CHAPTER 1 - The Role of Nutrition in Social and Economic Development

Overview of nutrition in human resource and economic development

Nutritional status is a measure of the health condition of an individual as affected primarily by the intake of food and utilization of nutrients. According to the World Health Organization (WHO), health is not only the absence of disease but a state of complete mental and physical wellbeing in relation to the productivity and performance of an individual.

Good nutritional status can only be realized and sustained when individuals within families and communities are food-secure. Food security has been defined as access by all people at all times to the food needed for a healthy life (FAO/WHO, 1992a). Food security has three important dimensions: adequate availability of food supplies; assured access to sufficient food for all individuals; and its proper utilization to provide a proper and balanced diet.

The state of hunger and malnutrition within a country is related to its level of development (OMNI, 1998). The relationship between nutrition and human resource development was best described by the 1992 International Conference on Nutrition (ICN) held in Rome, which, in its World Declaration and Plan of Action for Nutrition, stated that nutritional well-being of all people is a pre-condition for the development of societies and is a key objective of progress in human development.

A well-nourished, healthy workforce is a pre-condition for sustainable development. At the same time, the nutritional well-being of a population is a reflection of the performance of its social and economic sectors; and to a large extent, an indicator of the efficiency of national resource allocation.

In order for a national social and economic development programme to be successful and sustainable, the majority of the population should be able to participate in the process. Therefore, the majority of the population should be in good health and have good nutritional status.

Nutrition plays a critical role in human resource development since deficiencies in essential nutrients lead to malnutrition, which affects an individual's mental and physical state, resulting in poor health and poor work performance. In addition, a hungry, malnourished child may have mild to serious learning disabilities, resulting in poor school performance; a sick, poorly nourished individual will not respond well to treatment, could lose many working hours and may continue to drain family and national resources. Thus, malnutrition may undermine investments in education, health and other development sectors.

A. Odoul

A well-nourished, healthy workforce is a pre-condition for sustainable development

When human potential and resources are trapped in the vicious cycle of malnutrition, development goals and improved standards of living will not be realized. Hence, the ICN recommended that nutrition be at the centre of socio-economic development plans and strategies of all countries (FAO/WHO,1992a) (see Box 1).

This recommendation was based on the fact that significant improvements in nutritional status can result from incorporating nutritional considerations into broader policies of economic growth and development, food and agricultural production activities, health care, education and social development.

In order for the human resource capital to be sustainable, it is important to promote nutrition objectives within current development strategies, plans and priorities.

Prevalence and consequences of malnutrition

Malnutrition has been defined as a pathological condition, brought about by inadequacy of one or more of the nutrients essential for survival, growth, reproduction and capacity to learn and function in society (Latham, 1997). People whose diets fall short of standard levels of intake for essential nutrients suffer from malnutrition that can be mild, moderate or severe, depending on the level of deficiency.

Current trends in malnutrition (Gillespie Mason and Martorell, 1996) show that although nutritional status is improving for many people in the world, for some the rate is not fast enough. At the World Food Summit (WFS) in 1996, it was stated that more than 800 million people do not have sufficient food to meet their nutritional needs (See Tables 1-3). This situation results from many inter-related factors, including social, economic, environmental and political ones.

The nutrition situation reports of the United Nations Administrative Committee on Co-ordination/Sub-Committee on Nutrition (ACC/SCN) stated that protein-energy malnutrition (PEM), measured by the proportion of children falling below the accepted weight standards, affects 26.7 percent of all pre-school children in the developing world. In 2000, the problem affected some 150 million children, based on national anthropometric measurements (ACC/SCN, 2000). WHO reports that in developing countries, 10.7 million children die each year, and of these deaths, 49 percent are associated with malnutrition (WHO, 2000). Data from Table 4 confirm that malnutrition has a far more powerful impact on child mortality than is generally believed (WHO, 1995).

R. Jones

A community health attendant examines a two-month-old baby during a monthly medical check-up at a health post

Trends in underweight prevalence among children are key to understanding nutritional status in relation to human development. About 29 percent of children in South Asia, 6 percent in Latin America and 28 percent in Sub-Saharan Africa are underweight. Although Sub-Saharan Africa has a slightly lower prevalence than South Asia, the situation in this region is not improving. Underweight prevalence rate in South Asia is improving slowly but is still the highest in the world, and more than half of the underweight children in the world live in this region (ACC/SCN, 2000) (see Table 5).

Asia has also been characterized by a slowly rising gross national product per capita and a high rate of poverty.

