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Part I. Causes of malnutrition

Part I. Causes of malnutrition

Chapter 1. International nutrition and world food problems in perspective

These are the opening sentences of the World Declaration on Nutrition produced by the FAO and World Health Organization (WHO) International Conference on Nutrition (ICN) held in Rome in December 1992. That important conference reviewed the current nutrition situation in the world and set the stage for markedly reducing these unacceptable conditions of humankind. Reaching the ICN goal is possible. Most of the work will need to be done in the developing countries by their own people. However, cooperative work across nations and across disciplines is also essential.

This book is aimed to help move forward the noble objectives elaborated by the ICN. It is hoped that a comprehensive text that describes the nature of the problems, their causes and ways to deal with them can be helpful. A brief review highlighting international food and nutrition issues can help to bring the most important issues into perspective.

The ICN declaration goes on to state:

The scale of the problem

Protein-energy malnutrition (PEM), vitamin A deficiency, iodine deficiency disorders (IDD) and nutritional anaemias - mainly resulting from iron deficiency or iron losses - are the most common serious nutritional problems in almost all countries of Asia, Africa, Latin America and the Near East.

Nutrition and development: a global assessment, prepared by FAO and WHO for the ICN, reviewed all available current information on the prevalence of hunger and malnutrition and provided a global estimate for the various regions of the world. FAO updated the estimates of the chronically undernourished population of the world for the Sixth World Food Survey and in preparation for the World Food Summit (Table 1), and WHO updated the estimates for iodine, vitamin A and iron deficiencies in 1995 (Table 2). The figures suggest that one of every five persons in the developing world is chronically undernourished, 192 million children suffer from PEM and over 2 000 million experience micronutrient deficiencies. In addition, diet-related non-communicable diseases such as obesity, cardiovascular disease, stroke, diabetes and some forms of cancer exist or are emerging as public health problems in many developing countries.

While these numbers and trends are alarming, progress has been made in reducing the prevalence of nutritional problems, and many countries have been remarkably successful in addressing the issues of hunger and malnutrition. For the developing countries as a whole there has been a consistent decline since the early 1970s in the proportion and absolute number of chronically undernourished people. From 1969 to 1971 approximately 893 million people were chronically undernourished, compared with 809 million from 1990 to 1992; these figures represent a drop from 35 to 20 percent of the population of these countries. The current - and achievable - challenge is to build upon and accelerate the progress that has been made.

FAO and WHO data indicate improvements of the nutritional situation in Asia and Latin America from 1980 to 1990 but a deterioration in sub-Saharan Africa. Although the prevalence of underweight children remained virtually unchanged in sub-Saharan Africa during that decade (increasing from 29 to 30 percent), the prevalence rates are much better than in South Asia, where about 59 percent of children - almost twice the prevalence in Africa - were underweight in 1990 (Table 3). In the same year, in total numbers, five times as many children were underweight in South Asia (101 million) as in sub-Saharan Africa (19.9 million).

Many nutritional statistics show the numbers of persons who have overt evidence of a deficiency. However, "at risk" populations are not often identified. In nutrition, as in public health, people considered at risk of developing malnutrition should be among the primary concerns. Prevention becomes more feasible and cost effective if groups at risk are identified and the causes of malnutrition are clearly understood.

One of the most dramatic aspects of the global nutrition situation is the extent of famine, hunger and starvation. While good progress has been made in averting famine, especially in Asia, these horrifying conditions persist throughout the world. Their occurrence is commonly attributed to drought and other natural disasters, but war, civil unrest and political instability have far greater importance. In the mid-1990s, hunger and malnutrition resulting from civil strife are serious problems in many parts of the world including Europe (particularly former Yugoslavia), Asia (for example, Afghanistan), the Near East (Iraq) and most extensively Africa. Tragically, civil strife often affects not only the countries in turmoil but also those that provide hospitality to the refugees who flee their homes in terror. In mid-1994, the United Republic of Tanzania accepted about 500 000 refugees from Rwanda, most of them in less than one week. Their arrival more than doubled the population of the resource-poor region, which welcomed them as best it could. The influx placed overwhelming pressure on local resources and necessitated a major international effort to prevent an increase in nutrition and health problems among the local people as well as to contain these problems among the refugees.


Prevalence of chronic undernutrition in developing regions


Percentage of population

Number (millions)








Latin America and the Caribbean







Near East and North Africa







Sub-Saharan Africa







East and Southeast Asia







South Asia







Continental Africa







Developing regions








Population at risk of and affected by micronutrient malnutrition (millions)


Iodine deficiency disorders

Vitamin A deficiency

Iron deficiency or anaemia


At risk

Affected (goitre)

At risk2

Affected (xerophthalmia)














Southeast Asia




1 7








Eastern Mediterranean






Western Pacific3





1 058


1 572




2 150

1 WHO regions.

2 Preschool children only.

3 Including China.


Prevalence of underweight1 children under five years of age, by region


Percentage underweight

Number underweight (millions)








Sub-Saharan Africa







Near East/North Africa







South Asia


61 1





Southeast Asia


34 7












Central America/Caribbean




3 1



South America







Global (average percentage/total number)







Source: UN ACC/SCN, 1992a.

1 Underweight is defined as weight-for-age less than -2 standard deviations from the mean.

Nutrition improvement: Nature and evolution

Data from around the world show that the causes underlying most nutrition problems have not changed very much over the past 50 years. Poverty, ignorance and disease, coupled with inadequate food supplies, unhealthy environments, social stress and discrimination, still persist unchanged as a web of interacting factors which combine to create conditions in which malnutrition flourishes. However, what does change greatly is the approach to tackling malnutrition. Each decade or so witnesses a new dominant framework, paradigm, panacea or quick fix claimed to be capable of reducing the malnutrition problem greatly before ten years have passed.

During the 1950s and 1960s, kwashiorkor and protein deficiencies were seen as the major problems. Quick fixes such as fish protein concentrate, single-cell protein or amino acid fortification and increased production of protein-rich foods of animal origin were the strategies proposed for the control of malnutrition in the tropics and subtropics.

During the late 1960s and 1970s, the term "protein-energy malnutrition" entered the literature. Increasing protein and energy intake by children was the solution, and nutrition rehabilitation centres and applied nutrition programmes (ANPs) were offered up as sure strategies.

The 1974 World Food Conference began a decade of macroanalysis which placed first nutrition planning and then nutritional surveillance among the dominant strategies for the countries most affected. Economists began to take over from nutritionists and paediatricians as the architects of new policies, with much talk about national food security and agencies such as the World Bank stressing income generation.

In 1985 the International Monetary Fund (IMF) began to push structural adjustment, and WHO and UNICEF reinvented ANPs, which they renamed Joint Nutrition Support Programmes (JNSPs). In the early 1990s the subject of micronutrients pushed PEM to the background, as nutritionists, international agencies and universities attempted quick fixes to control vitamin A deficiency, anaemia and IDD. The micronutrient wave has not yet crested, and very large sums of money are likely to be provided by the World Bank, the United States Agency for International Development (USAID) and others to address this hidden hunger". This effort is, in part, a response to the goals set by the 1989 World Summit on Children and the 1992 International Conference on Nutrition, which include the virtual elimination of vitamin A deficiency and IDD before the turn of the century.

Increased funding is needed if improvements in nutrition are to be achieved. However, there is a danger that the limited resources available may be diverted towards the development of new quick-fix strategies for micronutrient deficiencies. Little, then, will remain for addressing the underlying and basic causes of malnutrition. The quick fix addresses only the immediate causes of a problem, scratching the surface and providing no sustainability.

It is well recognized that inappropriate development strategies also contribute to the underlying causes of hunger in many countries. Policy reform and the institution of appropriate development and macroeconomic policies are advocated by many economists to improve nutrition. The ICN also emphasized that developing countries must work to ensure that development policies and projects are designed to include nutrition improvement objectives. Furthermore, in the low-income food-deficit countries, where most of the world's malnourished people live, economic growth and poverty alleviation must be based on better development of agricultural resources and improvement of food supplies. This approach should promote sustainable development, expand employment opportunities and improve access to food by the poor. Free and fair trade is clearly important for stimulating economic growth, and the prices for primary and processed agricultural products must be adequate to ensure sustained development. The primary producers must receive fair prices for their products, labour and use of resources.

It has to be recognized that inappropriate application and transfer of technology and even aspects of certain development projects can have negative as well as positive consequences for health and nutrition in poor countries. It is important that such possible negative consequences be identified early and that measures be taken to offset and prevent them. It may be more important to enhance during project preparation those aspects that will have a positive impact for maximum nutritional benefits.

There is also a greater realization that the poor should be more involved in solving their own problems and that the causes of malnutrition and the different levels of society implicated vary from place to place. People should be able to ask appropriate questions relevant to their situation, at the national, local or even family level, and they should be aware of the multisectoral nature of the problem of malnutrition. They can then, together with persons from different disciplines, suggest actions that might be taken at different levels. During the past ten years a good deal has been written about local participation in development decisions and programmes. The innate wisdom of peasants, with regard to agriculture as well as other development-related matters such as health and nutritional status, has finally been widely acknowledged.

It has also been recognized that international and national policies and actions can influence nutritional status in the rural villages and city slums of developing countries. The State may determine taxes, control prices, run national institutions and oversee a legal system. Almost all of these factors influence, and some of them are influenced by, the formal and informal institutions in society. Clearly these institutions influence the causes of malnutrition. Thus the presence or absence, the relevance and the quality of formal local institutions such as agriculture advisory services, health centres, primary schools and community centres have a very important role in areas related to nutrition. But the more informal institutions can also have a role in influencing food, health and care. The most important of these is the family; others include groups of friends and religious, sporting or social groups.

The realization that malnutrition is not just a food problem has been appreciated for many years, but the concept of the importance of giving consideration to food, health, education and care is of more recent origin. It is vital that this thinking continue to develop and to move forward steadily, in the place of erratic leaps in pursuit of fashion or funding. For a healthy approach, in the next ten years, the achievements should be reassessed; old strategies that have sound logic and a successful record should be protected and supported, and new policies promoted only when needed. This approach is possible with both discipline and flexibility, and examples of its success are visible today.

A framework for causes of malnutrition

Malnutrition or undesirable physical or disease conditions related to nutrition can be caused by eating too little, too much or an unbalanced diet that does not contain all nutrients necessary for good nutritional status. In this book the term malnutrition is restricted to undernutrition, or lack of adequate energy, protein and micronutrients to meet basic requirements for body maintenance, growth and development.

An essential prerequisite to the prevention of malnutrition in a community is the availability of enough food to provide for the nutrient needs of all people. For adequate food to be available, certainly there must be adequate food production or sufficient funds at the national, local or family level to purchase enough food. Availability of food, however, is just part of the picture. It is now recognized that malnutrition is only the overt sign, or symptoms, of much deeper problems in society.

Inadequate dietary intake and disease, particularly infections, are immediate causes of malnutrition. It is obvious that each person must eat an adequate amount of good-quality and safe food throughout the year to meet all nutritional needs for body maintenance, work and recreation, and for growth and development in children. Similarly, one must be able to digest, absorb and utilize the food and nutrients effectively. Poor diets and disease are often the result of insufficient household food security, inappropriate care and feeding practices and inadequate health care. It is now understood that good nutrition depends on adequate levels of all three of these factors.

Other factors can also contribute to unavailability or inadequacy of resources for afflicted families. Every rural community or society has certain natural or human resources as well as a certain potential for production. A host of factors influence what and how much food will be produced and how and by whom it will be consumed.

The proper use of resources may be affected by economic, social, political, technical, ecological, cultural and other constraints. It may be affected by lack of tools or training to use them and by limited knowledge, skills and general ability to use the resources. The cultural context is of special importance for its influence, especially at the local level, on the use of resources and the establishment and maintenance of institutions.

Malnutrition may manifest itself as a health problem, and health professionals can provide some answers, but they alone cannot solve the problem of malnutrition. Agriculturists, and often agricultural professionals, are required to ensure that enough foods, and the right kinds of food, are produced. Educators, both formal and non-formal, are required to assist people, particularly women, in achieving and ensuring good nutrition. Tackling malnutrition often requires the contributions of professionals in economics, social development, politics, government, the labour movement and many other spheres.

Promotion and protection of nutritional well-being: The ICN approach

The International Conference on Nutrition developed nine common areas for action to promote and protect the nutritional welfare of the population:

Addressing issues under these themes facilitates the development of a common understanding of nutrition problems by various sectors and allows a more focused approach for working towards solutions. Taking this thematic approach to nutrition problems should ensure that each of the many facets of a problem are noted, which should allow each sector or agency to assess how it can best work for improvements. These issues are discussed in detail in Part V.

The six Ps

By shedding the sectoral perspective and adopting a multisectoral, multidisciplinary one, it is possible to see the causes of malnutrition in a different guise and to focus the development of solutions less narrowly than in the past. Each case will be different, of course, and the extent to which one cause or one area of expertise predominates will vary with the circumstances. However, six determinants of malnutrition are especially important, although none is usually the only cause of malnutrition or the only discipline that needs to be involved in nutrition strategies.

These six determinants - the six Ps - are:


The production of food comes mainly from agriculture. Most countries have a ministry of agriculture and different kinds of agricultural staff whose contributions are very important to nutrition, but adequate national agricultural and food production does not guarantee good nutritional status for all people. As described in Chapter 2, there have been remarkable developments in agriculture in the past four decades. High-yielding varieties of the important cereals (rice, wheat and maize) have been successfully developed, and much progress has been made in increasing food yields per hectare of land. Some countries that are self-sufficient in their production of staple foods, however, still have the highest prevalence of malnutrition. Agriculturists and agriculture ministries have an absolutely vital role in improving nutritional status, but they cannot win the battle against malnutrition without action from other ministries and without other expertise. Other areas such as food safety, food losses and food storage influence the availability of food. Consideration has to be given to food demand as well as food production.


Despite the remarkable progress made in increasing food production at the global level, approximately half of the people of developing countries do not have access to an adequate food supply. A substantial part of the food produced is lost, for various reasons, before it can be consumed. It has been estimated that about 25 percent of the grains produced are lost because of bad post-harvest handling, spoilage and pest infestation. Losses of easily perishable fruits, vegetables and roots have been estimated to be about 50 percent of what is grown. After food reaches the home, about 10 percent is lost in the kitchen. Therefore, ensuring that appropriate measures are taken to prevent food losses during harvesting, transportation, storage, processing and preservation should be an integral component of any programme for the prevention of malnutrition and the improvement of the population's access to food in developing countries. Processing can also add nutritional and economic value to foods. Adequate measures for the provision of safe and quality food should also be taken.


The population question and the relationship of fertility and the availability of family planning to nutrition are discussed in Chapter 5. The food available per person in a family, a district or a nation depends on the amount of food produced or purchased divided by the number of people who have access to that food. A family of eight that produces and purchases the same amount of food as a family of four has less food available per person. However, it also needs to be recognized that among producing families, larger family size can also lead to greater family productivity.

