewith a normal birthweight,11 indepen-dent of their social class and suchadult risk factors as smoking, drink-ing and overeating.

Low birthweight, as well as thin-ness at birth, has also been correlatedwith glucose intolerance in childhood12

and non-insulin dependent diabetes inlater life.13

Professor Barker and his colleaguesspeculate that maternal dietary imbal-ances at critical periods of devel-opment in the womb can trigger aredistribution of foetal resources, af-fecting a foetus’s structure and metab-olism in ways that predispose the

Impact of deficiency

Zinc deficiency in malnourished childrencontributes to growth failure and suscep-tibility to infections. Zinc deficiency isalso thought to be associated withcomplications of childbirth.

Who is affected

Data on the prevalence of zinc deficiencyare unavailable, as there is no reliablemethod of determining zinc status at thepopulation level. Zinc deficiency is likelyto be a public health problem, however,in areas where overall malnutrition isprevalent; it is now recognized as suchin many countries.

What zinc does

Zinc promotes normal growth anddevelopment. It forms part of themolecular structure of 80 or more knownenzymes that work with red blood cellsto move carbon dioxide from tissues tolungs. Zinc also helps maintain an effec-tive immune system. Severe zinc defi-ciency causes growth retardation,diarrhoea, skin lesions, loss of appetite,hair loss and, in boys, slow sexualdevelopment. Zinc has now beenshown to have a therapeutic effecton diarrhoea cases.

Sources

Breastmilk has small amounts of zincthat are readily absorbed. Other sourcesinclude whole-grain cereals, legumes,meat, chicken and fish. Vegetables andfruits contain little zinc but when eatenwith cereals may increase the bio-availability of zinc in cereals.

Spotlight: Zinc

77

78

individual to later cardiovascular andendocrine diseases. The correlationbetween low birthweight and latercardiovascular disease and diabetesmay arise from the fact that nutri-tional deprivation in utero ‘pro-grammes’ a newborn for a life ofscarcity. The problems arise when thechild’s system is later confronted by aworld of plenty.14

In central India, an ambitious studyhas been funded by UK Welhome Trustand coordinated by Dr. Ranjan Yajnikat the King Edward Memorial Hos-pital Research Centre in Pune (India)and Dr. Caroline Fall at the MRCEnvironmental Epidemiology Unit. Itis exploring the impact that a mother’snutrition may have on the develop-ment of diabetes, high blood pressureand coronary heart disease in her off-spring when they reach adulthood.The results could resolve some of theuncertainties about causation of chronicillness, offering nutritional informa-tion relevant to both developing andindustrialized countries.

The study has followed over 800women through pregnancy, monitor-ing foetal growth, maternal weightgain and biochemical indicators of nu-tritional status.15 The nutritional valueof the women’s daily food intake —including calorie, protein and micro-nutrient content — was measured andrecorded. Within 24 hours of birth,both infant and placenta were weighedand other body measurements made.16

Almost one third of the nearly 800 in-fants born during the study were clas-sified as low birthweight, under 2.5 kg.17

An interesting early finding suggeststhat birthweights are most strongly as-sociated with the size of the mother —not just her weight gain during preg-nancy, a well-known determinant ofnewborn size, but also her weight,height, percentage of body fat andhead circumference before conception.The weight and body mass index of

many of the women before pregnancysuggested chronic undernutrition. Thestudy also suggested that women’sdiet during pregnancy did not appearto have influenced foetal size substan-tially, although regular consumptionof two particular items — green leafyvegetables and dairy products — wasassociated with larger birth size. Theseearly findings lend support to thepremise that building a sturdy babydepends on good nutrition for the ex-pectant mother throughout her life.

The children from the Pune studyare growing up in a society of increas-ing urbanization and prosperity. Urbandwellers in India are already fivetimes more likely to develop diabetesthan their rural relatives,18 and thosewho have migrated to industrializedcountries like the United Kingdom diein significantly larger numbers fromcoronary heart disease than theirindigenous white counterparts.19

In 1999, the first of the children inthe study will be tested for signs ofglucose intolerance and insulin resis-tance; these are early hints of diabetesthat have already been noted in chil-dren of low birthweight in Pune.20

Soon after, blood pressure monitoringwill begin in an effort to look for ini-tial signs of hypertension. As thestudy progresses, findings can be re-lated back to birth size, foetal growthand maternal diet before and duringpregnancy. From an undertaking of thismagnitude, clear evidence may emergeabout the importance of improvingmaternal nutrition as a means of pre-venting chronic later-life disease inchildren — before these children havechildren of their own.

New ways to reducemalnutrition deathsin emergenciesThe sheer extent of mild and moderatemalnutrition makes these conditions

Impact of deficiency

Iron deficiency anaemia, the most commonnutritional disorder in the world, impairsimmunity and reduces the physical andmental capacities of populations. In infantsand young children, even mild anaemiacan impair intellectual development.Anaemia in pregnancy is an importantcause of maternal mortality, increasingthe risk of haemorrhage and sepsisduring childbirth. Infants born to anaemicmothers often suffer from low birthweightand anaemia themselves. Causes includeblood loss associated with menstruationand parasitic infections such as hookworm,but an inadequate intake of iron is themain cause.

Who is affected

Nearly 2 billion people are estimated tobe anaemic and even more are irondeficient, the vast majority of them women.Between 40 and 50 per cent of childrenunder five in developing countries —and over 50 per cent of pregnantwomen — are iron deficient.

What iron does

The body needs iron to produce haemo-globin, the protein in red blood cells re-sponsible for carrying oxygen. Iron is alsoa component of the many enzymes essen-tial for the adequate functioning of brain,muscle and the immune-system cells.