In 1995, the global underweight rate in developing countries was estimated to be 29 percent (ACC/SCN,1996). Cutbacks in health expenditures in some developing countries could account for this high rate. Other factors influencing underweight prevalence can be political instability, insufficient and inaccessible health care (i.e. immunization), poor hygiene and sanitation, and poor access to nutrient-rich foods (ACC/SCN,1996).

TABLE 1
Average per caput dietary energy supply (DES)

TABLE 2
Population in countries grouped by average per capita (DES)

TABLE 3
Estimates and projection of undernourished populations in developing countries

TABLE 4
Percentage of all deaths of children under five years of age associated with malnutrition for selected countries in Africa

TABLE 5
Estimated prevalence and number of underweight preschool children, 1990-2005

Notes: Underweight is defined as low weight-for-age at <-2 standard deviations of the median value of the NCHS/WHO international growth reference

TABLE 6
Estimated prevalence and number of stunted children, 1990-2005

Notes: Underweight is defined as low weight-for-age at <-2 standard deviations of the median value of the NCHS/WHO international growth reference

Micronutrient malnutrition

Micronutrient malnutrition is a term commonly used to refer to vitamin and mineral deficiency disorders. Vitamins and minerals are referred to as micronutrients because the body needs them in only small amounts to maintain normal health and functioning. However, lack of these micronutrients results in serious health repercussions. Vitamin A deficiency (VAD), iron deficiency anaemia (IDA) and iodine deficiency disorders (IDD) are among the most common forms of micronutrient malnutrition. Vitamin A is found only in animal products such as eggs, liver and milk. Many fruits and vegetables, such mangoes, papaya, pumpkin and carrots, contain chemicals called carotenes which the body can convert into vitamin A. Good sources of iron are foods such as meat, beans and dark green leafy vegetables. Iodine is normally found in foods that are grown in soils that are rich in iodine, as well as food from the sea. Because it is not normally easy to know if the food we eat contains enough iodine, the use of iodized salt for normal seasoning of food is highly recommended.

A large proportion of people, particularly children under five years of age, school-age children, and pregnant and lactating women, suffer from problems of PEM and micronutrient malnutrition disorders. Usually, people do not suffer from single nutrient deficiencies, as micronutrient deficiencies often occur in conjunction with other nutritional deficiencies. The concurrent prevalence of chronic malnutrition, IDD and IDA can reduce the gross domestic product (GDP) by 2-4 percent. According to FAO, over 2 billion people in the world suffer from micronutrient malnutrition (FAO 2002).

VAD principally affects pre-school age children. The March of Dimes estimates that worldwide, about 251 million children from 0-5 years of age are either at risk of or affected VAD because of inadequate diets; and 2.8 million are afflicted with xerophthalmia (see Table 7). VAD can lead to xerophthalmia, night blindness and, eventually, total blindness. Every year, 250,000 to 500,000 children lose their sight as a result of VAD: two-thirds of these children are likely to die. An estimated one million additional children die each year of infectious diseases because VA D impairs their resistance to infection (FAO, 2002).

IDA is caused by insufficient intake and/or inadequate biological utilization of dietary iron. It is considered the most frequently occurring nutritional disorder in the world, and affects mainly young children, pregnant women, lactating women and women in the reproductive age range. It is estimated that in developing countries, the prevalence of anaemia is three to four times that of industrialized countries (see Table 7). In developing countries, the most affected group are pregnant women (57%), compared to 43 percent in women in the 15- to 59-year age range, and 42.2 percent in children 0-4 years of age. The prevalence in developed countries is almost reversed, with the highest figure being that of the 0- to 4-year age group at 16.7 percent, followed by 14 percent for pregnant women and 10.3 percent for women in the 15- to 59-year age range (March of Dimes, 2002).

For women, poor nutritional status is associated with an increased prevalence of anaemia, pregnancy and delivery problems, increased rates of intra-uterine growth retardation, low birth-weight and perinatal mortality. According to FAO, where iron deficiency is prevalent, the risk of women dying at childbirth can be increased by as much as 20 percent. Anaemia in infants and children is associated with retardation of physical, intellectual and psychomotor development, as well as reduced resistance to infection. In adults, undernourishment and anaemia can lead to poor health and productivity, resulting in impaired physical and intellectual performance, and subsequently constrained community and national development. Studies show that IDA can reduce work capacity and productivity by 10-15 percent, and GDP by 0.5-1.8 percent (FAO, 2002a).