In some countries the population problem is considered to be of great importance, and overpopulation, family size and child spacing are considered important determinants of malnutrition. Demographers study population, and many countries have a government body, often in the ministry of health, responsible for family planning. Birth spacing may deserve a very high priority. However, as with production, it is naive to believe that in any country population control or successful family planning will by itself solve the problems of hunger and malnutrition.


Poverty is often stated to be the very root cause of malnutrition. Certainly in most countries it is mainly, and sometimes only, the poor whose children suffer from severe or moderate PEM or show evidence of vitamin A deficiency. In contrast, nutritional anaemias and IDD may not be confined to the poor.

Economists are the professionals who study poverty and income and suggest economic solutions for problems of poverty which may be related to malnutrition. Most governments have a group of economists working in the ministry of finance and sometimes also in a ministry of economic planning.

The experience of many developing countries shows that a major reduction in poverty would have a significant impact on rates of PEM in most countries and communities. Efforts to reduce poverty, raise incomes, lower food prices and redistribute wealth, as well as a host of other economic policies, can have a major impact on nutrition. But just as agriculturists and demographers alone cannot solve the nutritional problems of a nation, so also economic actions alone do not usually rid a country or area of malnutrition. In some cases raised incomes have not resulted in major reductions in malnutrition and certainly have not led to its eradication.

Poverty takes many forms and is expressed in many ways. Inadequate household income is one manifestation, but poor communities and nations lack the wealth needed to build and support schools and training programmes to improve water supplies and sanitation and to provide needed health and social services.


All countries have a mechanism to create and implement policies in spheres of development. The systems differ from one country to another, but agriculture, health, education, economic and other related policies strongly influence the well-being of the people, including their nutritional status. Some governments take their obligations seriously. If government leaders take the right to freedom from want seriously, then they also respect the right to freedom from hunger, freedom from lack of health services, freedom from poor housing and so on. These conditions, however, also depend on the resources of the country. The way in which political ideology can have a significant influence on malnutrition is probably through government acting to ensure some level of equity. Equity does not imply equality, it simply means a reasonable or relatively fair access of all people to the essential resources such as housing, education, food and health care. Policies directed towards improving access of women to resources for income generation, education and health care would particularly improve the nutritional welfare of the family and children.


This sixth P connotes disease. Physiology refers to the normal functioning of the body and its organs and cells. Pathology refers to abnormal function and to disease. Much malnutrition in the world is caused or influenced not only by shortage of food, but by disease.

The relationship between malnutrition and infection has been extensively studied and documented. There is no doubt that common infections such as diarrhoea, respiratory disease, intestinal worms, measles and acquired immunodeficiency syndrome (AIDS) are important causes of malnutrition. These relationships are discussed in Chapter 3. In addition, certain non-infectious diseases may also be causes of malnutrition. Examples of these include a variety of malabsorption syndromes (conditions where the body does not absorb nutrients properly), many cancers and malignancies and some psychological illnesses.

Ministries of health and a variety of health personnel in the public and private sectors are responsible both for treatment of disease and for public health or preventive measures. In many countries the responsibility for government nutrition policies rests with the ministry of health, and often national institutes of nutrition fall under this ministry. Certainly health measures to prevent disease, especially infections, and also actions to provide medical care and appropriate treatment will help very much to reduce the extent of malnutrition in a country or a community. Health measures alone, however, have never been able to eliminate malnutrition totally.

A multidisciplinary perspective

This discussion of the six Ps, namely production, processing, population, poverty, politics and pathology, is designed to illustrate the complexity of both the underlying causes of malnutrition and the solutions. It illustrates that agriculturists, industrialists, demographers, economists, politicians and health personnel all have important roles in controlling malnutrition. It is also clear that no one ministry or single group of professionals is likely to eliminate hunger and malnutrition in society. Nutritionists, food scientists and others work across all these lines, and in a properly functioning national food and nutrition strategy they will collaborate with professionals in several of these disciplines as well as others. Achieving good nutrition may also require experts in anthropology, sociology and community development; it requires a good transport and marketing system; it benefits greatly from an education system that provides school for all, especially females, and guarantees the highest levels of literacy; and it may involve many other actors. Nutrition strategies are truly multisectoral, which may sometimes present more difficulties at the national level than at the local or community level. Community participation, with the assistance of actors from different sectors including at least agriculture, health, community development and education, will often be needed to meet the challenge of good nutrition for all. The chapters in this book are designed to allow persons from different disciplines to understand the complexities of the nutrition problem but also to see that a variety of quite simple actions can contribute to improving nutrition.

Chapter 2. Food production and food security

A national food policy should be a part of an overall nutrition strategy with household food security for all people as a central objective. Achieving food security includes ensuring:

For all households to be food secure, each must have physical and economic access to adequate food. Each household must always have the ability, the knowledge and the resources to produce or procure the foods that it needs. Nutritionists stress also the need for the food to provide for all the nutritional requirements of the household members, which means a balanced diet providing all necessary energy, protein and micronutrients.

Beyond household food security is the need to encourage food distribution that ensures good nutritional status for all the members of the household. The right to an adequate standard of living, including food, is recognized in the Universal Declaration of Human Rights. National development policies should include food security as an objective, and achieving food security for all is an indication of success.

In nutrition there exists the paradox that while undernutrition leads to a serious set of health problems, overconsumption of food and of certain dietary components carries other risks to health. This book is particularly concerned with undernutrition. This chapter considers food security, at both the national and household levels, and food policy.

National food security

Food security is often defined as access by all people at all times to sufficient food required for a healthy and active life. It is now widely accepted that most of the undernutrition in developing countries is due to inadequate intake of both protein and energy and that it is often associated with infectious diseases.

In the past, protein deficiency was overemphasized as an important nutrition problem in the world. Commercial production of relatively expensive protein-rich foods, amino-acid fortification of cereal grains, production of single-cell protein and other ventures were offered as panaceas for the world's nutrition problems. These ventures only reduced the problem of protein-energy malnutrition (PEM) by a very small degree. Thus, in the context of combating malnutrition, attempts at making small changes in the amino-acid pattern of cereal grains by means of genetic manipulation are much less useful than increasing the yields per hectare of cereals and other food crops or enabling people to purchase the foods they need.

Satisfying the energy needs of a population, which should be the first goal of a food policy, has been a relatively neglected matter. In most populations where the staple food is a cereal such as rice, wheat, maize or millet, serious protein deficiencies seldom occur except where there is also an energy or overall food deficiency. The reason is that most cereals contain 8 to 12 percent protein and are often consumed with moderate quantities of legumes and vegetables. Protein deficiencies in people consuming these diets are mainly confined to very young children suffering increased nitrogen losses because of frequent infections. However, among populations whose staple food is plantain, cassava or some other food with a low protein content, protein intakes may be a problem for greater sections of the population.

A modest increase in cereal, legume, oil and vegetable consumption by children will greatly reduce the prevalence of PEM and growth deficits for children in developing countries, especially if combined with control of infectious diseases. Breastfeeding during the first few months of life can ensure an adequate diet, whereas bottle-feeding is a major cause of diarrhoea and nutritional marasmus (see Chapter 7).

Food availability (food supply)

To nourish a population adequately, there must be a sufficient quantity and variety of good-quality and safe food in the country. Therefore, in most low-income food-deficit countries a fundamental strategy of food policy is to improve and increase food production - a domain for agriculture experts. Clearly, decision-makers in the agriculture sector need to be aware of the nutritional needs of the population and to understand the nutritional implications of their actions.

Most food in the world comes from cereals. The second largest amount of food comes from root crops, followed by legumes or pulses. In round figures, the world produces about 2 000 million tonnes of cereals, 600 million tonnes of root crops and 60 million tonnes of pulses per year. In addition, about 85 million tonnes of fats and oils and 180 million tonnes of sugar are produced worldwide each year. Developing countries produce more of all these items than do industrialized countries. In contrast, industrialized countries produce more foods of animal origin meat, milk and eggs, for example - than do the developing countries.

In the last few decades, truly remarkable advances have influenced food production. Agricultural research has developed and made available new varieties of the main cereals: rice, maize and wheat. These new varieties produce much higher yields per hectare than the old varieties. Some have a shorter period between planting and harvesting, and some are relatively resistant to disease. However, most of these new varieties require increased fertilizer use. In addition, many of the improved rice varieties and some of the wheat and maize varieties require irrigation or more water. Both of these options may be economically unfeasible for most poor farmers. In general, cultivation of improved varieties is more suitable for large, economically comfortable farms with access to agricultural inputs. It should be a major agricultural policy objective to see that more resource-poor farmers have adequate access to such inputs.

The development of these new varieties - the green revolution - has allowed much higher yields of cereals for a given area of land. As population pressure increased on arable land, the green revolution offered an alternative to the old method of increasing production, namely expanding the area of land cultivated.

Average world food production has kept pace with or very slightly exceeded the increase in world population. In round figures, 2 700 kcal are available per person per day in the world. However, the figures vary among regions; the mean for industrialized countries is around 3 400 kcal, and that for developing countries is around 2 500 kcal. Of course, average availability figures for a country mask very large differences among groups of the population.

To improve nutrition, agricultural planners should aim to expand the production of currently grown staple cereals and legumes and should promote consumption of fruits, vegetables, oilseeds and livestock products or those of small animal husbandry. Where land pressures are a constraint, particular attention should be given to maintaining a proper balance between crops and livestock.

Some countries that were major food importers in the 1960s, such as India, are virtually self-sufficient in cereal production (mainly rice and wheat). Yet in India undernutrition and malnutrition remain highly prevalent. Other countries, such as Indonesia, have become self-sufficient in rice production and have significantly reduced the prevalence of malnutrition. Some countries are far from being self-sufficient in food production yet have far less malnutrition than countries like India. For example, many Caribbean countries have very low levels of PEM, and many have emphasized sugar production for export and chosen to pay to import much of their food. However, it should be pointed out that in environments with risky markets, joint promotion of both food and cash crops is required to achieve food security.

Developing countries should strive for integrated rural development combining sustainable agricultural development and the promotion of off-farm economic activities. Expanding agricultural efforts to increase and improve food production as well as to increase the income of rural families through greater production of cash crops is the job of most ministries of agriculture in developing countries.

Agricultural research in universities or in research stations is important to agricultural efforts. A good agricultural extension service can help farmers increase their productivity and make decisions about their farm practices. Agricultural research and extension, leading to higher levels of agricultural production, can have a major impact on nutrition, especially if improved production makes it easier for the poor to consume an adequate diet. Many textbooks examine how agriculture and food production are used to improve food intakes and nutritional status. They are essential reading for those who are interested in these aspects.

Local seasonal factors are very important influences on food supply. For example, rainfall patterns can give marked variations in food production within a year and between years. Food production can also be influenced by other factors such as pests, prices, availability of agricultural inputs and farmers' ability to procure them, political stability and peace. Climatic variations, especially rainfall (or its lack) and inclement weather, can dead to annual variations in food production. These variations may bring about complex food storage and management requirements. Seasonally high food prices may be tied to costs of storage and failure to manage public food stocks adequately.

Food storage limits and post-harvest losses due to insects, pests, moulds, bruising, high temperatures, etc. can seriously destabilize food supply. Yet even after production, harvest and storage are successfully accomplished, other factors can affect food supply. These include commercial food processing and industrialization; food marketing, including transport; policies related to importation and exportation of food, including food donated in multilateral or bilateral agreements; and external assistance and debt repayment.

Access to food (food demand)

Access to food, or food demand, is influenced by economic issues, physical infrastructure and consumer preferences.

Per caput incomes and food prices are important determinants of food demand. Since the poor are the most vulnerable to food deficits and malnutrition, policies that increase their purchasing power will provide them with the potential to improve their nutrition. Therefore, increased employment and better wages become components of policies and programmes to improve nutrition. In many poor countries the minority of the working population are wage-earners and the majority are self-employed in agriculture. About 65 percent of the population in developing countries of Asia and Africa and about 35 percent in Latin America live in rural areas and rely on agriculture, fishing, animal production and forestry for food as well as for income to purchase food and other necessities. Assistance to help this group of poor farmers and rural workers increase their incomes and food productivity will have an effect similar to that of increasing the wages of the urban poor.

Food prices affect both supply and demand. Lower prices give farmers less revenue for their produce. If prices drop too low, farmers may not produce or sell at all. However, lower prices represent an increase in the purchasing power of the consumer. Lowering the price of a common staple food such as maize or rice is equivalent to raising the income of all those who purchase this food. Similarly, raising the price (a more common occurrence) is equivalent to lowering the income of those who purchase it.

Governments have various mechanisms at their disposal to help satisfy the needs of both producers and consumers. One of these is subsidizing food prices: the price paid to the farmer for a sack of maize or rice is raised while market prices for consumers are maintained, with the government paying for the difference between the two. Food price subsidies may be disastrous for the economy but politically expedient for the government. They may help the poor to improve their nutrition.

Too often in the past, pricing policies and subsidies have been directed at foods consumed mainly by high-income groups and have thus had no beneficial effect on vulnerable groups. For example, price restrictions on meat, powdered milk or tinned baby foods or subsidies on beef or margarine would hardly benefit the poor at all, nor would they have important nutritional impact. Structural adjustment programmes put in place to mitigate severe economic crises often adversely affect the poor, particularly in the urban areas, through increased food prices. However, in many countries the majority of the rural poor are food producers, and structural adjustments may benefit them by raising their income from the sale of food produced and providing incentives to improve production efforts. By limiting inflation and reducing other macroeconomic distortions, structural adjustment programmes may benefit all population groups.

Food demand is also affected by consumer preferences, which can be shaped by cultural beliefs and practices or intra-household food allocation. An efficient infrastructure, including roads, railways, bridges and marketing facilities, is a determinant of the extent and success of food distribution to different segments of society. In the developing world and also in some industrialized countries, families living near food markets have a steady and easy access to cheaper foods and a more diversified diet, while people living far from markets usually have a rather narrow range of foods to choose from.

Household food security

Household food security is the ability of the household to secure enough food to provide for all the nutrient requirements of all members of the household. It is critical to link national food security and household food security, because availability of food supplies in adequate quantity and variety is a necessary but insufficient condition for ensuring adequate access by all households in need. Furthermore, having adequate overall food supplies in households is a necessary but insufficient condition for ensuring nutritionally adequate consumption by all individuals within households. Clearly, the overall availability of food in a country, community or household is no guarantee of its equitable consumption.

Components of household food security

Household food security depends on a nutritionally adequate and safe food supply nationally, at the household level and for each individual; a fair degree of stability in the food availability to the household both during the year and from year to year; and access of each family member to sufficient food to meet nutritional requirements. (This last criterion includes not only physical access but also economic and social access to foods that are culturally acceptable.)