A certain amount of iron is stored inthe liver, spleen and bone marrow. Irondeficiency develops as these stores aredepleted and there is insufficient ironabsorption. In anaemia, the iron deficiencyis so severe that the production ofhaemoglobin is significantly reduced.The main symptoms and signs are pale-ness of the tongue and inside the lips,tiredness and breathlessness. Deficienciesof folic acid, vitamin A, ascorbic acid,riboflavin and various minerals can alsocontribute to anaemia.

Sources

Iron is found in liver, lean meats, eggs,whole-grain breads and molasses.

Spotlight: Iron

79

among certain severely malnourishedchildren. The revised ORS reducesthat risk. Known as ReSoMal (rehy-dration solution for malnutrition), itcontains more potassium and differ-ent concentrations of elements fromthose in standard ORS.

The new protocol for the care ofthe severely malnourished also em-phasizes elements that have beenknown by nutrition workers for sometime, but perhaps not well enough tobe integrated into regular practice.These include the need for rapid at-tention to clinical factors, such as lowbody temperature (hypothermia) andlow body sugar (hypoglycaemia), aswell as to less strictly medical factorssuch as meeting malnourished chil-dren’s great needs for emotional sup-port, intellectual stimulation and play.Experienced emergency nutrition per-sonnel working in places such as theGreat Lakes region of Central Africaand the Democratic People’s Republicof Korea have adopted this methodand noted how quickly it helps reducemortality. One challenge is to ensurethat supplies of the appropriate high-energy milk and rehydration solutionare steady and sufficient (Panel 19).

New ways to measuremalnutrition

Much of the new knowledge de-scribed above will contribute to effec-tive actions to reduce malnutritionand related conditions. But even whenactions are effective, assessing theirimpact is often difficult. Measuringmalnutrition initially can also poseproblems — and make it difficult toplace the issue on the policy and pro-gramme agenda.

There is thus a need for assessmentand analysis techniques that are lowin cost, produce rapid results and areeasy to use and understand. Here aresome of the promising new tools:

responsible for much more sicknessand death globally than does severemalnutrition. But a severely malnour-ished child — usually defined as under70 per cent of the median weight-for-height reference or having oedema(water retention and swelling) at leastin the feet — is at very high risk ofdeath, and requires prompt and inten-sive care in a health facility.

Until recently, health professionalsdealing with severe malnutrition inemergency situations or in large hos-pitals in poor countries had beenusing an approach practised for years.The protocol was to treat infectiousconditions, correct rehydration andfeed, at least in the early stages, withhigh-energy milk — usually a com-bination of dried skim milk, veg-etable oil and sugar. In the last fewyears, however, with the help ofWHO and the benefit of the experi-ence of a number of NGOs specializ-ing in this field, the new protocol isimproving the treatment of severemalnutrition.

While the new protocol retainssome elements of former standardpractices, there are significant changes.The milk now recommended for theearly stages of therapeutic feeding,for example, is enhanced by the addi-tion of both oil and a vitamin andmineral mix, which addresses thespecial micronutrient imbalance thataccompanies severe malnutrition.Called F-100 because it gives 100kilocalories per 100 grammes, themilk optimizes the chance for rapidweight gain and the eventual recoveryof a severely malnourished child.

Another important change is a newrecommendation calling for modifica-tion of the standard oral rehydrationsalts (ORS) to address the specialelectrolyte needs of severely malnour-ished children. The use of standardORS has been known to increase riskof heart failure and sudden death

Impact of deficiency

Iodine deficiency is the single mostimportant cause of preventable braindamage and mental retardation, most ofthe damage occurring before birth. It alsosignificantly raises the risk of stillbirthand miscarriage for pregnant women.

Who is affected

The successful global campaign to iodizeall edible salt is reducing the risk associ-ated with this deficiency, which threat-ened 1.6 billion people as recently as1992. Nevertheless, it is estimated that43 million people worldwide are sufferingfrom varying degrees of brain damage;there are an estimated 11 million overtcretins. Some 760 million people havegoitres.

What iodine does

Iodine is needed by the thyroid gland fornormal mental and physical development.Most commonly and visibly associatedwith goitre (a swelling of the neck as theenlarged thyroid works to collect iodinefrom the blood), iodine deficiency takes agraver toll in impaired mental acuity.Persons suffering from IDD face a rangeof serious impairments including cretinism,spastic diplegia (a spastic paralysis of thelower limbs) and dwarfism. Less severedeficiencies in both adults and childrencan mean the loss of 10 to 15 intelligencequotient (IQ) points, as well as impairedphysical coordination and lethargy.

Sources

Iodized salt is the best source of iodine.Sea fish and some seaweed also containiodine, although sea salt does not.

Spotlight: Iodine

Panel 19

80

When refugees stream into acountry, when families losetheir homes, fields and

crops in war or disaster, when chil-dren cry from hunger, it is not sur-prising that food can seem like theonly priority and the only answer toaverting widespread malnutrition.

But in emergencies as well as inother situations, food, health andcare are all crucial to saving lives.Access to basic health services andwater and sanitation facilities is es-sential in emergencies not only tokeep children alive, but also to pro-tect their growth and development.To prevent outbreaks of measles,mass immunization usually alongwith the distribution of vitamin Asupplements has become standardpractice in emergencies. In Haiti, forexample, a measles vaccination cam-paign in 1994-1995 reached almost 3million children, helping end an epi-demic that began when the countrywas in the midst of civil unrest.

Preventing death and malnutri-tion from cholera and other diar-rhoeal diseases — through adequatesanitation, access to safe water andoral rehydration therapy — savedthousands of children’s lives in therecent emergencies in Rwanda andSomalia. This is standard practice inthe current emergency in Burundi,for example.

Breastfeeding is an important ele-ment of nutrition-related ‘care’ inemergencies. There has been markedprogress in this area as governmentsand agencies become increasinglysensitive to supporting women’s abil-ity to breastfeed. Workers with someNGOs that specialize in preventingmalnutrition in times of crisis havehad success in recent years in pro-moting relactation — helping womenwho may have been separated fromtheir children to begin breastfeedingagain after having stopped.