IDD occur in populations living in areas where iodine in the soil has been washed away by glaciers and rain, and in areas of frequent flooding. Over 2 billion people in the world are at risk of IDD, although this is undoubtedly the easiest of the micronutrient deficiencies to reduce (March of Dimes, 2002). IDD can lead to visible goitre and impaired physical and mental development. Worldwide, about 20 million people are mentally retarded due to iodine deficiency. Severe or moderate iodine deficiency during pregnancy can lead to foetal neurological or hypothyroid cretinism, resulting in impaired hearing, mutism, impaired motor co-ordination, severe mental defects and increased rates of abortion and/or still births. It is the most common cause of preventable mental retardation. The March of Dimes reports that about 741 million people worldwide are affected by goitre (see Table 7). South East Asia has the highest number of people at risk (599 million), followed by West Pacific (513 million) and East Mediterranean (348 million). East Mediterranean has the highest number of people affected by goitre (152 million), followed by Africa and West Pacific, with 124 million people affected in each of the two regions.

Fortifying salt with iodine is one of the most effective ways of eliminating IDD. Increasingly, countries with IDD problems are now using iodized salt (see Table 8).

Although some countries continue to have significant iodine deficiency, availability and consumption of iodized salt has increased significantly to about 90 percent in the Americas, 70 percent in Southeast Asia and 63 percent in Africa (see Table 8). This has had a significant effect on the goitre rate in those regions, and millions of children each year are being protected from mental retardation and loss of intellectual potential.

TABLE 7
Global prevalence estimates of deficiencies of iodine, vitamin A, and iron

Multisectoral and multifactoral causes of malnutrition

It is often assumed that access to a stable and varied food supply and good health are the only pre-conditions for good nutritional status. Yet, achieving nutritional well-being can be a complex issue because of the intersectoral factors involved in the process.

TABLE 8
Current status of household consumption of iodized salt, 1999

Notes: These figures reflect household survey data where this is available; otherwise, production-level data are used as a proxy. To estimate the overall iodization rate, the total population of each country is multiplied by the percent of households consuming iodized salt. Numbers are then totaled for each region and divided by the total regional population.

Factors which influence nutritional well-being relate to a country's political, economic and social environment; its institutional capacity; and delivery and empowerment capacity. This range of factors may be grouped into three categories: basic factors, underlying factors and outcomes.

To a large extent, the development process determines people's health and nutritional well-being. It is influenced by a country's potential resources, which are its people, natural resources and agricultural land.

However, the political, economic and socio-cultural environment which influences the control, management and distribution of national resources is a major determinant of the extent to which national resources can be exploited, to enable the majority of the inhabitants to participate in and benefit from the development process (see Figure 1).

In order for people to enjoy active, productive lives, it is mandatory that their basic needs a stable and varied food supply all year-round, for all family members; good health services; safe water supply and good sanitation; education; and adequate family care are met. Where these basic needs cannot be met by the majority, good health and nutritional well-being will remain elusive.

Current efforts to prevent and control malnutrition

Globally, efforts to prevent and control malnutrition have been in the areas of advocacy, service delivery, institutional capacity building and community empowerment. Programmes for improving nutrition have focused on several interventions, including household food security, a problem that is of major concern to many countries. The success of nutrition interventions is dependant on prevailing socio-economic and political conditions. As such, attributing positive or negative nutritional outcomes to specific interventions could be a very complex and nebulous issue. Nevertheless, there are successes that have been demonstrated and widely acknowledged, and it is intended that lessons learnt from these positive experiences can be applied to benefit other countries, particularly the most disadvantaged people in these countries. Programmes included are:

Household Food and Nutrition Security

Child Survival and Development

Micronutrient Initiatives (such as backyard gardening, Vitamin A fortification and salt iodization)

Nutrition Surveillance and Intervention

Poverty Alleviation

Nutrition Education

The organization and process of implementing activities are crucial. In particular, genuine community ownership of programmes, from the initial planning, organization and implementation stage, is a key factor for success. An integrated community development approach, in which nutrition improvement is a key outcome indicator, has facilitated success in many programmes.

G. Bizzarri

A woman farmer raises chickens as part of a food security and poverty alleviation project

An analysis of case studies of nutrition programmes from Africa, Asia and Latin America, carried out by FAO, revealed that the following factors play a significant role in the success of nutrition projects: supportive macro environment; effective community participation; promotion of nutrition and food security as a human right; linking nutrition to the development process; clearly defined intersectoral approach and collaboration; and decentralization (FAO, 2003).