It is also important that the available food be both safe and of good quality. Attention to the food at every step of the food chain or food cycle is required to ensure its quality and safety. These steps include the cultivation of the food in the field (including protection against damage from pests or contamination with farm chemicals or pesticides); the harvesting, transport and storage of the food; processing and marketing; and finally the preparation and cooking of the food in the home and aspects of its consumption in the household. From the nutritionist's point of view, food losses and wastage along the chain are of great importance. However, important health concerns can also be raised if foods are not used correctly. An example is possible contamination, particularly from pesticides or other chemicals used to enhance production or to control pests such as insects, fungi, bacteria and viruses, or from natural toxins.

Food quality and safety are also affected by food hygiene, food handlers, people involved in food processing, those retailing the food and finally practices in the home. Certain codes and government inspections may help ensure some degree of safety, and education and knowledge of food hygiene by al] people will reduce the likelihood of contamination in the home. However, available facilities also influence food hygiene. Households that have poor facilities, no refrigeration, contaminated or inadequate water supplies or fuel shortages will find it more difficult to ensure food safety. See Chapter 33 for some ways to improve food safety and a discussion of food-borne diseases.

Another important aspect of food security is stability. The family or household must have the ability all year round to produce or procure the food its members require. The food must provide for all the family members' essential micronutrient and energy requirements, plus their wants, or desirable allowances, provided this does not lead to overconsumption. Of the greatest importance, especially when food or certain nutrients are available in marginal amounts, is proper distribution within the family to satisfy the special needs of children and females of childbearing age.

Incomes received from cash crops or wage earnings and prices paid for purchased items influence a rural population's food security. Inadequate landholdings, landlessness, sharecropping and other causes of poverty are all potent causes of family food insecurity. For the one-third of the population of developing countries who live in urban areas, much of the food obtained is purchased. The household food security of the urban poor depends on incomes, prices and the need to spend earnings on other essentials such as housing and transport. Their food security can be threatened by increased prices, job loss, income reduction, rent increases, larger numbers of dependent persons (more children, or relatives moving into the household) and other factors.

In both urban and rural areas the food must satisfy not only the energy needs but also the micronutrient needs of each household member. Therefore, the food consumed by each person must be varied and its quantity must be sufficient. If this is not the case, micronutrient deficiencies may occur.

Household food insecurity

Malnutrition may result from inadequate food, inadequate health or inadequate care (see Chapter 1). Inadequate food, be it due to food shortages or to inappropriate consumer behaviour or intrahousehold distribution, is termed food insecurity.

Food insecurity at the household or individual level may be transitory, or short-term, because of a particular event of short duration. In these circumstances it results from a temporarily limited access to food. Chronic food insecurity is long-term, may have a more marked impact and may be more difficult to control. The intensity of either short-term or long-term food insecurity is also important. Food insecurity occurs in mild, moderate and severe forms, just as PEM does. The level of food insecurity may be related to the relative availability of food.

A "shock" often precipitates household food insecurity. The shock can aggravate poverty (suddenly making a poor family very poor) or adversely influence food production (suddenly threatening farm food availability). There are many different kinds of shock, for example, serious illness, which may result in loss of income in an urban family or reduced agricultural production in a farm family; loss of a rural or urban job; farm production crises, such as failure of the rains; or a plague of locusts or some other agricultural catastrophe. Any crisis that has an adverse impact on the livelihood of the family may also result in household food insecurity.

Another important determinant of food insecurity is gender discrimination. Subordination of women in society, their overburdening and the greater difficulties faced by female-headed households contribute to food insecurity. Chapter 35 discusses ways to improve food security and reduce malnutrition in society.

Food policies in a development context

Clearly, development strategies and interventions pursued by developed and developing nations have an impact on nutrition. For this impact to be positive, developed and developing countries must decide what "development" really means.

Too often in the past, development has been associated with industrialization and measured by the productive capacity and the material output of a country. Indicators of development were gross national product (GNP) or mean per caput incomes. Economists tended to view improved nutrition and health as welfare questions. However, it is now clear that economic development does not benefit everyone equally. The poor have often been bypassed, and improvements in the quality of life of most low-income families in many countries have not kept pace with the improvements in national economic figures. The purpose and the intended beneficiaries of economic development should be examined before the interventions begin. If development plans do not encompass improved health and better nutrition for people, then their worth must be seriously questioned.

Nutrition-positive development projects are those that will benefit a large segment of the population, help reduce inequalities in income distribution and be likely to improve the nutrition, health and quality of life of those currently deprived. Labour-intensive projects are often preferable to capital-intensive ones, and support for small farmers may be more useful in regard to nutrition than assistance for large estates. Small farmers and especially women farmers are the most disadvantaged and require the most help. They are also the ones who receive the least assistance, in terms of both extension services and access to credit. In many countries, too little of the national budget is devoted to support for agriculture, which is essential for social and economic development and for nutritional well-being.

Food policy should make marketing as logical, simple and well-organized as possible, with a minimum involvement of intermediaries, to help ensure that the producer gets a fair return for his or her produce and that the consumer pays the lowest reasonable price for his or her food. Cooperatives are one form of marketing that may benefit both producer and consumer.

Recently, both adequate food and good nutrition have been declared basic human rights. As discussed in Chapter 1, good nutrition goes beyond food rights, including also adequate care and adequate health. It has been suggested that household food security should be examined as part and parcel of a broader food and nutrition system. Food factors included in the system are food production and some of the influences on it; the transport system; the market and its relationship to exchange and storage; and finally household food availability and access. Most "food systems" do not give consideration to the health causes of malnutrition such as infections including diarrhoea and intestinal worms. They also do not include caring factors that may influence nutritional status, such as breastfeeding, weaning and psycho-social stimulation. All of these factors are vital components of nutritional well-being. They are discussed in detail in other chapters of this book.

Chapter 3. Nutrition and infection, health and disease

The interaction or synergism of malnutrition and infection is the leading cause of morbidity and mortality in children in most countries in Africa, Asia and Latin America. Viral, bacterial and parasitic infections tend to be prevalent, and all can have a negative impact on the nutritional status of children and adults. The situation was similar in North America and Europe from about 1900 to 1925; common infectious diseases had an impact on nutrition and produced high case fatality rates.

The synergistic relationship between malnutrition and infectious diseases is now well accepted and has been conclusively demonstrated in animal experiments. The simultaneous presence of both malnutrition and infection results in an interaction that has more serious consequences for the host than the additive effect would be if the two worked independently. Infections make malnutrition worse and poor nutrition increases the severity of infectious diseases.

Effects of malnutrition on infection

The immune system

The human body has the ability to resist almost all types of organisms or toxins that tend to damage the tissues and organs. This capacity is called immunity. Much of the immunity is caused by a special immune system that forms antibodies and sensitized lymphocytes which attack and destroy the specific organisms or toxins. This type of immunity is called acquired immunity. An additional portion of the immunity results from the general processes of the body; this is called innate immunity

Innate immunity is due to:

There are two basic but closely allied types of acquired immunity. In one of these the body develops circulating antibodies, which are globulin molecules that are capable of attacking the invading agents and destroying them. This type of immunity is called humoral immunity. Antibodies circulate in the blood and may remain there for a long time, so that a second infection with the same organism is immediately controlled. This is the basis for some forms of immunization, which are designed to stimulate antibody production.

Questions and answers

Why are the case fatality rates from measles often 200 times higher in poor, developing countries than in the industrialized countries? The main reason is that the malnourished child is of ten overwhelmed by the infection, whereas the well-nourished child can combat it and survive.

Why do so many cases of kwashiorkor develop following an infectious disease and so many cases of nutritional marasmus following gastro-enteritis? It is well established that infections result in increased nitrogen loss and that diarrhoea reduces the absorption of nutrients from the intestinal tract.

The second type of acquired immunity is achieved through the formation of large numbers of highly specialized lymphocytes which are specifically sensitized against the invading foreign agents. These sensitized lymphocytes have the ability to attach to the foreign agents and to destroy them. This type of immunity is called cellular immunity. It is a highly complex system involving many different body organs (such as the spleen, thymus, lymph system and bone marrow) and also body fluids, particularly blood and its constituents and lymph.

The study of the complex system of immunity is termed immunology.

Effects of malnutrition on resistance to infection

A considerable amount of literature, documenting studies both in experimental animals and in people, demonstrates that dietary deficiency diseases may reduce the body's resistance to infections and adversely affect the immune system.

Some of the normal defence mechanisms of the body are impaired and do not function properly in the malnourished subject. For example, children with kwashiorkor were shown to be unable to form antibodies to either typhoid vaccine or diphtheria toxoid; their capacity to do so was restored after protein therapy. Similarly, children with protein malnutrition have an impaired antibody response to inoculation with yellow fever vaccine. An inhibition of the agglutinating response to cholera antigen has been reported in children with kwashiorkor and nutritional marasmus. These studies provide a fairly clear indication that the malnourished body has a reduced ability to defend itself against infection.

Another defence mechanism that has been studied in relation to nutrition is that of leucocytosis (increased production of white blood cells) and phagocytic activity (destruction of bacteria by white corpuscles). Children with kwashiorkor show a lower than normal leucocyte response in the presence of an infection. Perhaps of greater importance is the reduced phagocytic efficiency in malnourished subjects of the polymorphonuclear leucocytes that are part of the fight against invading bacteria. When malnutrition is present, these cells appear to have a defect in their intracellular bactericidal (bacteria-destroying) capacity.

Although malnourished children frequently have increased immunoglobulin levels (presumably related to concurrent infections), they also may have depressed cell-mediated immunity. In a recent study, the extent of this depression was directly related to the severity of the protein-energy malnutrition (PEM). Serum transferrin levels are also low in those with severe PEM, and they often take considerable time to return to normal even after proper dietary treatment.

A quite different kind of interaction of nutrition and infection is seen in the effect of some deficiency diseases on the integrity of the tissues. Reduction in the integrity of certain epithelial surfaces, notably the skin and mucous membranes, decreases resistance to invasion and makes an easy avenue of entry for pathogenic organisms. Examples of this effect are cheilosis and angular stomatitis in riboflavin deficiency, bleeding gums and capillary fragility in vitamin C deficiency, flaky-paint dermatosis and atrophic intestinal changes in severe protein deficiency and serious eye lesions in vitamin A deficiency.

Effects of infection on nutritional status

Infection affects nutritional status in several ways. Perhaps the most important of these is that bacterial and some other infections lead to an increased loss of nitrogen from the body. This repercussion was first demonstrated in serious infections such as typhoid fever, but it has subsequently been shown in much milder infections such as otitis media, tonsillitis, chicken pox and abscesses.

Nitrogen is lost by several mechanisms. The principal one is probably increased breakdown of tissue protein and mobilization of amino acids, especially from the muscles. The nitrogen is excreted in the urine and is evidence of a depletion of body protein from muscles.

Full recovery is dependent upon the restoration of these amino acids to the tissues once the infection is overcome. This requires increased intake of protein, above maintenance levels, in the post-infection period. In children whose diet is marginal in protein content, or those who are already protein depleted, growth will be retarded during and after infections. In developing countries, children from poor families suffer from many infections in quick succession during the post-weaning period, and they often have multiple infections.

Anorexia or loss of appetite is another factor in the relationship between infection and nutrition. Infections, especially if accompanied by a fever, often lead to loss of appetite and therefore to reduced food intake. Some infectious diseases commonly cause vomiting, with the same result. In many societies mothers and often medical attendants as well consider it desirable to withhold food or to place the child with an infection on a liquid diet. Such a diet may consist of rice water, very dilute soups, water alone or some other fluid with a low calorie density and usually deficient in protein and other essential nutrients. The old adage of "starve a fever" is of doubtful validity, and this practice may have serious consequences for the child whose nutritional status is already precarious.

The traditional treatment of diarrhoea in some communities is to prescribe a purgative or enema. The gastro-enteritis may already have resulted in reduced absorption of nutrients from food, and the treatment may further aggravate this situation.

These are all examples of how illnesses such as measles, upper respiratory infections and gastro-intestinal infections may contribute to the development of malnutrition. The relationship of intestinal parasites, diarrhoea and measles to nutrition is discussed below.

Parasitic infections

Parasitic infections, particularly intestinal helminthic infections, are extremely prevalent and are increasingly being shown to have an adverse effect on nutritional status, especially in those heavily infected. Hookworms (Ancylostoma duodenale and Necator americanus) infect over µ00 million people, mainly the poor in tropical and subtropical countries. They used to cause a prevalent debilitating disease in the southern United States. Hookworms cause intestinal blood loss, and although it appears that most of the protein in the lost blood is absorbed lower down in the intestinal tract, there is considerable loss of iron.

Hookworm disease is a major cause of iron deficiency anaemia in many countries. The extent of the loss of blood and iron in hookworm infections has been studied (Layrisse and Roche, 1966): daily faecal blood loss per hookworm (N. americanus) was reported to be 0.031 ± 0.015 ml. It was estimated that about 350 hookworms in the intestine cause a daily loss of 10 ml of blood, or 2 mg of iron. Infection densities much higher than this are not uncommon. In Venezuela, where much of this work was done, iron losses greater than 3 mg per day often resulted in anaemia in adult males, and losses of half this amount frequently produced anaemia in women of child-bearing age and in young children.

Worldwide, roundworm (Ascaris lumbricoides) is among the most prevalent of intestinal parasites. It is estimated that 1 200 million people in the world (one-quarter of the world's population) harbour roundworms. The roundworm is large (15 to 30 cm long), so its own metabolic needs must be considerable. High parasite densities, particularly in children, are common in environments where sanitation is poor. Complications of ascariasis can develop, including intestinal obstruction or the presence of worms in aberrant sites such as the common bile duct. In some countries ascarids are a cause of surgical emergencies in children, and many with obstruction die. In the majority of children, however, when malnutrition is prevalent, deworming improves child growth.

Trichuris trichiura or whipworm inhabits the large intestine and infects about 600 million people worldwide. The worms are small and, in heavily infected children, may cause diarrhoea and abdominal pain.

Many children living in poor sanitary conditions are infected with several parasitic infections at the same time. In areas where infection with these three parasites is common and where malnutrition is prevalent, deworming of children leads to an improvement in growth, a reduction in the extent of malnutrition and an increase in appetite. It also positively influences physical fitness and perhaps psychological development.

Bilharzia or schistosomiasis infections are prevalent in some countries. They also contribute to poor nutrition, poor appetite and poor growth. The three organisms that cause schistosomiasis (Schistosoma haematobium, Schistosoma mansoni and Schistosoma japonicum) are flukes, rather than ordinary worms.

Somewhat less is known about the relationship between intestinal protozoa! diseases and nutrition, but amoebas, causing serious dysentery and liver abscess, are highly pathogenic organisms, and infection with Giardia lamblia may cause malabsorption and abdominal pain.