Sometimes infant formula mustbe used in emergencies — for in-

stance, when young children havebeen separated from their mothers.In these cases, all UN agencies work-ing in emergencies and many NGOshave committed to supplying onlygenerically labelled (no brand name)formula, to prevent commercial ex-ploitation of emergency situations.During the conflict in Bosnia andHerzegovina, UNICEF and other UNagencies jointly urged that infant for-mula distribution be severely limited,and relief organizations subsequentlyended mass distribution programmesin January 1995. UNICEF and WHOstrongly promoted breastfeeding,targeting health workers and joiningwith local health professionals dur-ing and after the war to develop a na-tional policy on infant feeding.

Children ages 6 to 18 months,pregnant women and women whoare breastfeeding all need energy-dense, nutrient-dense foods. In emer-gencies, the approach to meetingthese special needs varies. Agenciesthat are part of the International Fed-eration of Red Cross and Red Cres-cent Societies, for example, try toprovide a family ration to meet every-one’s requirements, including thoseof children and pregnant and breast-feeding women. The World Food Pro-gramme and some other agenciesgenerally distribute a ration that meetsminimum needs and, in addition, theycover vulnerable groups with supple-mentary feeding programmes. Thecomparative benefits of the two ap-proaches need to be evaluated.

Triple A — assessment, analysisand action — is an essential approachin emergencies as well as in other sit-uations. Monitoring children’s nutri-tional status, with weight-for-heighta commonly used indicator, is crucialduring emergencies to help target re-sources and reach the most affected.

Protecting nutrition in crises

UNIC

EF/9

4-02

77/P

ress

81

t A simplified way to look for vitaminA: Population-level surveys of vitaminA status have been a particular chal-lenge. In the past, when it was thoughtthat the main impact of vitamin A defi-ciency was damaged eyes and blind-ness, population surveys of vitamin Astatus involved examining children’seyes for early signs of damage. Nowthat it is understood that this deficiencyhas lethal consequences on a subclinicallevel — that is, at levels of deficiencythat do not yet show up as damage tothe eye — more sensitive methods ofdetecting its presence are needed.

Most of the national or regional vi-tamin A surveys that have been con-ducted in recent years have usedblood retinol as the principal indicatorof vitamin A status. There are somedifficulties with the interpretation ofthis indicator, and it is expensive anddifficult to collect and analyse thevenous blood samples needed forthese surveys.

A new technique that promises tobe easier, cheaper and less invasive is‘dark adaptometry’. This method,which has been tested and found ef-fective in several field situations,21

takes advantage of the fact that in veryearly stages of vitamin A deficiencythe ability of the pupil of the eye toconstrict under illumination is im-paired. By flashing a simple hand-held light at one pupil and coveringthe other, the degree of impairment ofthe pupillary reflex can be estimated.It is hoped that this simple method,which is non-invasive, will becomewidely available soon.

t ‘Dipsticks’ for iodine deficiency:Iodine deficiency disorders (IDD) canbe assessed in populations by palpat-ing goitres, but this method requires ahigh level of training and is less use-ful as goitres begin to disappear withbetter access to iodized salt.

Photo: Health workers vaccinate twogirls at a camp for unaccompaniedRwandan refugee children in theDemocratic Republic of the Congo.

Early warning systems andemergency preparedness are cost-effective means to prevent mal-nutrition in emergencies. TheUnited Nations Department ofHumanitarian Affairs’ early warn-ing system draws on the work ofsimilar systems within and out-side the United Nations in prepar-ing comprehensive assessmentsof potential emergency situations,and UNHCR and other agencieshave set up rapid deploymentmechanisms for emergencies.Nonetheless, early warning sys-tems and emergency planningand preparedness remain sadlyunderfinanced, a shortfall that en-dangers children in particular whencrises loom.

Since iodine excreted in the urineis a good indicator of iodine con-sumed, IDD can be reliably detectedby analysing urine samples. Manycountries have undertaken urinary io-dine surveys, which involve collectingsamples, preserving them carefullyand sending them to a laboratory foranalysis in a central location.

A new technique may eliminatesome of those steps and much of thecost. A reagent-treated testing strip or‘dipstick’ now being developed willsimplify the procedure by allowingthe iodine content of urine to beanalysed and read directly on the spotwithout transporting samples to a lab-oratory. It is hoped that this tool willsoon be available for field surveys.

t Improved test kits for iodized salt:Simple iodized salt test kits havehelped make salt-testing a communityaffair. Anyone can use the small plas-tic bottles of test solution that causesalt to turn blue if it is iodized, andsome countries have distributed thesekits to schoolchildren, teachers andcommunity workers. The test kits,however, have a limited shelf life, andthey do not distinguish very sensi-tively among levels of salt iodization.Work is now under way to improve thetest kit in both these respects and makeit an even more useful assessment tool.

t Computerizing anaemia surveys:Thanks to computer chips, assess-ment of anaemia at the populationlevel is becoming easier. There havebeen methods for some time to assessperipheral blood (from a fingertip, forexample) without sending the sam-ples to a laboratory, but some of themare slow and inaccurate.

Portable electronic haemoglobi-nometers are now available, however,that enable blood to be drawn easilyfrom a finger into a small cuvette thatis inserted directly into a machine that

gives a digital read-out of the precisehaemoglobin level in a few seconds.The wider use of these machines inpopulation surveys will help to raiseawareness of the enormous magni-tude of the anaemia problem.

New ways toenrich diets

There are many ways to enhancefoods to improve the content of the vi-tamins and minerals that are so impor-tant for the well-being of children andtheir families. Food fortification isone very important way of doing this,and has already helped overcomemicronutrient deficiencies in manyindustrialized countries and somedeveloping ones.