HOUSEHOLD FOOD AND NUTRITION
SECURITY PROGRAMMES

At the household level, food security implies physical and economic access to foods that are adequate in terms of quantity, nutritional quality, safety and cultural acceptability to meet each person's needs. However, household food security can only be translated into good nutritional status if household members have:

sufficient knowledge and skills to acquire, prepare and consume food that provides a nutritionally balanced-diet, with special attention to the needs of young children; and

access to health services and a healthy environment to ensure effective biological utilization of foods consumed.

Household food insecurity can result from decreased crop production caused by droughts and seasonal constraints; inappropriate or unfavourable agricultural trade (disruption of exports or imports); sudden and large rises in food prices; decreases in household or individual wage earnings; political and policy failures; and vulnerability affecting some population groups such as women, children and the elderly (FAO/WHO 1992b).

FAO, in collaboration with governments and all actors in civil society, is working on developing and maintaining up to date, the Food Insecurity and Vulnerability Information and Mapping System (FIVIMS), which was launched at the WFS in 1996. FIVIMS was developed to identify food-insecure and vulnerable groups; prevalence and degree of low food intake; undernutrition; and causes of food insecurity and vulnerability (FAO, 2000). Seven general categories of national information systems relevant to FIVIMS are listed below:

agricultural information systems;

health information systems;

land, water and climatic information systems;

early warning systems;

household food security and nutrition information systems;

market information systems; and

vulnerability assessment and mapping systems.

Because of lack of access to resources and information, food security has remained elusive to many, particularly small, resource-poor, farm families in developing countries.

FAO and national counterparts have implemented various projects and programmes to help stabilize food supply and therefore increase food security, and improve nutritional status. (Two household food security initiatives are described in boxes 2 and 3).

Other successful innovative efforts to ensure household food and nutrition security in developing countries include:

Iringa Nutrition Programme in Tanzania;

Tamal Nadu Integrated Nutrition Project in India;

Project COPA C A in Peru;

Pilot Food Price Subsidy Scheme in the Philippines; and

Alternative School Nutrition Programme in the Philippines (ACC/SNC, 1991).

Box 4 displays factors that may be used for measuring successes of community-based food and nutrition projects. These factors can also be used as a guide when designing, implementing, monitoring and assessing project activities:

CHILD SURVIVAL AND DEVELOPMENT
PROGRAMMES

Young child malnutrition in developing countries remains high. This has been largely attributed to poor breastfeeding practices and inadequacy of complementary feeding. WHO recommends that all infants receive only breastmilk from birth to six months of age. This requires appropriate policy support from governments to encourage and assist all women to initiate and exclusively breastfeed their infants for four to six months and continue breastfeeding with adequate complementary feeding up to two years (WHO/UNICEF, 1989). In order to promote and support breastfeeding, it is recommended that institutions have in place supportive policies and measures such as the establishment of daycare facilities at the work place and/or paid maternity leave.

I. Balderi

Experts recommend that infants be fed breastmilk only, from birth to six months of age

Appropriate supportive measures should be put in place at the community and household levels as well, such as providing breastfeeding outlets/rooms in public places; and alleviating the nursing mother's workload to allow her time for relaxation and breastfeeding.

It is further recommended that countries participate in the Baby Friendly Hospital Initiative (BFHI), which guides hospitals and health facilities in promoting and supporting good breastfeeding practices (WHO/UNICEF, 1991). Since the launch of the BFHI in 1992, an increasing number of countries have adopted the initiative. Statistics show that by 2000, more than 14,500 hospitals in 142 countries had been designated as baby-friendly (ACC/SCN, 2000).

Efforts towards child survival and development have also concentrated on preventing and controlling infections through immunization for infants and mothers, as well as other critical micronutrient supplementation programmes and projects.

MICRONUTRIENT INITIATIVES

Although malnutrition is associated with poverty, this does not mean that some forms of malnutrition do not exist among population groups that have enough food to eat. Micronutrient deficiencies continue to exist even among these population groups. For example, moderate levels of iodine deficiency still exist in some European countries that have failed to take adequate, sustainable measures to overcome the disorder. Four main strategies have been proposed to combat micronutrient deficiencies (FAO/ILSI, 1997):

i. Dietary diversification (availability and consumption of micronutrient-rich foods) through: social marketing of micronutrient-rich foods; increasing consumption of dark green leafy vegetables; small-scale and community gardening; and solar drying technology for preserving micronutrient-rich foods.