The fish tapeworm (Diphyllobothrium latum) has an avidity for vitamin B12 and can deprive its host of this vitamin, with megaloblastic anaemia resulting. The fish tapeworm is common in people in only limited geographic areas, mainly in temperate areas and where undercooked fish is frequently consumed.

In many northern industrialized countries, farm animals and domestic pets such as dogs and cats are dewormed routinely. Much evidence suggests that pigs grow better when they regularly receive anthelmintics. Now that highly effective, relatively inexpensive and safe broad-spectrum anthelmintics such as albendazole and mebendazole are available, routine mass deworming should be introduced where parasitic infections are prevalent in humans and where PEM and anaemia are common. Similarly, routine efforts to treat children with schistosomiasis using metrifonate or praziquantel seem highly desirable both to rid children of potential serious pathology and to improve their nutritional status. More attention needs to be given to population-based chemotherapy for these infections along with intensification of public health and other measures to reduce their transmission, including improved sanitation and water supplies. Such efforts would improve the health and nutritional status of millions of the world's children.

Effects of diarrhoea

Many studies have indicated that gastrointestinal infections, and especially diarrhoea, are very important in precipitating serious PEM. Diarrhoea is common in, and often lethal to, the young child. In breastfed infants there is often some protection during the first months of life, so diarrhoea is often a feature of the weaning process. Weanling diarrhoea is extraordinarily prevalent in poor communities throughout the world, both in tropical and temperate zones. The organism responsible varies and often cannot be identified. Diarrhoea was a major cause of mortality in children in industrialized countries up to the beginning of the twentieth century.

Several studies have shown that admissions of cases of malnutrition are greatly increased during the season when diarrhoea is most common. For example, in a report from the Islamic Republic of Iran, more than twice as many cases of PEM were admitted in the warm summer than in the cold winter. The incidence of diarrhoeal disease followed the same pattern.

Hospital and community studies indicate that cases of xerophthalmia and keratomalacia are frequently precipitated by gastro-enteritis, as well as by other infectious diseases such as measles and chicken pox. Xerophthalmia is the major cause of blindness in several Asian countries; it is also prevalent in certain parts of Africa, Latin America and the Near East.

Intestinal parasites may contribute to diarrhoea and to poor vitamin A status. The exact mechanism of this relationship has not been proved, but it is likely that many infections reduce vitamin A absorption and that some result in decreased consumption of foods containing vitamin A and carotene.

Diarrhoea can be fatal, usually because it can lead to severe dehydration (see Chapter 37). Diarrhoea, and the complication of dehydration, may be said to be a form of malnutrition. Dehydration is a "deficiency" in the body of water and mineral electrolytes, and providing adequate quantities of these cures the deficiency. The term "fluid electrolyte malnutrition" (FEM) has been coined for this condition. Provision of water and adequate minerals in home-prepared food, breastfeeding or administration of oral rehydration fluids is now the accepted treatment. Although these are forms of therapy or treatment, they are really refeeding and replenishment. However, prevention requires measures and interventions to reduce infections, poverty and malnutrition. These are essential if countries are to reduce the incidence of diarrhoea.

Fatality rates for measles and other infectious diseases

A dramatic illustration of the effect of malnutrition on infection is seen in the fatality rates for common childhood diseases such as measles. Measles is a severe disease with a case fatality rate of about 15 percent in many poor countries because the young children who develop it have poor nutritional status, lowered resistance and poor health. In Mexico the fatality rate for measles has been reported to be 180 times higher than that in the United States; in Guatemala, 268 times higher; and in Ecuador, 480 times higher. The decline in case fatality rates of measles in North America, Europe and other industrialized countries has been dramatic over the last century.

Differences in the clinical severity and the fatality rates of measles in developed and developing countries are due not to differences in virus virulence but to differences in the hosts' nutritional status. For example, during a measles epidemic in the United Republic of Tanzania that was causing considerable mortality among the children of poorer families, it was observed that fatalities from the disease were extremely uncommon in the children of families of moderate income, such as those of hospital employees. Measles is also related to vitamin A deficiency. It has been shown that providing vitamin A supplements to children with measles who have poor vitamin A status greatly reduces case fatality rates.

Immunization against measles is proving very effective, and in many countries measles incidence has been markedly reduced.

Other common infectious diseases such as whooping cough, diarrhoea and upper respiratory infections also have much more serious consequences in malnourished children than in those who are well nourished. Mortality statistics from most developing countries show that such communicable diseases are the major causes of death. It was observed in several African countries at the end of the Sahel famine that very few children were dying of starvation or malnutrition, but that deaths from measles, respiratory infections and other infectious diseases were still very much above pre-famine levels. It is clear that many, perhaps the majority, of these deaths were due to malnutrition. This may seem a moot point for a grieving parent, but for the policy planner and the public health official it is important to know to what extent morbidity and mortality rates are due to or related to undernutrition.

An inter-American investigation of mortality in childhood showed that of 35 000 deaths of children under five years of age in ten countries, in 57 percent of the cases malnutrition was either the underlying or an associated cause of death. Nutritional deficiency was the most serious health problem uncovered, and it was frequently associated with common infectious diseases.

HIV infection and AIDS

Perhaps no disease has a more dramatic and obvious effect on nutritional status than acquired immunodeficiency syndrome (AIDS), the disease caused by the human immunodeficiency virus (HIV). In Uganda for many years the disease was called "slim disease" because extreme thinness was the main visible manifestation of the disease. Although the mechanisms by which AIDS leads to severe malnutrition have not been proven, there is no doubt that the disease and its associated opportunistic infections cause marked anorexia, diarrhoea and malabsorption as well as increased nitrogen losses. Some of the infections and conditions that are part of the AIDS complex of diseases were known to affect nutritional status long before the HIV virus was identified: tuberculosis has for many decades been associated with cachexia and weight loss, and malignancies such as sarcoma have long been known to result in wasting as they advance.

For a discussion of the relationship of AIDS to breastfeeding, see Chapter 7.

Chronic diseases and old age

There is a relationship between certain chronic diseases and immune response. It has also been clearly shown that in old age immunologic response is reduced, and undernutrition worsens this decline. The association of diabetes with infections is well known, and it is clear that in diabetes there is often impaired cellular response. Other diseases, for example several cancers, may also be related to lowered immune response (see Chapter 23).

Intervention studies

There have been relatively few well-controlled intervention studies to demonstrate either the effects of improved diets on infection or the nutritional effects of control of infectious diseases. Research in the village of Candelaria in Colombia showed that diarrhoea declined sharply as a result of supplementary feeding of children. A similar study in a Guatemalan village illustrated a significant decline in morbidity and mortality from certain common illnesses following the introduction of a nutritious daily supplement for preschool children.

A classic study conducted in Narangwal in the Punjab region of India demonstrated the value of combining nutritional care and health care in one programme. Children were divided into four groups. One group was given dietary supplements, one group was given health care, one group received both the supplements and the health care, and the fourth group served as control. As far as nutritional status and certain other health parameters were concerned, the combined treatment gave the best results. Nutritional supplementation alone also had a major impact. In comparison with the control group, there was no improvement in the nutritional status of the group that received only medical care but no dietary supplements.

Nutrition, infection and national development

Clearly, the effects of nutritional status on infections and of infections on malnutrition signify a very important relationship. The majority of children in most developing countries suffer from malnutrition at some time in their first five years of life. The problems of infection and malnutrition are closely interrelated, yet programmes to control communicable diseases and to improve nutrition tend to be introduced quite independently. It would be much more efficient and effective if the twin problems were attacked together.

Success in improving the health and reducing the mortality of children is dependent both on control of infectious diseases and on improvements in the children's food intake and care. There is increasing evidence to suggest that parents are more willing to control their family size when the chances are good that most children born will survive into adulthood. Consideration also needs to be given to providing a stimulating environment for the growing child.

The situation in the major industrial cities of Europe and North America a century ago was comparable to that in the poorest developing countries today. In New York City in the summer months of 1892, the infant mortality rate was 340 per 1 000, and diarrhoea. accounted for half these deaths. Improvements in nutrition, through the use of milk stations, for example, and a reduction in infectious disease served to lower these mortality rates by half in a period of less than 25 years. In the United Kingdom at the beginning of the twentieth century, rickets, combined with infectious diseases, took a heavy toll in the insanitary, smoky slums of the industrial cities, and measles was very often fatal among children of poor families, presumably because of poor nutrition.

Malnutrition and infections combine to pose an enormous hazard to the health of the majority of the world's population who live in poverty. This ever-present hazard particularly threatens children under five years of age. Many of the children who suffer from both malnutrition and a series of infections succumb and die. They are continually replaced in answer to parents' strong desire and often real need to have surviving children. The children who live beyond five years of age are not mainly those who have escaped malnutrition or infectious diseases, but those who have survived. Seldom are they left without the permanent sequelae or scars of their early health experiences. They are often retarded in their physical, psychological or behavioural development, and they may have other abnormalities that contribute to a less than optimal ability to function as adults and possibly to a shortened life expectation. Other factors influencing the development of these children include a lack of environmental stimulation and a host of other deprivations related to poverty.

The challenge to health workers, development economists, governments and international agencies is how best to reduce the morbidity, mortality and permanent sequelae that result from the synergism of malnutrition and infection. The politicians must be persuaded that attention to these problems is not only highly desirable but politically advantageous.

The control of infectious diseases and projects aimed at providing more and better food for people are fully justified and important components of a development plan. By themselves they may contribute to increased productivity and better lives. An improved infant or toddler mortality rate, a lowered disease incidence and a better-nourished population are probably better indicators of development shall national averages of telephones or automobiles per 1 000 families, or even than dollars or pesos per caput. Efforts for the control of infectious diseases and the improvement of nutrition both deserve a high priority in development plans and in international or bilateral assistance to low-income countries. They should be undertaken together because they will be mutually reinforcing and more economical if provided in a coordinated manner rather than separately. An allied issue is the need to provide a stimulating environment for the growing child.

Historical and epidemiological evidence suggests that reductions in infant and child mortality and improvements in health and nutritional status may be prerequisites to successful family planning efforts. Birth spacing deserves a high priority, especially where women are already overworked and undernurtured. Parents in all countries should receive assistance to help them achieve their desired family size.

Alarming as the situation of children's malnutrition and infection is, there is a general tendency to overlook the significance of these conditions in adults. Weakness, lethargy, absenteeism, poor productivity and stress can all have social and economic costs for individuals, families and communities.

There seems to be unassailable logic in recommending coordinated programmes that have three objectives: to control infectious disease, to improve nutrition and to make family planning services widely available. These three types of endeavour may themselves be synergistic.

Chapter 4. Social and cultural factors in nutrition

Social factors and cultural practices in most countries have a very great influence on what people eat, on how they prepare food, on their feeding practices and on the foods they prefer. Nonetheless, cultural food practices are very rarely the main, or even an important, cause of malnutrition. On the contrary, many practices are specifically designed to protect and promote health; providing women with rich, energy-dense foods during the first months following childbirth is an example. It is true, however, that some traditional food practices and taboos in some societies may contribute to nutritional deficiencies among particular groups of the population. Nutritionists need to have a knowledge of the food habits and practices of the communities in which they work so that they can help to reinforce the positive habits as well as strive to change any negative ones.

Food habits and their origins

All people have their likes and dislikes and their beliefs about food, and many people are conservative in their food habits. They tend to like what their mothers cooked for them when they were young, the foods that are served on festive occasions or those eaten with friends and family away from home during their childhood. The foods that adults ate without a second thought in childhood are seldom totally disagreeable to them in later life.

What one society regards as normal or even highly desirable, however, another society may consider revolting or totally inedible. Animal milk is commonly consumed and liked by many people in Asia, Africa, Europe and the Americas, but in China it is rarely taken. Lobsters, crabs and shrimps are considered delicacies and prized foods by many people in Europe and North America, but are revolting to many people in Africa and Asia, especially those who live far from the sea. The French eat horse meat; the English generally do not. Many people will delightedly consume the flesh of monkeys, snakes, dogs and rats or will eat certain insects, yet many others find these foods most unappealing. Religion may have an important role in forbidding the consumption of certain foods. For example, neither the Muslim nor the Jewish peoples consume pork, and Hindus do not eat beef and are frequently vegetarians.

Food habits differ most widely in regard to which foods of animal origin are liked, disliked, eaten or not eaten in a society. The foods in question comprise many of those that are rich in good-quality protein and that contain haem iron, both of which are important nutrients. People who do not consume these foods are deprived of the opportunity of obtaining these nutrients easily. On the other hand, those who overconsume animal flesh, some seafoods, eggs and other foods of animal origin will have undesirable amounts of saturated fat and cholesterol in the diet. Balanced consumption is the key.

Relatively few people or societies have strong negative feelings about consuming cereals, roots, legumes, vegetables or fruit. They may have strong preferences and likes, but most maize-eating people are also willing to eat rice, and most rice-eating people will eat wheat products.

It is often stated that food habits seldom or never change and are difficult to change. This is not true; in many countries the current staple foods are not the same as those eaten even a century ago. Food habits and customs do change, and they are influenced in many different ways. Maize and cassava are not indigenous to Africa, yet they are now major food staples in many African countries. Potatoes originated in the Americas and later became an important food in Ireland.

Food preferences are not made and abolished by whims and fancies, of course. More often the adjustments are generated by social and economic changes that take place throughout the community or society. The issue is often not what foods are eaten but rather how much of each food is eaten and how the consumption is distributed within the society or within the family.

The tendency of many wage-earners to spend almost all their wages within a few days of receiving them often results in a family diet of varying nutritive value. The family eats much better just after one payday than just before the next. Wages are often paid monthly, and there seems little doubt that a change to weekly payment of wages would improve the diet of wage-earners and their families.

The person who controls the family finances influences (intentionally or unintentionally) both the family diet and the food fed to children. In general, when mothers, rather than just fathers, have some control over finances, the family diet is likely to be better. When the mother has little control over family funds, dietary arrangements may become haphazard or even dangerous.

Nutrition education has been an important influence on food habits, and not always a positive one. Fortunately, the days are long gone when nutritionists promoted costly protein-rich foods to eople who couldn't possibly afford them. Unfortunately, the tendency to single out foods or nutrients either to promote or to prohibit has not yet gone, nor has the tendency to try to teach by creating fear and taking the enjoyment out of eating. However, change always comes slowly and old habits die hard; people who were taught in these old ways are still responsible for feeding themselves and their families, and they may find it hard to change again.

Nutritional advantages of traditional food habits

The traditional diets of most societies in developing countries are good. Usually only minor changes are needed to enable them to satisfy the nutrient requirements of all members of the family. Although the quantity of food eaten is a more common problem than the quality, this chapter focuses on types of food and eating habits.