But many of the world’s poorestpeople eat locally grown crops thatcannot be fortified. Agricultural sci-entists are now demonstrating thatstaple crops can be modified in sev-eral ways at the breeding stage, withgreat nutritional benefit.

The grains and tubers on whichthe vast majority of people in the de-veloping world depend have certaininherent shortcomings nutritionally.For one thing, these staples tend notto provide all the minerals and vita-mins needed to ensure good nutri-tion. In addition, cereals, dependingon several factors, including the de-gree to which they are refined, con-tain substances that impede the‘bioavailability’ of some importantminerals — the ability of the body toabsorb and use them. The most im-portant of these substances is knownas phytate, a molecule containingphosphorus. Micronutrients usuallycome from non-staple foods — ani-mal products, vegetables and fruits.But the poorest populations oftencannot afford these foods and dependon the grains and tubers they can af-ford. This fact helps explain the high

82

Interaction and stimulation are essential tosound nutrition as well as intellectual andemotional development. In China, a boydelights in his meal and the attention ofhis aunt.

UNIC

EF/9

3-17

26/L

emoy

ne

prevalence of some micronutrientdeficiencies.

Agricultural research has turned tothe science of plant breeding to im-prove this situation. The goal is to de-velop staple food crops that containhigher quantities of essential mi-cronutrients — or lower amounts ofphytate. In this connection, work iscurrently being done in the UnitedStates to develop low-phytate grainfoods for animal consumption. Suchgrains hold nutritional promise forpeople as well, according to the re-sults of a recent study, which foundthat human volunteers absorbed ironat a significantly higher rate fromfoods prepared using a new low-phytate strain of corn than from anolder higher-phytate strain.22

The Consultative Group on Inter-national Agricultural Research, madeup of 17 internationally funded agri-cultural research centres, is trying toraise farm productivity and food con-sumption in developing countries.The group is now coordinating aglobal effort to increase the micronu-trient content of five major staple foodcrops: rice, wheat, maize, beans andcassava. The aim is to breed plantsthat load high amounts of vitaminsand minerals into their edible parts —and also into their seeds, allowingthem to enrich themselves for subse-quent harvests without changing theirtaste, texture, or the ease with whichthey are grown.

In developed countries, such cropshave already been successfully pro-duced: high-zinc wheat, for example,is being grown in Australia. Estimatesare that it will take 6 to 10 years tobreed comparable new plants in de-veloping countries. Scientists believethat they will not only improve thedaily dietary intake in the developingworld but will also significantlyincrease crop yields because thesemicronutrient-dense plants have better

germination and more resistance to in-fection at the vulnerable seedling stage.

More effective actionfor nutritionimprovement

The technical advances described inthis report, whether new research onnutrition and illness or better ways todetect problems, are not magic bul-lets. They will contribute to sustain-able improvement in nutrition only ifthey sharpen the ability of people, in-cluding the poor, to assess and analysethe causes of malnutrition aroundthem — and to plan and carry out ap-propriate responses.

Recent advances in the fields ofsocial science and communicationwill also help accelerate and sharpenpeople’s ability to take control ofactions to reduce malnutrition.

Actions described here to improvechild nutrition and thereby improvegrowth, resistance to illness and cog-nitive development need to be cou-pled with other highly effectivelow-cost interventions that have al-ready been proven to prevent diseaseand improve child development.

Some of these have yet to bewidely exploited. For example, in-testinal worms, which contribute topoor growth and development, can becombated through routine dewormingusing low-cost drugs that are bothvery safe and highly effective (Panel20). And child deaths from malariacan be reduced through the use of in-secticide-impregnated mosquito nets.These measures have not received ad-equate global attention and resources,even though every child has a right totheir benefits.

Actions to prevent malnutrition inyoung children also need to be linkedto efforts to promote early child de-velopment through stimulating playand early learning, and by strengthen-

83

Impact of deficiency

Folate deficiency causes birth defects inthe developing foetus during the earliestweeks of pregnancy — before mostwomen are aware that they are pregnant.Folate deficiency has been found to beassociated with a high risk of pre-termdelivery and low birthweight, though it isnot clear that this would hold in all popu-lations. Folate deficiency also contributesto anaemia, especially in pregnant andlactating women.

Who is affected

Although data are not abundant, in severaldeveloping countries women in theirreproductive years have been found tohave very high rates of folate deficiency.Young children are also likely to be at risk.

What folate does

This B vitamin helps in the formation ofred blood cells. Folate also regulates thenerve cells at the embryonic and foetalstages of development, helping to pre-vent serious neural tube defects (of thebrain and/or spinal cord).

Sources

Folate is found in almost all foods, butthe best sources are liver, kidney, fish,green leafy vegetables, beans andgroundnuts.

Spotlight: Folate

Panel 20

84

Asked to name the most wide-spread diseases, few peoplewould think of including worms.

Yet, helminth (worm) infections areindeed one of the most common —and neglected — of diseases, affect-ing more than 30 per cent of theworld’s people. Health, productivityand physical and mental capacitymay all suffer.

Children in developing countriesare the most severely affected, par-ticularly those between the ages of 5and 14, in whom intestinal worms ac-count for up to 12 per cent of totaldisease burden — the largest singlecontributor. While the impact ofworms on health and growth is com-monly believed to be most signifi-cant in children after they reach theage of five, a new study in India linksworm infection with growth falteringin children between one and fouryears old.

As many as 150,000 children dieeach year from intestinal obstruction

and other abdominal complicationscaused by large adult worms. In mil-lions more, worms are a significantcause of malnutrition, stunting growthand causing severe anaemia, dysen-tery, delayed puberty and problemswith learning and memory. In 1990,an estimated 44 million pregnantwomen were infected with hook-worm; their foetuses, therefore, wereat risk of retarded intrauterine growth,prematurity and low birthweight.