ii. Food fortification (the addition of nutrients to commonly eaten foods to maintain or improve the quality of a diet). A fortification programme is usually undertaken in response to dietary, biochemical or clinical evidence of nutrient needs. Table 9 lists foods that have been fortified with vitamin A, iron and iodine in developing countries.

iii. Vitamin and mineral supplementation programmes and initiatives such as the Vitamin A Supplementation and the Expanded Programme on Immunization. These programmes incorporate the transition from reliance on universal supplementation to a mixture of fortification, other food-based approaches, and targeted supplementation (OMNI, 1998).

iv. Global public health and disease control measures such as combatting public health diseases and providing safe water and sanitation to communities. Diseases such as diarrhoea, intestinal parasites (caused mainly by lack of good sanitation and clean drinking water) and childhood illnesses which primarily afflict young children in developing countries, often have a negative impact on nutrient absorption and utilization (FAO/ILSI, 1997).

TABLE 9
Foods fortified with micronutrients in developing countries

Food-based approaches play an essential role in preventing micronutrient malnutrition since they increase the availability and consumption of micronutrient-rich foods. In the long term, such approaches are more likely to be sustainable. If overt micronutrient malnutrition is present, short-term supplementation programmes can be helpful but need to be gradually taken over by food-based activities, as the former are generally not sustainable.

In rural areas, major food-based efforts will likely be linked to horticulture programmes. In urban settings, overall food availability as well as the potential for access to fortified food products is generally better than in rural settings. It is the cost of food that is the impediment. However, it is still beneficial to promote home gardens in peri-urban areas. Furthermore, nutrition education activities will strengthen and complement efforts to enhance availability of micronutrient-rich foods.

NUTRITION SURVEILLANCE AND INTERVENTION PROGRAMMES

Nutrition surveillance systems can be described as the broadest management information systems found in nutrition programmes (Mason and Gillepsie, 1991). They entail monitoring the nutrition situation and taking appropriate action. Even under favourable conditions of development at the national level, discrete sub-groups remain in need of nutrition information and support on a continual basis.

A. Conti

Statisticians analyse data from maternal and child health clinics to generate information for appropriate interventions and programme development

Indicators commonly used in nutrition surveillance are: (i) food security information such as food availability and access; (ii) nutritional status such as anthropometric data which includes underweight, stunting and wasting; (iii) specific micronutrient status such as for vitamin A, iron and iodine; (iv) health information such as birthweight, infant and child mortality rates, morbidity incidence or prevalence; and (v) socio-economic variables such as income and selected assets. These indicators are used in order to generate estimates on the number of people at risk of inadequate access to food or undernourishment. Most nutrition programmes emphasize the use of nutrition surveillance systems and an early warning system to monitor and evaluate the efficacy of these programmes.

Many countries have established information units or systems for specific purposes, such as providing early warning, promoting market efficiency, monitoring health and nutrition status, or preparing food security situation assessments. In many developing countries, similar information systems are maintained by donor agencies or non-governmental organizations (NGOs), either in parallel to ongoing government-supported information systems or in partnership with governments. These activities are usually established for purposes of monitoring specific programmes or for assessing the need for food aid and targeting its delivery. Some examples of national surveillance systems which have been developed using the FIVIMS guidelines are (FAO, 1998d):

Mozambique's National Early Warning System (SNAP)

Zambia’s Food, Health and Nutrition Information System (FHANIS)

Peru's Food and Nutrition Surveillance Information System (SUISAN)

POVERTY ALLEVIATION PROGRAMMES

In general, the major objective of poverty alleviation programmes is to assist communities to meet their basic needs. Food is usually the first need identified by poor people. Hence, nutrition projects are a good entry point in developing poverty alleviation programmes. In many projects designed to alleviate poverty, income-generating activities are developed to assist poor households to purchase food.

Thailand is one of the countries that has had much success in improving nutritional status through poverty alleviation programmes. Four key programmes described below were implemented as part of a poverty alleviation plan which began in Thailand in 1982 (Tontisirin and Winichagoon, 1977):

Rural job creation programme: Jobs were created within the rural setting during the dry season to boost household income and to ensure that people would remain in their communities and participate in community development activities.

Agricultural production programme: Agricultural programmes included production of nutritious foods (especially crops used for supplementary feeding of young children), upland rice improvement projects and soil improvement projects. Direct benefits of these projects were income generation and household food security.

Village development projects: Activities included building village fish ponds, creating safe water sources, poultry raising and other projects that focused on helping the rural poor to improve their economic status and household food security.