Eating certain protein-rich foods such as insects, snakes, baboons, mongooses, dogs, cats, unusual seafoods and snails is definitely beneficial. Another habit that is good nutritionally is the consumption of animal blood. Some African tribes puncture the vein of a cow, draw off a calabash of blood, arrest the bleeding and consume the blood, usually after mixing it with milk. Blood is a rich food, and mixed with milk it is highly nutritious.

A custom frequently found among pastoral and other peoples is the drinking of soured or curdled milk, rather than fresh. The souring of milk has little effect on its nutritive value but often substantially reduces the number of pathogenic organisms present. In communities where milking is not hygienically performed and where the containers into which the milk goes are likely to be contaminated, it is safer to drink sour rather than fresh milk. Boiled milk would be safer still.

Many societies, for example in Indonesia and in parts of Africa, partly ferment foods before consumption. Fermentation may both improve the nutritional quality and reduce bacterial contamination of the food.

The traditional use of certain dark green leaves among rural peoples is another beneficial practice and should be encouraged. These leaves are rich sources of carotene, ascorbic acid, iron and calcium; they also contain useful quantities of protein. Non-cultivated or wild dark green leaves such as amaranth leaves as well as those from cultivated food crops such as pumpkin, sweet potato and cassava are much richer in vitamins than pale, leafy vegetables of European origin such as cabbage and lettuce. Well-meaning expatriate horticulturists in Africa have too often tried to get villagers to cultivate such European vegetables rather shall their traditional vegetables.

Many wild fruits are rich in vitamin C; an example is the pulp within the pod of the frequently consumed baobab.

Traditional grain preparation methods produce a more nutritious product than does elaborate machine milling.

Some communities sprout legume seeds prior to cooking, which enhances their nutritive value, as does the soaking of whole-grain cereals before their processing into local beers and some non-alcoholic beverages. These seeds and grains usually have a high vitamin B content. Finally, it cannot be stressed too strongly that the traditional method of infant feeding- from the breast - is nutritionally far superior to bottle-feeding (see Chapter 7).

Food taboos

A number of food habits and practices are poor from a nutritional point of view. Some practices result from traditional views about food that are liable to change under the influence of neighbouring peoples, travel, education, etc. Other food practices are governed by definite taboos.

A taboo may be followed by a whole national group or tribe, by part of a tribe or by certain groups in the society. Within the society, different food customs may be practiced only by women or children, or by pregnant women or female children. In certain cases traditional food customs are practiced by a particular age group, and in other instances a taboo may be linked with an occupation such as hunting. At other times or in other individuals a taboo may be imposed because of some particular event such as an illness or an initiation ceremony.

Although these matters border on the realm of anthropology, it is important for a nutritionist to be familiar with the food customs of people in order to be able to improve their nutritional status through nutrition education or other means. Moreover, it is evident that anthropology and sociology are important to the nutrition worker who is either investigating or trying to improve the nutritional status of any community.

Some customs and taboos have known origins, and many are logical, although the original reasons may no longer be known. The custom may have become part of the religion of the people involved. For example, the Jewish taboo against pork was probably introduced to eliminate the prevalent pork tapeworm, which was thought to be sapping the strength of the Jewish people. Even though 2 000 years later it is now possible to eat pork safely, Jews still do not eat pork. Muslims share this view about pork. In neither case is this a nutritionally damaging taboo.

Many taboos concern the consumption of protein-rich animal foods, often by those groups of the community most in need of protein. A common taboo in Africa against the consumption of eggs is rapidly disappearing. This taboo usually applies to females, who are said to become sterile if they eat eggs. The psychological connection between human fertility and the egg is obvious. In other places the custom applies to children, perhaps to discourage them from stealing the eggs of setting hens, which would endanger the survival of poultry. Other customs, again often affecting women and children, concern fish. These customs may amount to a full taboo, although people not used to fish often dislike it merely because they find its smell distasteful or its appearance "snake-like". Many cultures have strong views about the consumption of milk or milk products.

The customs that prohibit consumption of certain nutritionally valuable foods may not have an important overall nutritional impact, particularly if only one or two food items are affected. Some societies, however, forbid such a wide range of foods to women during pregnancy that it is difficult for them to obtain a balanced diet.

Many of the nutritionally undesirable taboos that existed a quarter of a century ago have weakened or disappeared as a result of education, mixing of people from different societies and travel. Of those that remain, some food habits may seem illogical and their origins obscure, but it is not advisable for outsiders to try to alter ancient food habits without looking very closely into their origins. Moreover, it makes no sense to attempt to alter a habit that does not negatively affect nutritional status.

Nutritionally bad habits, like all other habits, are best changed by the people who have them. In this regard, influential local people, with the welfare of their fellows at heart, may join nutritionists and become part of an important alliance pledged to eradicating malnutrition. A speech by the president or a cabinet minister, the sight of a respected tribe leader eating some forbidden food and coming to no harm or the return to the village of educated and enlightened local people will prove much more effective than the preaching or goading of an outsider.

Changing food habits

In some parts of the world the staple foods are changing or have changed. Maize, cassava and potatoes, now grown in large amounts in Africa, originated outside the continent. Since none of these foods were eaten in Africa a few hundred years ago, it is clear that the food habits of millions of people have changed. Vast numbers of people in Africa have abandoned yams and millet for maize and cassava, just as many in Europe abandoned oats, barley and rye for wheat and potatoes. Food habits are still changing rapidly. The difficulty, of course, lies in trying to guide and foster desirable changes and to slow down undesirable ones.

It is often difficult to fathom what factors have been most important in stimulating or influencing changes in food habits. The rapid increase in bread consumption in many African, Latin American and Asian countries where wheat is not the staple food is understandable. It is at least in part a labour-saving phenomenon; bread is one of the first "convenience" foods to have become available. Before leaving home to go to work one can eat some slices of bread instead of the traditional breakfast of porridge, which requires preparation time and is unpleasant cold. Bread can be carried in the pocket and eaten during a break in the working day, or when travelling.

In most of the world the traditional main staple food has remained constant, irrespective of urbanization, modernization or even westernization. Thus in much of Asia rice remains the preferred staple food in rural and urban areas. Some people in Africa, such as the Buganda in Uganda and the Wachagga in the United Republic of Tanzania, continue to have a preference for plantains as their staple food. Maize based products such as tortillas remain important in the diets of most Mexicans and many in Central America.

Changes in food habits are not just accidental, of course; they can be deliberately initiated. At community and family level, school-age children can be important agents for change. They are still forming their tastes and developing their preferences. If they are introduced to a new food they will often readily accept it and like it. School meals may usefully introduce new foods to children and thus influence food habits. This widening of food experience in childhood is extremely important. Children may influence the immediate family and later their own children to eat new, highly nutritious foods.

Harmful new habits

Not all change is desirable, of course, and not all new food habits are good. Chapter 7 describes in detail the harmful effects of the rapid spread of bottle-feeding using infant formula or animal milk in place of breastfeeding. This is an undesirable, relatively new food trend. Less attention has been given to the question of other baby foods that have been marketed and much promoted and advertised in developing countries. Locally available complementary or weaning foods, home-produced and traditionally fed, are often as or more nutritious than the manufactured baby foods, and then are always much cheaper. They are usually introduced gradually while breastfeeding continues well into the second year and beyond. Manufactured baby foods should only be promoted to those who are unable or unwilling to continue breastfeeding. They are safe and nutritionally adequate when prepared hygienically and in the right dilution. They are convenient for those who can afford to purchase them. However, such manufactured foods are expensive compared with local foods, and for most families in developing countries, other than the very affluent, they may be a waste of money. For families who already have too little money to spend on food and other essentials, these foods are a very expensive way of buying the nutrients that they are advertised to contain.

Another particularly misleading type of advertising relates to the glucose products said to provide "instant energy". Energy is present in large amounts in nearly all the cheapest foods. Similarly, drinks advertised as "rich in vitamin C" are usually unnecessary, since few children suffer from vitamin C deficiency. Vitamin C can be obtained just as well from fruits such as guavas, mangoes and citrus, or from a range of vegetables.

The so-called protein-rich weaning foods are also much advertised. These arc nutritionally good products, but they cost much more shall protein-rich foods available in the market such as beaus, groundnuts or dried fish, meat, eggs or milk. It usually costs much more to provide 100 g of protein from these commercially advertised products than, for example, from beans bought in the local market. The essential question is how a mother could best improve her child's diet if she had a little extra to spend. The answer would seldom be a manufactured baby food.

In some countries the staple food has remained unaltered, but the form in which it is preferred may have changed over the years. As described in Chapter 16, the rapid spread and popularity of highly milled rice in Asia had disastrous consequences and led to a high prevalence of beriberi, with much morbidity and many deaths. In many parts of the world highly milled cereals have replaced traditionally lightly milled and more nutritious wheat, rice and maize. In the United Kingdom and the Russian Federation, white bread has replaced brown or whole-grain breads, and in East Africa highly milled maize meal is often purchased and has replaced lightly milled maize flour. Urbanization, modernization and sophistication have often led to diets in which a greater percentage of energy intake comes from sugar and fats, and to increased consumption of salt. All Of these are generally undesirable changes from a nutritional standpoint.

Influencing change for the better

What can health workers or nutritionists in a community do about food habits, old and new? They can:

Chapter 38 describes the use of social marketing and other well-tested nutrition education techniques that can help achieve some of these objectives.

Chapter 5. Population, food, nutrition and family planning

Many thinkers in the world and many who work in the development field believe that the world's population size and increase is its greatest problem and humanity's gravest threat. Clearly the ratio of the number of people to the amount of food available has an impact on nutrition, but how are the two caused to interact? Late in the eighteenth century the British political economist Thomas Malthus grimly speculated that population growth could soon outstrip food production and supply. Close to the end of the twentieth century this has not yet happened, but malnutrition is widespread.

Many books and journal articles address the enormously important questions of population, demography and family planning. These texts should be consulted by readers wishing to understand population issues in their entirety. This chapter briefly discusses some aspects of fertility and family planning as they relate to nutrition, and observes their importance for the world and particularly for the developing countries, where most population growth is taking place.

Population growth

World population is increasing at an alarming rate. Unless the rate of increase is slowed down in the next few decades, the world will face extremely serious problems. Figure 1 illustrates the rate of population increase over the last 2 000 years. The world population was around 250 million people 2 000 years ago. After taking 16 centuries to double to 500 million, it then doubled in two and a half centuries to reach ] 000 million in 1850, and it doubled again in one century to reach 2 000 million people in 1950. Now the population of the world is doubling every 35 years; it reached 5 000 million before 1990.

Population pressure is most marked and is having a major impact in Asian countries such as Bangladesh, India and Pakistan. China has the largest population, but its government now manages to ensure that its people are reasonably fed. It has also recently managed to prevent any large increase in population.

FIGURE 1. Growth of world population

Africa as a whole may not be overpopulated at present, but population density is putting pressure on land distribution in certain areas. In Kenya the population is increasing at about 3 percent per year. At this rate - among the highest in the world - the population will double in 25 years. The country may well have sufficient land, food-producing capacity and other resources to meet the demands of double or triple the present number of people. However, doubling food production is not enough. Kenya must also double the number of schools or school places, of hospitals or hospital beds, of houses and of all services in the 25 years that it will take for the population to double. Even then it will only have maintained the current level of development.

Each government must take its own decisions concerning population policy, but all governments must be aware that, if the nutritional status of people is to improve, the availability of food and services must increase more rapidly than the population.

Clearly when the number of people in a country, a community or a family increases, its food needs also increase. However, food availability is influenced by more shall population size. Economics, politics and geography are factors, too. Hong Kong and the Netherlands are both densely populated, yet they have little hunger and their infant and child mortality rates are low.

In most developing countries - even the poorest - in Africa, Asia and Latin America, infant and young child mortality rates have declined markedly in the past 30 years. When women continued to have the same number of babies and fewer died, family size increased.

In some countries, increased family size has also resulted from narrower spacing between pregnancies (partly because of a shorter duration of exclusive or nearly exclusive breastfeeding, as discussed in Chapter 7), younger age at first pregnancy and lack of knowledge about, or lack of availability of, family planning services. It is generally agreed that when the mother or the parents have confidence that most children born are likely to survive into adulthood, they are much more likely to consider and practice birth control.

Many of the more prosperous countries, particularly in Europe, have reached the stage of zero population growth, excluding growth from immigration. This means that the number of births per year nearly equals the number of deaths. In contrast, many developing countries have far more births than deaths and, consequently, rapidly increasing populations. However, several poor countries have reduced their rate of population increase, mainly through family planning methods.


Overall population growth is not the only demographic concern of many developing countries. The rapid increase in the percentage of people living in large cities is also a growing worry.

Population in urban areas has increased in part because of increased fertility rates, but migration from the rural areas to the cities is also a major cause. City dwellers in general are consumers, not producers, of food; as they become more numerous relative to the rural residents, the food production burden on the few becomes greater. In 1900 there were only four cities in the world with over 2 million residents; now there are over 100 such cities, as well as a number of megalopoli with over 10 million inhabitants.

The nutritional outcome of urbanization is on the whole positive. Urbanization, together with population growth and increasing incomes, contributes to tremendous increases in food demand and thus in the volume of food required, but also to varied and dynamic changes in dietary structure. The most significant dietary change caused by the urban migration has been the substitution of staple foods such as roots, tubers and coarse grains by other sources of energy such as highly milled cereals, sugar, soft drinks and other processed foods. In the urban environment, time constraints, availability of cheap, often subsidized processed foods and convenience of preparation are important considerations in influencing food consumption patterns.

The urban diet is generally more varied than the rural diet, mainly because of changes in non-staple foods. Fish, fresh vegetables, meat, poultry, milk and dairy products are consumed more often by urban people. Urban populations generally have lower energy intake than rural populations, but their physical activity may also be comparatively low. Consumption of animal protein, fat and vitamin A is higher in urban areas, and the iron consumed is better utilized. On the whole the diets of urban populations are more balanced than those of rural people.

A typical effect of urbanization is an increase in the amount of food eaten outside the home. Commercially prepared meals and other ready-to-eat foods are consumed from street vendors and food stalls. In many developing countries an informal sector for the sale of food has developed as a typically indigenous response to some of the food needs of the cities; this sector provides a cheap source of food and a significant source of income, particularly for women.

Urban nutrition is also affected by the fact that in most low-income urban households women work outside the home; as a consequence there has been an almost universal decline in breastfeeding in urban areas in all regions of the developing world, with a concomitant increase in the use of more costly breastmilk substitutes and commercial weaning foods (see Chapter 7).

On average, urban dwellers enjoy better nutritional status than their rural counterparts because of better health coverage and greater diversity in the diet. A more varied urban diet with minimal seasonal fluctuations confers important nutritional benefits. FAO data show that the incidence of child malnutrition, especially chronic malnutrition, is lower in urban areas. In Ghana, the weights of the adult urban population were found to be higher than those of the rural population. In general, urban areas also have lower morbidity and mortality rates, increased life expectancy, fewer children of low birth weight and fewer growth problems.