Transmission is insidiously easy,especially where hygiene and sanita-tion are inadequate. A child walkingbarefoot can pick up hookworm; byputting a dirty finger in her mouth,she may ingest roundworm eggs. Itis not uncommon for a child to carryup to 1,000 hookworms, round-worms and whipworms that depleteblood and nutrients.

Overall, about 1.5 billion peoplehave roundworms, making it thethird most common human infectionin the world. Whipworm infects 1 bil-

lion people, including nearly one thirdof all children in Africa. More than 1.3billion people carry hookworm intheir gut, and 265 million people areinfected with schistosomes, the para-sites that cause the debilitating dis-ease of schistosomiasis.

Worms affect nutrition in severalways, ingesting blood and leading tothe loss of iron and other nutrients.Worms also cause the lining of theintestines to change, which reducesthe surface membrane available fordigestion and absorption. As a result,fat, certain carbohydrates, proteinsand several vitamins (including vita-min A) are not absorbed properly.Lactose intolerance and poor use ofavailable iron can also result.

Treatment is simple and relativelyinexpensive. A single dose of anti-worm medicine such as Meben-dazole costs as little as 3 cents andcan eliminate or significantly reduceintestinal worm infections. The totalcost of treatment programmes is typ-ically $1 to $2 per year per person.Controlled experiments in India,Indonesia, Malaysia, Myanmar andTanzania have proved that the ther-apy works for months at a time.UNICEF, WHO and the World Bankhave identified pre-school and school-age children, women of childbearingage and adolescent girls as thosewho would benefit most from wormcontrol programmes.

The benefits are impressive. Aninnovative study in Kenya in 1994,which used motion detectors on thethighs of school children, found thatridding the youngsters of high levelsof hookworm improved physical ac-tivity. Dewormed children reportedbetter appetites and an end to ab-dominal pains and headaches. Withinnine weeks, the treated group showedbetter growth, weight gain (both in

Progress against worms for pennies

UNIC

EF/5

847/

Vila

s

85

ing interaction with parents and peers.The parents of young children every-where need regular contact withpeople who can help check their chil-dren’s growth and development andcan provide advice and support onbreastfeeding and complementaryfeeding. In many communities, par-ents and caregivers will also needboth advice on and access to supple-ments of vitamin A, iron, iodine andother micronutrients. Support in theseareas might best be provided throughestablished formal institutions —health centres, clinics or pre-schoolcentres (Panel 21). But where such fa-cilities do not exist or do not function,children cannot wait for them to bebuilt or staffed.

Communities must receive over-all support in their efforts to ensurethat all families have access to basicpreventive actions to improve thenutrition of children and pregnantwomen. This includes strengthenedhealth services to prevent and treatdisease, and increased support tostimulate early child learning, careand development.

None of the preventive and sup-portive actions to promote child growthand development described in this re-port require a doctor or nurse or atrained educator. Communities can behelped to organize themselves to pro-vide or administer these services, andin most communities, groups that cantake on these responsibilities alreadyexist. Communities can also behelped to assess their own priorityproblems and can learn to monitor theeffectiveness of their actions, re-designing their own programmes ac-cordingly. Combined with the use ofeffective low-cost technologies, theadoption of these measures could re-sult in rapid improvements not only inchild survival but also in child devel-opment, nutritional status and learn-ing capacity.

Photo: One of the most common infectionsin the world, worms impede children’sgrowth and cause anaemia. Learning andmemory suffer. Here, a girl attendsschool in India.

terms of fat deposits and musclemass), physical activity and ap-petite than the untreated group.Numerous studies have alsonoted the mental and cognitive ef-fects of anaemia in children in-fected with worms, with intellec-tual performance improving aftertreatment.

In a large-scale study done inIndia in 1996, two groups of chil-dren ages one to four years re-ceived twice-yearly vitamin A sup-plements; one group was alsogiven deworming tablets. At theend of the trial, the children in thegroup given worm treatmentwere on average 1 kg heavierthan the children who were nottreated. The study shows not onlythat mass deworming can im-prove the weights of young chil-dren in areas where worms arecommon, but it also opens up thepractical possibility of combiningworm treatment with vitamin Asupplementation in areas at risk.

Some believe that dewormingis not a satisfactory solution be-cause it must be repeated in theabsence of improved sanitation,hygiene and health education,and reinfection occurs frequently.Nevertheless, periodic deworm-ing reduces helminths’ drain onchildren’s development at criticaltimes in their lives, at least untilthe causes and conditions of envi-ronmental contamination and in-fection are successfully addressed.

A girl enjoys an ear of corn in the UnitedStates, where researchers have developed anew strain of corn that increases the body’sability to absorb iron.

UNIC

EF/9

7-04

23/T

outo

unji

Panel 21

86

Under apartheid, South Africahad a highly sophisticatedmedical research infrastruc-

ture that served the white minority,pioneering heart transplants, for ex-ample. Yet the majority of the peoplewere left with poor health and nutri-tion care. The advent of democraticrule in 1994, however, changed allthat. The Government is now reori-enting the health system to theneeds of the majority, and child nu-trition is a priority.

Establishing a community-levelnutrition monitoring system is an im-portant part of this effort, and onearea where this approach is takingshape is the Bergville district ofKwaZulu-Natal Province. Child healthand nutrition problems in the prov-ince are among the most challengingin the country. Over half the children

live in poverty, nearly 40 per centhave vitamin A deficiency, up to onequarter of the children in rural areasare stunted, and iodine deficiency isa problem in mountainous areas. Tenper cent of children ages six monthsto five years suffer from anaemia,which is also prevalant among preg-nant women, and low birthweight iscommon.