Provision of basic services: Public services for the rural poor, such as health facilities, clean water supplies, and literacy and nutrition education programmes, were improved.

L. Spaventa

Manual weeding of crops is an income-generating activity that provides non-farming families with seasonal work

NUTRITION EDUCATION PROGRAMMES

One of the principal aims of nutrition education is to provide people with adequate information, skills and motivation to procure and to consume appropriate foods. Education programmes can focus on strategies to improve family food supplies and efficient utilization of available food and economic resources to provide well balanced diets and better care for vulnerable groups.

Nutrition education programmes should have at least three components, which are directed at various social groups:

Increasing nutrition knowledge and awareness of the public and policymakers.

Promoting desirable healthy food choices and nutritional practices.

Increasing diversity and quantity of family food supplies.

Incorporating these three components into nutrition education and training programmes in ministries of agriculture, education and health can help to facilitate improvement in local food and nutrition conditions (FAO, 1997a). Both traditional and new methods are needed to reach large sections of the population, including school children, youth, men and women in the workplace and at home.

As part of the commitment to improving nutrition in developing countries, FAO sponsored the Expert Consultation on Nutrition Education for the Public in Rome in 1995. The consultation adopted recommendations regarding strategies for national and community programme development, training of nutrition educators, as well as evaluation and use of mass media and computer technologies. Experts highlighted the need for collaboration among government, the media, food industries, universities and NGOs in developing and implementing nutrition education activities (FAO, 1996a).

FAO Madagascar

Women learning about food groups in a nutrition education class

Economic benefits of investing in nutrition

Investing in nutrition is an efficient use of resources because the enormous social and financial costs of malnutrition are averted. Moreover, improved nutrition has an enhancing effect on investments in health, education and agriculture sectors. Investing in a wide array of low-cost solutions for malnutrition can therefore be of immense economic benefit to a country.

Investing in good nutrition can result in social and economic returns provided that it is firmly based on principles of effective community participation. Benefits include good quality of life, increased productivity and good economic returns. In children, the investment leads to an increase in their cognitive ability, attendance rate and intellectual performance in school. In addition, adequate returns in investment made in the educational sector can be realized (See Figure 2).

In adults, income will be improved through a substantial increase in productivity, resulting in a higher standard of living and overall improvement in the quality of life.

From a broad perspective, the basic economic goals of developing countries are related to (i) productivity growth in order to expand consumption of goods and services; and (ii) distribution of that consumption among members of society. The link between nutrition and productivity in developing countries suggests that improved nutritional status can contribute to the attainment of both broad goals (FAO/ILSI, 1997).

Determining the cost of malnutrition

The social and economic impacts of nutritional disorders on individuals are wide-ranging. For example, children with IDD have a reduced learning capacity and poor attendance at school. In adults, IDD leads to poor income-earning capacity due to mental and physical impairment, as well as decreased productivity, which has a negative effect on both family and national economies. As a result, health care costs for IDD sufferers are often high. Moreover, since IDD can result in cretinism, the implications are most serious, leading to a lifetime of complete dependency on social services and informal caregivers.

On the other hand, IDA in pregnant women affects not only the sufferer, but the outcome of pregnancy as well. Low birth-weight in newborns is often the result, and the mother’s energy level is reduced to the point of jeopardizing her caregiving practices for the newborn and other children in the family. The newborn will most likely be iron deficient and at high risk of remaining in this condition while undergoing rapid growth. Thus, a condition that affects women of child-bearing age has consequences for growth of the foetus, and for normal growth and development of newborns and other children in the family. This deficiency does not only affect the women afflicted by it, but it also disrupts normal growth and development potential for the next generation. Anaemia can therefore reduce the learning capacity and productivity of an entire nation.

In order to determine the Global Burden of Disease, WHO in collaboration with Harvard University and the World Bank (WB), developed an international standard form of the Quality-Adjusted Life Years (QALY) called Disability-Adjusted Life Year (DALY). The DALY expresses years of life lost to premature death and years lived with a disability of specific severity and duration (WHO, 1996). Overall, DALY is the disability suffered by an individual as a result of a disease condition, malnutrition being one of them.

The DALY helps provide a rough estimate of economic loss to a nation where malnutrition levels are high. For example, using 36 percent as the prevalent level of malnutrition in 1994, it has been estimated that Nigeria lost about US$ 489 million as a result. This is a conservative estimate and is certainly higher if current indices are used (See Box 5). In order to reduce economic loss due to malnutrition and related illnesses, political will and the commitment of all concerned to make a difference are essential.