Despite rapid population growth, the world produced enough food in 1995 to feed adequately all the people on the globe - if the food were equitably distributed. Even if the population of the world doubles from the current 5 500 million to 11 000 million by the year 2030, the world's production will be capable of feeding all those people. Beyond that level, unless population growth stabilizes, serious shortages of food could result. Unlimited population increase on a planet of finite size is impossible; before too long the world would have standing room only, and each inhabitant one square metre of space.

It is a credit to agricultural advances and the skills of farmers that food supplies have increased to meet population needs. Many countries have achieved increased production levels not by expanding the land under cultivation, but by increasing the yields of cereals and other important crops per hectare farmed. This trend will have to continue. In addition, processing and marketing of foods must be improved.

Reproduction and nutritional status

In most developing countries the mean age of first menstruation is 12 to 24 months later than in industrialized countries. Menarche usually occurs about 12 months after the year with the greatest growth spurt (also known as peak height velocity). The onset of menses signals the beginning of a female's ability to become pregnant. It is almost certain that undernutrition delays the onset of menses. In this way poor nutrition influences human fertility.

Starvation and severe undernourishment, as in food shortages or famines resulting from drought, war or other factors, will usually result in cessation of menstruation in women of child-bearing age. Women who have ceased to menstruate in this way are infertile until their food intake improves. This is nature's way of preventing conception in undernourished individuals. Psychological consequences also result (see Chapter 24).

Numerous pregnancies and lactations, especially at short intervals, are likely to deplete the mother of nutrients unless she has an exceptionally good diet. Therefore, women with many children narrowly spaced are more likely to have poor nutritional status.

A woman whose diet is deficient during pregnancy, especially in terms of total food and energy, is likely to give birth to a baby that is smaller than it would have been if she were adequately nourished. Since mortality is more likely in underweight babies, a poor maternal diet is seen to increase the chances of death in the baby. Some studies, for example in Guatemala, have shown that when the diets of pregnant women were supplemented their infants had higher birth weights.

It has also been shown that a short interval between successive children may increase their risk of malnutrition and even of dying, particularly for fifth and subsequent children. Pregnancies that are too numerous and too narrowly spaced may be harmful to both the mother and the child. A mother practicing family planning simply to space her children more widely benefits also in nutrition and health.

Family planning is intimately related to health and nutritional status. Small family size, long intervals between pregnancies and gradual termination of breastfeeding are all associated with good health, positive nutritional status and even decreased mortality rates in the mother and family.

The right to choose

Family planning is a concern of the family rather than the nation. People outside the family should become involved not in trying to limit the total number of children a couple should bear, but in giving the couple the means of determining themselves how many children they will have and at what intervals.

Family planning is also a right. Families, but women in particular, should be able to choose whether and when to have children. This choice used to be a luxury enjoyed only by those who had the knowledge to practice contraception and the funds to purchase contraceptive devices. Now education and services for family planning are available to more couples, providing them with the knowledge and means to prevent unwanted pregnancies. It has been said that every child born should be a wanted child; this is indeed a goal worthy of being pursued.

Breastfeeding, fertility and family planning

For many years the idea that lactation prevented pregnancy was considered an old wives' tale. Now it is known as a scientific fact that women who are intensively breastfeeding their babies do experience a longer interval before menstruation begins again, and they are therefore less likely to have an early successive pregnancy than those who do not breastfeed. Breastfeeding is likely to lengthen birth intervals by an average of five to eight months. In this way the prolongation of full breastfeeding in developing countries is having a major effect in reducing fertility, in population control and in child spacing. Breastfeeding is nature's way of helping to space children. If bottle-feeding were to replace breastfeeding without the availability of contraceptives, the result would be major increases in the number of children born.

Contraceptive pills, especially high-oestrogen pills, may reduce a woman's ability to produce breastmilk. Therefore care must be taken in advising women to take contraceptive pills soon after childbirth. In contrast, it has been suggested that the intra-uterine device (IUD) may enhance or improve lactation.

Some contraceptives may have an effect on nutritional status. Certain contraceptive pills are believed to cause anaemia because they affect folate utilization. The IUD may cause increased bleeding, which can lead to iron deficiency anaemia.

It seems likely that a decrease in infant and child mortality is a prerequisite to the wide acceptance of family planning in those societies in which childhood deaths are common. Parents need to have confidence that their children will survive before they will risk limiting their family size. As malnutrition is one of the leading causes or contributory causes of death in children, it follows that improved nutrition will expedite the acceptance of family planning.

Improved nutrition is part and parcel of a better quality of life. Having fewer children in a family means more food, more room and less poverty; these also contribute to an improved quality of life. Wider spacing of children results in improvements in the health and nutritional status of children and their mothers. There is thus a circular effect.

There is much sense in linking nutrition and family planning activities, and even in integrating them into one programme. Both are related to maternal and child health and to total family health care. It may be advantageous for the same health personnel to deal with nutrition, family planning and maternal and child health. Some countries, such as Indonesia, where family planning is having a significant impact in reducing the rate of population increase and where families are smaller shall they were 20 years ago, have combined family planning activities with nutrition and health programmes; it appears to have worked well.

The nutritionist's role in population and family planning

Nutritionists may be concerned about the alarming rate of increase of the world's population. Kenya, for example, had a population of 26 million in 1994 and will have over 50 million people in 2020; nutritionists may be alarmed by all the implications of this population growth in terms of land shortage and mushrooming urban slums. In their work, however, nutritionists usually deal with problems of families or communities. It is important then to help people, especially women and their partners, understand the benefits of smaller families and the fact that more children require more resources: more food, more care, more time, more school fees, more money and so on. The appropriate strategy may be to persuade them that children today have a better chance of surviving than children had in 1955, and that quality of life is more important than numbers of children.

It is of particular importance in many developing countries first to empower women to control their own fertility and to be in a position to have the numbers of children they desire, and second to influence men to respect these rights of their female partners. The onus of having more children falls on the whole family, but in most countries by far the greatest additional burden of work falls on the mother. It is she who must endure pregnancy for another nine months, breastfeed the infant, drain her own health and perhaps impair her own nutritional status.

The education of girls and the empowerment of women to earn money, control resources and have more independence are all achievements that generally lead women to control their own fertility and have fewer babies. Women's support groups, sex education in schools, involvement of men in discussions, later marriage and more intensive breastfeeding are all likely to reduce the mean number of babies produced per mother.

Nutrition workers, be they in the field of health, agriculture, education or social services, should make themselves conversant with modern methods of family planning. They should be able to discuss these methods with people either individually or in groups, and they should know how to advise people to use local family planning services. If these services are inadequate or cause problems for women or families, nutrition workers should be advocates for improved family planning services. The more the choices available to women and men, the more likely it is that the babies born will be wanted babies, Of course workers must respect national laws and cultural norms. If abortion is illegal, the law will need to be respected. Communities have been most successful in limiting unwanted births where several family planning methods are available: contraceptive pills, condoms, lUDs, male and female surgical sterilization and, if legal, well-conducted abortions. In some countries newer methods such as hormone-releasing implants (Norplant) or the so-called abortion pill may be expected to help in family planning in the next five years. The use of breastfeeding as a family planning method is discussed in Chapter 7.

Chapter 6. Nutrition during particular times in the life cycle: Pregnancy, lactation, infancy, childhood and old age

Nutrient requirements differ to some extent at different periods in the life cycle. Females of reproductive age have extra needs because of menstruation and, of course, during pregnancy and lactation. Infants and children have greater requirements on a unit weight basis than adults, mainly because they are growing. Older people are also a vulnerable group; they are at greater risk of malnutrition than younger adults.

Certain deficiency diseases are more prevalent in particular groups of the population. (The diseases are described and discussed in Part III.) In this chapter the emphasis is on the differing energy requirements of people at different stages of the life cycle.

Humans get energy from the foods and liquids they consume. The nutrient requirements of women of reproductive age (especially during pregnancy and lactation), of young children and adolescents and of older people are different from those of men between the ages of 15 and 60; therefore all people do not need the same amounts of food.

Figure 2 provides general guidance about the amounts of basic cooked foods needed each day by different categories of people.

Women of reproductive age

Women of child-bearing age have certain nutritional needs above those of adult males. One reason is that the loss of blood during menstruation leads to a regular loss of iron and other nutrients and makes women more prone than men to anaemia (see Chapter 13). In addition, however, in many developing countries women work much harder than men. In rural areas they are often heavily involved in agriculture, and in urban areas they may work long hours in factories and elsewhere; yet when they return home from the field or the factory they still have much work to do in the household, including food preparation and child care. Frequently the heavy burden of collecting water and fuel falls on women. All of this labour increases women's needs for nutritional energy and other nutrients.

The nutritional status of women before, during and after pregnancy contributes a good deal to their own general well-being, but also to that of their children and other members of the family. The field of maternal nutrition focuses attention on females as mothers. It has often concentrated on their nutritional status mainly as it is related to the well-being of the infants that they produce and their ability to breastfeed, nurture and raise their children. The health and well-being of the mother herself has been relatively neglected. Similarly, the field of maternal and child health has put major emphasis on the child and on providing services and help to women mainly so that they can have successful pregnancies and lactations; this is also in the interests of the infant, without much concern for the mother. The dual role of women as mothers and productive workers is compromised by poor diets and ill health; not only their own well-being but that of the whole family is affected. A heavy work load may push a woman with marginal food intake over the brink and into a state of malnutrition.

FIGURE 2. Comparison of amounts of basic cooked foods needed by different people each day

* On these diets menstruating and pregnant women need supplementary iron to cover needs. Fruit is included to increase iron absorption.

Source: King and Burgess, 1943

A poor diet, frequent acute and some chronic infections, repeated pregnancies, prolonged lactation and a heavy burden of work may all contribute to serious physiological depletion and sometimes to overt malnutrition. The term "maternal depletion syndrome'' has been suggested. In many countries young women in their late teens appear hearty, happy, healthy and attractive, but only ten or 15 years later, as young women in their late thirties, they are prematurely old, tired, down-trodden and unhealthy. Too often, the young female does not even live out her teens before her first pregnancy. Figure 3 illustrates the months of pregnancy and lactation for a Kenyan woman. She may not be completely typical of African mothers, but she is not atypical. During the, 25 years between age 18, when she first became pregnant, and age 43, she was pregnant for almost seven years, or 27.7 percent of the time; lactating for 16 years, or 65 percent of the time; and neither pregnant nor lactating for less than two years, or only 7 percent of the time. She hardly menstruated at all during these 25 years.

Pregnant women

During pregnancy a woman's nutritional needs become greater shall at other times in her life. Her diet needs to provide all the elements needed for the growth of a fertilized ovum or egg into a viable foetus and baby (see Table 4). As the woman nourishes herself she also nourishes the growing foetus as well as the placenta to which the foetus in her uterus is attached by its umbilical cord. At the same time her breast tissue prepares for lactation.

During the first half of pregnancy extra food is needed for the mother's uterus, breasts and blood - all of which increase in size or amount - as well as for the growth of the placenta. The increased need for food continues in the last half of the pregnancy, but during the last trimester the extra nutrients are required mainly for the rapidly growing foetus, which also needs to develop nutrient stores, particularly of vitamin A, iron and other micronutrients, and energy stores of fat. An adequate diet during pregnancy assists the mother to gain the extra weight that is physiologically desirable and helps ensure that the baby's birth weight is normal.

Healthy women gain weight during pregnancy if they are not overworked. Just as a heavy person needs more energy to perform the same amount of physical work as a lighter person, a pregnant woman also needs more energy. In industrialized countries many women have an easy life during pregnancy; they rest frequently, thus reducing their energy needs. However, in much of Africa and some other regions, pregnant women remain active, even during their last few months of pregnancy. The Basal metabolic rate (BMR) usually increases during pregnancy, which also raises energy requirements. Thus most women need more energy when they are pregnant, even if they are not overworked. For the overburdened woman of the developing world, who gets little rest and not much food, weight loss is a real and dangerous prospect.

There is little doubt that abortions, miscarriages and stillbirths are more common in women who are poorly nourished than in those who are adequately nourished. Dietary deficiencies probably also increase the risk of producing a malformed foetus. Severe malnutrition reduces fertility and therefore the likelihood of conception. A severely malnourished woman ceases to menstruate. This is clearly a natural device to stop the loss of nutrients in the menstrual flow and to protect the woman from the rigours of pregnancy and childbirth. Nevertheless, there is little evidence of lack of fertility among the less severely malnourished, and mildly malnourished women are the majority in Asia and parts of Africa.

FIGURE 3. Pregnancy and lactation of a Kenyan woman from 18 to 43 years of age

The weight of the infant at birth is influenced by maternal nutrition. Low birth weights can be expected of infants born to malnourished mothers. Even a modest increase in energy intake during pregnancy tends to increase the birth weight of the infant.

In many developing countries 50 to 75 percent of pregnant women have anaemia (see Chapter 13). Anaemia often contributes to high maternal mortality rates. All pregnant women should attend a clinic at regular intervals for antenatal examination which should include checking of haemoglobin levels. Practical advice should be given regarding diet, taking into account what foods are locally available and what the mother can afford. It is accepted policy in many countries that pregnant women be advised to take medicinal supplements of iron, or sometimes iron-folate.

In areas where vitamin A deficiency is known to be a public health problem, infants of mothers who have poor vitamin A status are born with low vitamin A stores.


Safe levels of intake of selected nutrients for active women of reproductive age






Vitamin A

Vitamin C







(µg retinol)



Not pregnant or lactating


2 210








2 410








2 710


13 26




A diet with adequate amounts of vitamin A is clearly important during pregnancy, both for the mother and the baby. However, high medicinal doses of vitamin A, as are given to young children, are not recommended during pregnancy. The recommended safe levels of intake of iron and folate, and also of vitamins A and C, are shown in Table 4. In the case of many other nutrients, however, the child is truly parasitic and takes all the nutrients it requires irrespective of whether the mother has a deficiency or not.

In some cultures there is a fear that extra food given during pregnancy will make the baby too large and thus cause a more difficult or complicated delivery. This is not true for healthy women of normal size. Women of short stature or with a contracted pelvis may have difficulty in delivering babies and may require special care before and during delivery.

At the time of birth the mother loses blood, not infrequently 500 to 1000 ml, and she needs nutrients to regenerate that blood.

Lactating mothers

In most developing countries the majority of women breastfeed their newborn infants for a period of weeks or months after delivery (see Chapter 7). The nutritional stores of a lactating woman may already be more or less depleted as a result of the pregnancy and the loss of blood during childbirth. Lactation raises nutrient needs, mainly because of the loss of nutrients first through colostrum and then through breastmilk.

Breastmilk volume varies widely, but for fully breastfed babies around four months of age, it is often 700 to 800 ml per day. It may rise later to as much as 1 000 ml or more. The nutrients present in this milk come from the diet of the mother or from her nutrient reserves. It is recommended that mothers exclusively breastfeed their infants for six months and then begin to introduce other food while continuing to breastfeed for as long as they wish, often into the second year or beyond.