In the Bergville district, with apopulation of 120,000, a network ofcommunity health workers and healthassistants is being trained as part ofthe new Child Survival Programme.The approach, based on regularweighing of young children in theirhomes to monitor growth, is similarto that used successfully in other de-veloping countries during the pastdecade. Health workers will use theweighing sessions to discuss chil-

dren’s growth with their families, re-inforcing positive trends and ex-ploring reasons behind falteringgrowth to devise solutions. To carryout the programme, the number ofcommunity health workers in the dis-trict will be expanded significantly.The main objective is to cover allfamilies, including the poorest andmost marginalized.

Community participation in plan-ning and operating health services isat the core of the programme. Com-munity members formed a healthforum in 1994, which serves as thesteering committee of the Child Sur-vival Programme. The group hashelped establish a district hospitalboard and local committees to su-pervise health workers and has or-ganized workshops on the newprogramme.

Since 1996, resources for healthcare have been channelled more eq-uitably to disadvantaged provincessuch as KwaZulu-Natal, and this willhelp finance the improved health ser-vices. The University of Natal inPietermaritzburg is taking a leadingrole in supporting child growth mon-itoring in the Bergville district. In ad-dition, World Vision of South Africa,an NGO which has been active inthe district since 1980, has helped laythe groundwork for the programmethrough various community devel-opment projects. These include localleadership training, skills training forwomen’s groups, support for a pre-school and crèche programme andcooperation with the health servicein addressing malnutrition.

The new system for monitoringgrowth is sorely needed, accordingto a recent survey, which found thatwhile most mothers had a health ser-vices card for monitoring child growth,many of the cards were either left

Child nutrition a priority for the new South Africa

UNIC

EF/S

outh

Afri

ca

87

It has often been said that meetingthis challenge is a matter of politicalwill. In a $28 trillion global economy,the problem is surely not a lack of re-sources. But it may be more useful tosee the challenge as a matter of politi-cal choice. Governments in poor andrich countries alike may choose toallow children to be intellectually dis-abled, physically stunted and vulnera-ble to illness in childhood and laterlife. This is the price of doing little ornothing to ensure good nutrition.

But governments could instead re-solve to move to consolidate lessonsalready learned about reducing mal-nutrition. They could do everythingpossible to mount massive actionsthat can clearly succeed and that canbe implemented by communities them-selves. And they could encourageresearch on, and implementation of,new and better actions.

For the well-being and protectionof children and the human develop-ment of the world, the course of ac-tion is clear.

Photo: In South Africa, community healthworkers weigh children and discussgrowth promotion with their families.

blank or were incomplete. Thesurvey also found that very littlenutritional counselling had ac-companied growth monitoring.

The new programme facesmany difficulties: Resources arestretched, personnel must betrained and there must be out-reach into communities. Nonethe-less, the new partnerships beingforged between government, theuniversity, NGOs and communi-ties represent an approach thatholds promise for the future.

A major effort to tackle vitaminA deficiency is also under way.Within months after the new Gov-ernment took office, the SouthAfrican Vitamin A ConsultativeGroup launched the country’slargest-ever nutrition survey, cov-ering nearly 20,000 households.The survey found that one third ofchildren ages six months to fiveyears are vitamin A deficient or onthe borderline. The Governmentand non-governmental partnersare gearing up to address the prob-lem. Steps planned include givingvitamin A supplements to youngchildren and to mothers shortlyafter giving birth, fortifying staplefoods with vitamin A and encour-aging the production and con-sumption of vitamin A-rich foods.

Governments could insteadresolve to move to consolidatelessons already learned aboutreducing malnutrition. Theycould do everything possibleto mount massive actions thatcan clearly succeed and thatcan be implemented bycommunities themselves.

The silent emergency

1. Gillespie, Stuart, ‘Increased MaternalMortality Risk’, section 5.1 in MajorIssues in Developing EffectiveApproaches for the Prevention andControl of Iron Deficiency: Anoverview prepared for theMicronutrient Initiative and UNICEF,work in progress, September 1996(first draft).

2. Draper, Alizon, ‘Child Development andIron Deficiency: Early action is criticalfor healthy mental, physical and socialdevelopment’, The Oxford Brief,Opportunities for MicronutrientInterventions, Washington, D.C.,May 1997.

3. World Bank, World DevelopmentReport 1993: Investing in health,Oxford University Press, Washington,D.C., 1993, p. 77, col. 1.

4. World Bank, Enriching Lives:Overcoming vitamin and mineralmalnutrition in developing countries,World Bank, Washington, D.C., 1994,p. 2; ‘Total GDP Table 1995’, WorldDevelopment Indicators 1997(CD-ROM), International Bank forReconstruction and Development/World Bank, Washington, D.C., 1997.

5. Draper, Alizon, op. cit., p. 1.

6. Maberly, Glenn F., ‘ Iodine Deficiencyin Georgia: Progress towardselimination, Summary Report’, TheProgram Against MicronutrientMalnutrition, Atlanta, April-May 1997,p. 1, col. 3.

7. Martorell, Reynaldo, ‘The Role ofNutrition in Economic Development’,Nutrition Reviews, Vol. 54, No. 4, April1996, p. S70.

8. In accordance with internationalterminology recommended by WHO,readings that are three or morestandard deviations from thereference median (based on areference population of Americanchildren) are referred to as ‘severelymalnourished’, while those between

two and three standard deviations arecalled ‘moderately malnourished’.

9. Young, Helen and Susanne Jaspars,Nutrition Matters: People, food andfamine, Intermediate TechnologyPublications, London, 1995, p. 17.

10. UNICEF, ‘Food, Health and Care’,UNICEF, New York, updated edition,November 1996, p. 13.

11. Draper, Alizon, op cit., p. 1.

12. What Governments Can Do: Seventhannual report on the state of worldhunger, Bread for the World Institute,Silver Spring, 1997, p. 8.

13. Ibid., p. 10.

14. Philip, W. et al., ‘The contribution ofnutrition to inequalities in health’,British Medical Journal, Vol. 314,British Medical Association, London,24 May 1997, p. 1545.

15. ‘Children at Risk in Central and EasternEurope: Perils and promises’,Economies in Transition Studies,Regional Monitoring Report, No. 4,UNICEF, International Child DevelopmentCentre, Florence, 1997, p. 43.

16. Fogel, Robert W., ‘Economic Growth,Population Theory and Physiology:The bearing of long-term processeson the making of economic policy’,The American Economic Review, Vol.84, No. 3, The American EconomicAssociation, Nashville, June 1994,pp. 369-395.

17. Grantham-McGregor, Sally, ‘A Reviewof Studies of the Effect of SevereMalnutrition on Mental Development’,The Journal of Nutrition, Supplement,Vol. 125, No. 8S, The AmericanInstitute of Nutrition, Bethesda, 1995,p. 2235S.

18. Cole, Michael and Sheila R. Cole,‘Prenatal Development’, TheDevelopment of Children, ScientificAmerican Books, New York andOxford, 1989, p. 72.

88

References

19. Nash, Madeleine J., ‘Fertile Minds’,Special Report, Time, Vol. 149, No. 5,3 February 1997, p. 52.

20. Landers, Cassie, ‘A Theoretical Basisfor Investing in Early ChildDevelopment: Review of currentconcepts’, Innocenti Global Seminaron Early Child Development, UNICEFInternational Child DevelopmentCentre, Florence, 1989, p. 4.

21. Hanson, Lars A. et al., ‘Effects ofbreastfeeding on the baby and on itsimmune system’, Food and NutritionBulletin, Vol. 17, No. 4, United NationsUniversity Press, Tokyo, December1996, p. 384.

22. De Zoysa, I., M. Rea and J. Martines,‘Why promote breastfeeding indiarrhoeal disease controlprogrammes?’, Health Policy Planning,Oxford University Press, 1991, 6:371-379,as cited in ‘A warm chain forbreastfeeding’, The Lancet, Vol. 344,No. 8932, 5 Nov. 1994, p. 1239.

23. Glick, Daniel, ‘Rooting for Intelligence,’Newsweek, Special Edition, Newsweek,New York, Spring/Summer 1997, p. 32.

24. UNDP, Human Development Report1997, UNDP, New York, pp. 164-165.

25. UNICEF, WATERfront, Issue 8, UNICEF,New York, August 1996, p. 16.

26. UNDP, Human Development Report1997, p. 29.

27. United Nations, Progress made inproviding safe water supply andsanitation for all during the first half ofthe 1990s: Report of the Secretary-General, United Nations, New York,A/50/213-E/1995/87, 8 June 1995, table1, p. 5.

28. UNICEF, The Progress of Nations 1997,p. 12.

29. US Department of Agriculture study(1990) cited in Tufts University, Schoolof Nutrition, Center on Hunger, Povertyand Nutrition Policy, ‘Statement on theLink Between Nutrition and CognitiveDevelopment in Children’, 1995, p. 8.

8. Katz, J. et al., ‘Night blindness isprevalent during pregnancy andlactation in rural Nepal’, Departmentof International Health, Johns HopkinsSchool of Hygiene and Public Health,Baltimore, Journal of Nutrition,August 1995.

9. Gillespie, Stuart, John Kevany andJohn Mason, ‘Controlling IronDeficiency: A report based on anACC/SCN workshop’, United Nations,Geneva, February 1991, p. 4.

10. Alnwick, David, ‘More for Less inCombating Iron Deficiency? Update onthe Effectiveness of WeeklySupplements’, Research in Action, No.2, UNICEF, New York, November 1995,p. 1; Schultink, W. et al., ‘Effect of dailyvs. twice weekly iron supplementationin Indonesian preschool children withlow iron status’, American Journal ofClinical Nutrition, Vol. 61, AmericanSociety for Clinical Nutrition, 1995,pp. 111-115.

11. Layrisse, M. et al., ‘Early response tothe effect of iron fortification in theVenezuelan population’, AmericanJournal of Clinical Nutrition, Vol. 64,1996, pp. 905-906.

12. Stoltzfus, R. J. et al., ‘Epidemiologyiron deficiency in Zanzibarischoolchildren: The importance ofhookworms’, American Journal ofClinical Nutrition, Vol. 65, 1997, p. 157.

13. United Nations, Progress at Mid-Decade on Implementation of GeneralAssembly resolution 45/217 on theWorld Summit for Children: Report ofthe Secretary-General, UnitedNations, New York, A/51/256, 26 July1996, p. 30, para. 130.

14. Lewnes, Alexia, Oral RehydrationTherapy: Elixir of life, UNICEF,New York, February 1997, p. 3.

Bringing science to bear

1. Piot, Peter, ‘Fighting AIDS together’,The Progress of Nations 1997, UNICEF,New York, 1997, p. 23.

89

30. Landers, op. cit., p. 7.

31. United Nations, The World’s Women1995: Trends and statistics, SocialStatistics and Indicators, Series K,No.12, United Nations, New York, 1995,p. 108.

32. Holmboe-Ottesen, Gerd, OpheliaMascarenhas and Margareta Wandel,‘Women’s Role in Food Chain Activitiesand the Implications for Nutrition’,ACC/SCN State-of-the-Art Series,Nutrition Policy Discussion Paper No.4, United Nations, New York, May1989, p. 37.

Approaches that work

1. Gillespie, Stuart, John Mason andReynaldo Martorell, ‘How NutritionImproves’, ACC/SCN State-of-the-ArtSeries, Nutrition Policy DiscussionPaper No. 15, United Nations, NewYork, July 1996.

2. ‘International Code of Marketing ofBreastmilk Substitutes’, World HealthOrganization, Geneva, 1981, pp. 6-7.