During the period of exclusive or full breastfeeding the woman usually will not menstruate. The duration of amenorrhoea varies from as little as four months to as long as 18 months or more. During that time the lactating woman will not be losing the iron normally lost with each menstrual period.

The conversion of nutrients in food to nutrients in breastmilk is not entire. In the case of energy, it is about 80 percent, so for every 800 kcal in breastmilk the mother needs to consume 1 000 kcal in her food. To have good nutritional status the breastfeeding woman has to raise nutrient intake (see Table 4).

There is a widely held belief that the composition of breastmilk varies enormously. This is not so. Human breastmilk has a fairly constant composition, and is only selectively affected by the diet of the mother. One litre of milk provides about 750 calories and contains approximately the following:

The fat content of breastmilk varies somewhat. The carbohydrate, protein, fat, calcium and iron contents do not change much even if the mother is short of these in her diet. A mother whose diet is deficient in thiamine and vitamins A and C, however, produces less of these in her milk. Thiamine deficiency in the lactating mother can lead to infantile beriberi in the baby (see Chapter 16). In general the effect of very poor nutrition on a lactating woman is to reduce the quantity rather than the quality of breastmilk.

Lactating mothers should be encouraged to attend a clinic with their babies during the months after delivery. At the clinic both mother and baby should be examined. The mother should have her haemoglobin level checked and also her weight. Medicinal iron in the same quantities as recommended during pregnancy should be given. The mother should be given advice on consuming a mixed diet. This is also a good time to discuss the mother's desire for further pregnancies and her view of the ideal spacing between pregnancies and to provide information and help regarding family planning. Relatively wide spacing between births is usually to the nutritional advantage of the mother the infant and even the next foetus. Narrow spacing between births prevents the mother from restoring her nutrient reserves before the next pregnancy, provides her with more work and a shorter time to care for her infant exclusively, and may influence her to breastfeed for a shorter period than is desirable.

At each postnatal visit both the mother and the baby should be examined, and advice on the diets of both mother and infant should be provided. A satisfactory gain in the infant's weight is the best way to judge the adequacy of the diet of the infant. In the first few months when there is exclusive breastfeeding the infant's adequate weight gain is a clear indication that the mother is producing sufficient breastmilk. Almost all mothers can successfully breastfeed their infants.

Infants and preschool-age children

Provided that the mother has adequate breastmilk, breastfeeding alone with no added food or medicinal supplementation is all that is needed for the normal infant during the first six months of life. The advantages of exclusive breastfeeding during that period are discussed in the next chapter. Exclusive breastfeeding means that not even water, juice or other fluids are provided; none of these are needed. The infant should be examined regularly at the clinic, where weight gain is seen to indicate adequate nutrition. At the clinic a schedule for immunization will be set up, and this needs to be followed. Infants born with low weight (because of prematurity, for example) or twins may need special attention, and possibly iron or other supplements should be given. Up to six months of age many breastfed infants have considerable natural immunity to many infections.

As the children get older they gain weight and length. The increased energy requirements are based more on the weight of the child than on the age. Because healthy, well-nourished children follow a growth pattern, however, there is a close correlation between recommendations based on age and those based on weight. Table 5 shows the energy requirements of infants. A baby 2.5 months of age weighing 5 kg requires 5 x 120 kcal = 600 kcal, whereas a baby eight months of age weighing 8 kg requires 8 x 110 kcal = 880 kcal.

At six months of age complementary feeding should be introduced gradually while the infant continues to be breastfed intensively and to receive most of his or her energy and other nutrients from breastmilk and not from complementary foods. From six to 12 months, it is highly desirable that breastfeeding should continue and that the child should get as much milk as possible from the mother while other foods, first semi-solid and then solid, should be introduced to the diet of the infant for normal growth and health.

Breastmilk is relatively deficient in iron, and the infant's store of iron is sufficient only until about six months of age. From six to 12 months, the normal infant may be expected to gain between 2 and 3 kg. The infant, while continuing to receive breastmilk, will now need foods to provide extra energy, protein, iron, vitamin C and other nutrients for growth.

The needed energy can usually be obtained from a gruel of whatever is the local staple food. The quantity and bulk can profitably be reduced if some edible oil or fat-containing food is also eaten. If the staple is a cereal such as maize, wheat, millet or rice, it will also provide a useful quantity of protein, but if it is plantain or a root such as cassava or yam, it will supply very little protein. In this case, once relatively little breastmilk is being consumed it is important to provide extra protein-rich foods from those available to the family.

In the 1950s and 1960s it was thought to be very important that complementary foods and then foods given after termination of breastfeeding should include animal protein in large amounts. This has been shown to be unnecessary. In developing countries these foods are often too expensive for poor families or are unavailable. More important is the need to feed the young child frequently, with foods that are not too bulky and are both nutrititious and of high energy density.


Energy requirements of infants during the first year


Energy requirement













Legumes such as beans, peas, lentils, cowpeas and groundnuts are good sources of protein and should be added to the diet of the child. They can be ground or crushed before or after cooking.

The above foods, as well as providing energy and protein, will also provide some iron. Additional iron can be obtained from edible green leaves, which also contain carotene and vitamin C. Carotene and vitamin C can also be obtained from fruit. Ripe papayas and mangoes are excellent sources and are usually most acceptable to young children. Vitamin C can alternatively be provided by citrus fruits (e.g. Oranges) or other fruits (e.g. guavas). Gradually, as more teeth erupt, the child can be put on a more solid diet. By the age of two years, the child may have stopped breastfeeding and may be completely weaned.

The term "weaning" has been used to describe the introduction of foods and fluids other than breastmilk and the transition to a solid diet without breastmilk. However, people in Northern countries also talk of "weaning from the bottle". The word is therefore often misunderstood, and it may be better not to use it because of the confusion it causes. Rather, the transition can be described as four stages:

After sevrage appropriate family foods are provided. These need to be nutritious, suitable for the child, energy dense and given frequently, perhaps four to six times per day, not just in two or three meals per day as may be the family practice. The young child should be fed between family mealtimes if these are limited to two or three per day.

The mother responsible for feeding a toddler who is no longer breastfeeding must keep in mind that the child, whether boy or girl, has special needs.

Special needs of a young girl in the months following sevrage

· She needs a variety of foods, as great as or greater than that given to any other member of the family.

· She is growing rapidly and needs energy-dense foods and extra protein-rich foods.

· She has few teeth, and requires soft food.

· She has a relatively small appetite and intake capacity and needs more frequent meals than older persons.

· She requires clean food and clean utensils to avoid infection.

· She must as far as possible be protected from communicable diseases.

· She should have the love, affection and personal attention of her mother for her mental and, indirectly, her physical well-being.

· Attention from the father and other members of the family will also contribute to her development and well-being.

The proper feeding of a toddler requires time and patience. Special utensils or equipment are not necessary, but a sieve or strainer is useful. Adult foods can be chopped up and forced through a strainer into a cup or on to a plateful of gruel for the child. A strainer can readily be made if none is available. Otherwise, various foods can be crushed before cooking using a pestle and mortar, which are found in most households.

In some societies gruel or porridge made from the local staple is made sour or partially fermented. This is a good practice. Small amounts of germinated cereal seeds, often millet or sorghum, are crushed and added to maize or other porridge. The amylase present breaks down some of the starch, causing the porridge to become thinner (more liquid), so it is easier for the young child to consume, and making it more energy dense. The food is also safer, because the growth of disease-causing organisms is inhibited in sour or fermented gruel. Some societies sour children's foods by addition of lime or lemon juice. This also is advantageous, and enhances the absorption of iron.

The period from six to 36 months of age is of paramount importance nutritionally. The mother should take the child regularly to a clinic if one is available. The happiness, general appearance and weight of the child are the best general indicators of adequate nutrition. The use of a weight chart to help the mother follow the growth of the child is described in Chapter 34. Many children of this age in developing countries do not grow at the rate they should, and some develop protein-energy malnutrition (see Chapter 12).

The first three years of life are also those when the important micronutrient deficiencies of vitamin A and iron are most likely to occur in children. From three years of age the risks are reduced, but in many parts of the world growth continues to lag, incidence of intestinal worms and other parasitic diseases may increase and other nutrition and health risks arise.

From three years of age onwards the child has usually stopped breastfeeding and is consuming family foods. The child can now obtain adequate nutrients in three meals per day, but until the child reaches the age of five years, parents should make certain that the child is eating adequately and getting his or her fair share of the most desirable foods, which may well be those that are most tasty and in shortest supply. Special attention may need to be given when children have a poor appetite or when they are ill and their appetite is reduced. For the whole family, but especially for children, care must be taken that food, water and other fluids are safe and not contaminated. Good personal and household hygiene are of the greatest importance. Washing hands with soap and water before meals or food handling is a good family rule.

Kimea or power flour: an approach to providing more energy-dense foods

Traditional ways of thinning porridge, using products which are termed "malted" (from the process used in beer production), are now being recommended for societies that do not customarily use them. Malted flour, termed "kimea" in the United Republic of Tanzania, is usually made by germinating cereal seeds or grains by moistening them, drying them for a few days and then pulverizing the dried grains into a powder. When added even in tiny amounts to stiff maize porridge (called "ugali" in Tanzania, Kenya and elsewhere in Africa), kimea thins the porridge into a more liquid gruel (termed "uji"). This remarkable property has led to its being called "power flour". The power lies in the enzyme amylase which is in the germinated flour. Amylase digests starch, the complex carbohydrate in cereal grains, into simple carbohydrates, thereby thinning the porridge. This makes the food easier for the young child to eat, safer because it harbours fewer disease-causing bacteria, and perhaps easier to digest. Above all it is more energy dense.

Parents should understand the needs of the child and see that the right foods are available in adequate quantities and prepared in palatable ways

The nutrient requirements of children of different ages and weights are provided in Annex 1. It is clear that as children increase in weight and age they need more food to provide them with more energy and more of the other nutrients essential for growth and health. Thus a child aged six to 12 months and weighing 8.5 kg requires 950 kcal per day, whereas a child aged five to seven years weighing 19 kg requires 1 820 kcal [almost twice as much) and a boy aged 17 years weighing about 60 kg requires 2 770 kcal (almost three times as much).

Mothers need to understand that as children grow beyond infancy, they increase in weight and require more food to eat. Table 6 indicates that as young boys and girls get older, heavier, taller and more active, they need to eat more food, especially a greater quantity of staple foods including cereals (e.g. rice, maize, wheat) and legumes (e.g. beans, cowpeas).

School-age children

The vast majority of schoolchildren in developing countries attend primary schools. Most are at day schools, few of which provide a midday meal. In rural areas the school is often some kilometres from the parents' home. The child frequently has to leave home early and walk a considerable distance to school. Often the child has little or no breakfast at home before he or she sets out; there is no meal at school; and the first, and sometimes only, meal of the day is late in the afternoon.

The nutritional needs of a schoolchild are high. The adolescent child has proportionately higher requirements for most nutrients than the average adult. It is practically impossible for an adolescent to obtain adequate quantities of the right foods from one or even two meals a day. It is highly desirable that school-age children cat some food before going to school and some food at school, or during the middle of the day outside the school grounds, as well as the food eaten at home.

Food before going to school

It is not practical for many mothers to rise before dawn to spend the considerable time necessary to light a fire and prepare a hot meal for children before school-time. Therefore, if no hot breakfast is available, some fruit, cold cooked potatoes, rice, cassava or even cold porridge should be left over from the previous day for the schoolchild to eat before leaving home in the morning. In some areas cold chapattis, tortillas or wheat products such as bread may be available.

Food eaten at school

This may consist of a midday school meal or a snack taken to school.

A midday school meal is the ideal. It should provide reasonable amounts of the nutrients most likely to be missing or short in the home diet. A whole-grain cereal as the basis and a side dish of legumes with vegetables or green leaves make an excellent school meal. There are many possibilities, depending on what foods are locally available. The meal might include some protein-rich food and some food containing vitamins A and C.

School meals are beneficial because they often supply much-needed nutrients; they can form the basis for nutrition education; they are a good way of introducing new foods; and they prevent hunger and malnutrition. School meals, in addition to improving nutritional status, may increase enrolment, especially for girls, and may reduce absenteeism. However, in many developing countries, for many reasons, school meals are unavailable. Parents' organizations can sometimes work with teachers to organize community school feeding or food supplementation or nutritious snacks. School meals can provide a good environment for nutrition education. Further nutrition education can be carried out as an extracurricular project. A school vegetable garden or orchard can provide foods with valuable extra nutrients for the midday meal. Poultry keeping, small animal production (rabbits, guinea-pigs, pigeons, etc.) and fish pond construction, in areas where they are suitable, are educative projects and can provide food for a school meal


Amount of uncooked foods to satisfy the nutrient needs of children (g)


Cereal grains




Oils or fat





100- 125

75- 100

50 100




125 175
















A midday school meal might be provided by the government or local authority as part of the education system and could be paid for from the normal school fees Alternatively, a midday meal system might be started and paid for from special fees collected from the pupils daily, weekly or per term. Local organizations might provide certain food items free or at low prices for school feeding, thus reducing the overall cost.

The cost of school feeding can be reduced by local self-help efforts on the part of villagers, parents' committees and pupils These efforts may fit in well with self-help community projects For example, a small kitchen shelter can be built on a self-help basis Instead of a paid cook, a rota of parents can take turns doing the cooking. Pupils can collect fuelwood at weekends However, it must be stressed that the provision of a midday school meal must not detract from the parents' responsibilities to provide a good diet for schoolchildren at home.

In the absence of a school lunch, parents should send their children to school with some food to be eaten at midday. However, they may have real difficulty in finding suitable foods The various foods suggested for a cold breakfast can equally provide the solution for a midday snack The sort of food taken will vary according to what is available locally Possibilities include a few bananas, cooked whole cassava, sweet or ordinary potatoes roasted in their skins, fruit, tomatoes, roasted maize on the cob, roasted groundnuts, coconuts, cold grilled fish, smoked cooked meat, hard-boiled eggs, a calabash of sour milk or some bread, a chapatti or tortillas.

Some schools above primary level are boarding schools These usually provide three meals a day, and the menu should be based on recommendations made to the school by someone with dietetics training Occasionally schools plead lack of money as an excuse for an inadequate diet School meals need not be luxurious, but they should be balanced and should provide all the nutrients necessary for growth and health The child with an inadequate diet will not only fail to grow properly, but may also develop anaemia and other signs of malnutrition and will not be able to concentrate on or benefit fully from the education provided.