3. UNICEF, The Progress of Nations 1997,UNICEF, New York, 1997, p. 21.

4. Micronutrient Initiative, Ottawa,facsimile dated 14 Oct. 1997.

5. Sommer, Alfred et al., ‘Impact ofvitamin A supplementation onchildhood mortality: A randomisedcontrolled community trial’, TheLancet, 1986, Vol. 1, pp. 1169-1173.

6. Beaton, G. H. et al., ‘Effectiveness ofVitamin A Supplementation in theControl of Young Child Morbidity andMortality in Developing Countries’,ACC/SCN State-of-the-Art Series,Nutrition Policy Discussion PaperNo. 13, United Nations, December1993, p. 61.

7. Ross, David A. et al., ‘Vitamin Asupplementation in northern Ghana:Effects on clinic attendances, hospitaladmissions and child mortality’, TheLancet, Vol. 342, 3 July 1993, pp. 7-12.

2. Sommer, Alfred and Keith P. West, Jr.,Vitamin A Deficiency: Health, survivaland vision, Oxford University Press,New York and Oxford, 1996, pp. 41, 48,66-70.

3. Roy, S. K. et al., ‘Impact of a singlemegadose of vitamin A at delivery onbreastmilk of mothers and morbidity oftheir infants’, European Journal ofClinical Nutrition, No. 51, StocktonPress, 1997.

4. ‘Zinc for Child Health: Child HealthResearch Project Special Report’,Report of a meeting, Baltimore,Maryland, 17-19 Nov. 1996, Vol. 1,No. 1, June 1997, p. 8.

5. ‘Improving Iron and Zinc Nutrition inInfancy and Early Childhood:Proceedings of the Bali ConsultationMeeting for the Planning of Multi-Country Iron and Zinc InterventionTrials’, in Bali, Indonesia, 4-6 February1997, UNICEF, 1997, pp. 6-7.

6. Semba, Richard D., ‘Will vitamin Asupplementation reduce mother-to-child transmission of HIV?’ Researchin Action, No. 5, UNICEF, New York,July 1996.

7. Adamson, Peter, ‘A failure ofimagination’, The Progress of Nations1996, UNICEF, New York, 1996, p. 8.

8. Rasmussen, Kathleen M. and MichelleK. McGuire, ‘Effects of breastfeedingon maternal health and well-being’,Food and Nutrition Bulletin, Vol. 17,No. 4, United Nations University Press,1996, p. 366.

9. Murray, Christopher J. L. and Alan D.Lopez (eds.), The Global Burden ofDisease, Harvard School of PublicHealth, Cambridge, 1996, pp. 360-367.

10. Barker, David J. P., Mothers, Babiesand Disease in Later Life, BMJPublishing, London, 1994.

11. Law, Catherine M. and Alistair W.Shiell, ‘Is blood pressure inverselyrelated to birth weight? The strengthof evidence from a systematic reviewof the literature’, Journal of

20. Among 201 four-year-old childrenborn in Pune of known birthweight,those who were 2.4 kg or less at birthhad mean glucose and insulinconcentrations 8.1 mM (micromole)and 321 pM (picamole) respectively30 minutes after an oral glucosechallenge; in comparison childrenborn 3.0 kg or heavier had a meanglucose concentration of 7.5 mM anda mean blood insulin level of 289 pM.From Yajnik, M. et al., ‘Fetal growthand glucose and insulin metabolism infour-year-old Indian children’,Diabetic Medicine, Vol. 12, 1995,pp. 330-336.

21. Congdon, N. et al., ‘Pupillary andvisual thresholds in young childrenas an index of population vitamin Astatus’, American Journal of ClinicalNutrition, Vol. 61, The AmericanSociety of Clinical Nutrition, May1995, pp. 1076-1082; Sanchez, A. M. etal., ‘Pupillary threshold as an index ofpopulation vitamin A status amongchildren in India’, American Journalof Clinical Nutrition, Vol. 65, January1997, pp. 61-66.

22. Mendoza, C. et al., ‘Effect ofGenetically Modified, Low-PhytateMaize on Iron Absorption fromTortillas’, article submitted toExperimental Biology ’97(unpublished).

90

Hypertension, Vol. 14, No. 8, 1996,pp. 935-941.

12. Law, C. M. et al., ‘Thinness at birth andglucose tolerance in seven-year-oldchildren’, Diabetic Medicine, 1995,12:24-29.

13. Hales, C. N. et al., ‘Fetal and infantgrowth and impaired glucosetolerance at age 64’, British MedicalJournal, Vol. 303, 26 Oct. 1991, pp.1019-1022; Phipps, K. et al., ‘Fetalgrowth and impaired glucosetolerance in men and women,Diabetologia, 1993, 36:225-228;McCance, David R. et al., ‘Birth weightand non-insulin dependent diabetes:Thrifty genotype, thrifty phenotype, orsurviving small baby genotype?’,British Medical Journal, Vol. 308, 1994,pp. 942-945.

14. Barker, op. cit.; Hales, C. N. andD. J. P. Barker, ‘Type 2 (non-insulindependent) diabetes mellitus:The thrifty phenotype hypothesis’,Diabetologia, 1992, 35:595-601.

15. The Smallest Babies in the World,video, MRC EnvironmentalEpidemiology Unit, Southampton, 1996.

16. A study of maternal nutrition andintrauterine fetal growth, King EdwardMemorial Hospital Research CentreAnnual Report 1995-1996, KEMHRC,Pune, 1996, p. 36.

17. ‘Proceedings of the Third AnnualWorkshop on the Fetal and EarlyOrigins of Adult Disease’, meeting inKhandala, Maharashtra, India,September 1996, p. 6.

18. Fall, Caroline, Ranjan Yajnik andShobha Rao, personalcommunication, 1997.

19. McKeigue, P. M., G. J. Miller andM. G. Marmot, ‘Coronary heartdisease in South Asians overseas:A review’, Journal of ClinicalEpidemiology, Vol. 42, No. 7, UnitedKingdom, 1989, pp. 597-609.