Increasingly in urban areas, and even to some extent in more heavily populated rural districts, entrepreneurs set up stalls and the like near schools so they can prepare and sell foods to schoolchildren (see Chapter 40) These "street foods" often have the advantage of providing access to cooked foods at relatively low cost, but the disadvantages include poor hygiene, poor-quality food and high prices. Where the main source of a midday snack or meal for primary or secondary schoolchildren is a vendor, the food is available only to children who have money to purchase it. Often the wealthier children participate and the children from the poorest families, or those whose parents will not provide money, do not.

Other concerns

The health of schoolchildren also needs consideration. In many countries school health services are non-existent or very poor. Examination for sight and hearing defects is important. Routine deworming might be initiated. Attention to micronutrient deficiencies may be needed in areas where children are at risk of iron, vitamin A or iodine deficiency. Iodine is especially important when girls reach puberty and before they have their first pregnancy.

Unfortunately, in some countries a large percentage of school-age children do not attend school. In some countries far more boys than girls attend school. Out-of-school children have the same nutritional and health needs as children attending school, but they do not benefit from school meals and other services. They are an often forgotten and relatively neglected group of the population, including children from the poorest families as well as children with disabilities, either physical or psychological.

Older persons

Older people, like all others, need a good diet that provides for all their nutrient needs. In more affluent societies, older adults are often plagued with chronic diseases that have nutritional origins or associations. These conditions include, among others, arteriosclerotic heart disease, sometimes leading to coronary thrombosis; hypertension, which may lead to stroke or other manifestations; diabetes, with its serious complications; osteoporosis, which frequently leads to hip fracture or collapse of vertebrae; and loss of teeth because of dental caries and periodontal disease. As discussed in Chapter 23, these diseases are rapidly becoming more prevalent in developing countries.

Many older people, especially if unfit, take less exercise and so may need less energy (see Annex 1). They may, therefore, eat less food and as a result get fewer micronutrients, but their needs for micronutrients are unchanged (see Figure 2). Consequently, conditions such as anaemia are common. Older people who have lost many or all of their teeth or who have gingivitis or other gum problems may find it difficult to chew many ordinary foods and may need softer foods. Fed on a normal family diet, they may eat too little and become malnourished. They may also suffer from illnesses which reduce their appetite or desire for food, which may also lead to malnutrition.

In many rural traditional societies old people are cared for at home by relatives and others in the community. By contrast, many older people in the richer, industrialized countries of the North live lonely lives and are relegated to old people's nursing homes and other unpleasant institutions. In some developing countries the traditional support systems and extended families are breaking down, especially with urbanization and migration, and old people there may end up lonely, living in poverty, with chronic illnesses, poor hearing and vision and perhaps psychological problems. Compounding these problems, they will face difficulties in producing food, purchasing it and preparing it.

Many of the older people are poor women, who are especially vulnerable. They are members of society in special need of both good care and a good diet, just as children are in their early years.

In some countries special services are established to help older or poor people obtain food in soup kitchens or in their homes. These services can be helpful. Preferable, however, would be community and family efforts to care for older people who cannot care for themselves and who are at risk of malnutrition and disease.

Chapter 7. Breastfeeding

For most of human history nearly all mothers have fed their infants in the normal, natural, no-fuss way: breastfeeding. Most traditional societies in Africa, Asia and Latin America have had good local knowledge about breastfeeding, although practices have varied from culture to culture.

The famous paediatrician Paul Gyorgy said, "Cows' milk is best for baby cows and human breastmilk is best for human babies". No one can deny the truth of that statement. It is increasingly acknowledged, therefore, that every mother has the right to breastfeed her baby and every infant has the right to be breastfed. Any obstacles placed in the way of breastfeeding are an infringement of these rights; yet in almost all countries there are many babies who are not breastfed or are breastfed for a relatively short time.

In recent years interest in breastfeeding has grown. Part of the reason is the much-publicized controversy over the replacement of breastfeeding by bottle-feeding and the related aggressive promotion of manufactured breastmilk substitutes by multinational corporations. The womanly art of breastfeeding has in recent years been rediscovered in Europe and to a lesser extent in North America. Unfortunately, however, use of bottle-feeding continues to increase in many non-industrialized countries of the South. The most serious consequences of this shift from breast to bottle are seen among poor families in Africa, Asia and Latin America.

Advantages of breastfeeding

Extensive studies comparing the composition and relative benefits of human milk and its substitutes have been published over the past 50 years and especially in the last decade. Most of the new research has supported the many advantages of breastfeeding over other methods of infant feeding. A vast body of research from all over the world sustains the recommendation that only breastmilk be fed to infants for the first six months of life. Certainly in developing countries where the risks of complementary feeding usually outweigh any possible advantages, breastfeeding alone up to six months of age is advised.

The advantages of breastfeeding over bottle-feeding and the reasons wily it is so strongly recommended are summarized as follows.

There is now overwhelming evidence of the health advantages of breastfeeding as indicated by lower infant morbidity and mortality than for bottle-fed infants. The advantages accrue mainly to tile two-thirds of the world's population who live in poverty, although some studies have shown lower rates of diarrhoea and other infections and less hospitalization among breastfed infants even in affluent communities. There is now evidence that women who breastfeed their infants have a reduced risk of breast cancer, and perhaps of uterine cancer, than women who do not.

Problems with bottle-feeding or feeding breastmilk substitutes

An infant who is not breastfed, or even one who is not exclusively breastfed for the first four to six months of life, loses many or all of the advantages of breastfeeding mentioned above. The most common alternative to breastfeeding is bottle-feeding, usually with a manufactured infant formula, but not infrequently with cows' milk or other liquids. Less commonly an infant in the first four to six months of life is fed solid foods in place of breastmilk. Some mothers do use a cup and spoon rather than a bottle to provide cows' milk, infant formula or gruel to young babies. Spoon-feeding has some advantages over bottle-feeding but is much less satisfactory than breastfeeding.


Whereas breastmilk is protective, alternative infant feeding methods increase the risk of infection, mainly because contamination leads to the increased intake of pathogenic organisms. Poor hygiene, particularly with bottle-feeding, is a major cause of childhood gastro-enteritis and diarrhoea Infant formula and cows' milk are good vehicles and culture media for pathogenic organisms. It is incredibly difficult to provide a clean, let alone sterile, feed to an infant from the bottle under the following circumstances:


Artificial feeding may contribute importantly in two ways to protein-energy malnutrition (PEM) including nutritional marasmus. First, as discussed earlier, formula-fed infants are more likely to get infectious including diarrhoea which then contribute to poor growth and PEM in infancy and early childhood. Second, mothers in poor families often overdilute infant formula. Because of the high cost of breastmilk substitutes, the family

purchases too little and tries to stretch it by using less than the recommended amounts of powdered formula per feed. The infant may be given the correct number of feedings and the recommended volume of liquid, but if it is too dilute each feed may be too low in energy and other nutrients to sustain optimal growth. The result is first growth faltering and then perhaps the slow development of nutritional marasmus.

Economic problems

A very important disadvantage of formula feeding is the cost for the family and for the nation. Breastmilk is produced in all countries, but infant formula is not. infant formula is a very expensive food, and if countries import it, then foreign exchange is unnecessarily spent. Choosing breastfeeding over bottle-feeding, therefore confers significant economic advantages for families and for poor countries.

Infant formula is a better product for a one-month-old baby shall fresh cows' milk or whole milk powder. Dried skimmed milk (DSM) and sweetened condensed milk are contraindicated. However, infant formula is extremely expensive relative to the incomes of poor families in developing countries. In India, Indonesia and Kenya it would cost a family 70 percent or more of the average labourer's wage to purchase adequate quantities of infant formula for a four-month-old baby. The purchase of formula as a substitute for breastmilk diverts scarce family monetary resources and increases poverty.

A baby three to four months of age needs about 800 ml of milk per day or perhaps 150 litres in the first six to seven months of life. In the first four months of life a baby of average weight would need about 22 kg or 44 half-kilogram cans of powdered formula. I {earth workers and those providing advice on infant feeding in any country should go to local shops, find the price of locally available breastmilk substitutes and estimate the cost of feeding that product in adequate amounts for a given period, say one or six months. This information should be publicized, made available to government officials and parents and used as far as possible to illustrate the economic implications for poor mothers who do not breastfeed.

For many countries that do not manufacture infant formula a decline in breastfeeding means an increase in tile importation of manufactured breastmilk substitutes and the paraphernalia needed for bottle-feeding, These imports may lead to a worsening of the already horrendous foreign debt problems for many developing countries. Even where infant formula is locally made, the manufacture is frequently controlled by a multinational corporation, and profits are exported. Therefore, the preservation of breastfeeding or a reduction in artificial feeding is in the economic interests of most developing countries. Economists and politicians may be more inclined to support programmes to promote breastfeeding when they appreciate that such measures will save foreign exchange; the economic implications are often of more interest to them than arguments about the health advantages of breastfeeding.

Properties and value of breastmilk

Immediately after giving birth to a baby, a mother produces colostrum from both breasts. Within a few days the milk "comes in", and it increases in quantity to match the needs of the baby. A mother's milk production is influenced mainly by the demands of her baby, whose sucking stimulates breastmilk secretion. The more the baby sucks, the more milk the mother will produce. The amount will often increase from about 100 to 200 ml on the third day after the baby's birth to 400 to 500 ml by the time the baby is ten days old.

Production can continue to increase to as much as 1 000 to 1 200 ml per day. A healthy, normally growing four-month-old infant of average weight will, if exclusively breastfed, receive 700 to 850 ml of breastmilk in 24 hours. Provided the babies can suckle as much as they want, they will always get enough milk. This is probably the only time in life when a person can eat as much of what he or she likes whenever he or she likes! Feeding on demand - any time, day or night - is the traditionally practiced method of breastfeeding. It is best achieved by a mother who is happy, relaxed, confident and free to be with her baby all the time. In these circumstances, the mother and baby form what has been termed a dyed - a special twosome.

One litre of breastmilk produces about 750 kcal. Cows' milk provides about three times more protein and four times more calcium, but only about 60 percent of the carbohydrate present in human breastmilk (see Table 7).

Most studies now clearly indicate that the nutrients present in milk from a healthy, well-nourished mother satisfy all the nutritional needs of the infant if the infant is consuming enough milk. Even though the iron content of breastmilk is low, it is sufficient and well enough absorbed to prevent anaemia during the first four to six months of life. Cows' milk is even lower in its iron content and is not very well absorbed by the baby, so infants fed cows' milk are very likely to develop iron deficiency anaemia.

Breastmilk may vary somewhat between individuals, and probably to some minor extent in different parts of the world. It is also different at the beginning and end of each feed. The so-called foremilk is more watery and contains less fat in comparison with the milk of the latter part of the feed, which is somewhat thicker and whiter in appearance and more energy dense because it contains more fat.

Of particular importance is the presence in colostrum and breastmilk of anti-infective factors (which are not present in infant formula). These include:

In simple terms, breastmilk leads to an environment in the intestines of the baby that is harmful and unfriendly to disease-causing organisms. The stool of a breastfed infant differs in appearance from that of a formula-fed baby.

Science and industry have combined to produce breastmilk substitutes which are intended to mimic breastmilk in terms of quantities of known nutrients present in mothers' milk. These products, often called infant formulas, are the best alternative to breastmilk for those few babies who cannot receive breastmilk. All infant formulas are based on mammalian milk, usually cows' milk. Even though infant formulas may be the best alternative to human breastmilk, they are not the same. They do include the known nutrients that are needed by the infant, but they may not include those nutrients that have not yet been identified; in this case it is not possible to know what the bottle-fed infant is missing. Indeed, in some respects infant formulas are so different from human milk as to be at best unsuitable and at worst dangerous. The manufactured milks do not have the anti-infective properties and living cells that are present in human milk. The manufactured products may cause the infant to suffer health problems that would never be brought on by human milk.


Nutrient content of 100 g of human breastmilk and cows' milk compared

Type of milk







Vitamin A


Vitamin C











Human milk










Cows' milk (whole)










Breastmilk, particularly because of the immunoglobulins it contains, seems to protect babies against allergies. In contrast, the non-human and cow proteins present in breastmilk substitutes, as well as other substances which enter infant formulas during manufacture, may provoke allergies. The important end result is a much higher rate of eczema, other allergies, colic and sudden infant death syndrome (SIDS) in formula-fed infants than in breastfed infants.

On top of everything else, the manufactured products are very expensive.


Colostrum is the yellowish or straw-coloured fluid produced by the breasts for the first few days after the birth of the baby. Colostrum is highly nutritious and rich in anti-infective properties. It could be said that the living cells, immunoglobulins and antibodies in colostrum constitute the infant's first immunization.

In most societies, colostrum is recognized to differ from breastmilk because of its colour and its creamy consistency, but its enormous value to the baby is not universally acknowledged. In many parts of the world mothers do not feed colostrum to their babies; they wait until white milk

is secreted from the breast. Some mothers (and grandmothers) think that in the first days after birth the newborn infant should receive other fluids or foods, for example, tea in India, jamus (traditional medicinal potions) in Indonesia and sugar or glucose water in many Western hospitals. These foods are not needed and are in fact contraindicated. The baby at birth has adequate body water and fluids and enough nutrients, so the only feeding needed is colostrum and then breastmilk for the first four to six months of life.

How breastmilk is made

The milk in the breasts is produced in large numbers of sac-like structures called the alveoli and is then carried in milk ducts to the nipple. The nipple has nerves and is sensitive to stimuli. Around the nipple is a roundish pigmented area called the areola, beneath which are glands which produce oil to keep the nipple and areola surface healthy. Milk production is influenced by hormones, particularly prolactin and oxytocin, and by reflexes.

The infant's sucking at the nipple stimulates the anterior pituitary gland in the brain to produce prolactin, which influences the alveoli to secrete milk. This mechanism is sometimes called the "milk secretion reflex".

Sucking also influences the posterior pituitary gland to release the hormone oxytocin into the blood. It travels to the breasts and causes contractions around the alveoli and the ducts to let down or eject the milk. This oxytocin effect is often termed the "let-down reflex". Oxytocin also has another action in that it stimulates the uterine muscles to contract; soon after the delivery of an infant, these uterine contractions reduce haemorrhage. They also help to return muscle tone, eliminating the pregnant look and giving back to the post-partum mother the shape that she hasn't seen for so long.

Infant feeding trends

The percentage of mothers who breastfeed their infants and the duration of breastfeeding varies among countries and within them. Exclusive or near exclusive breastfeeding for the first four to six months of life, followed by breastfeeding for many more months while other foods are introduced, is considered by scientists to provide optimum infant feeding. This ideal, however, does not exist in any country, North or South.

Most mothers in traditional societies, particularly in rural areas in developing countries, still breastfeed all their children for a long time. Few, however, practice exclusive breastfeeding, and many do not provide colostrum to their babies.

Many mothers in Europe and North America, by contrast, do not breastfeed their children. The trend away from breastfeeding was most marked in the 1950s and 1960s, when fewer than 15 percent of American babies two months of age were breastfed. During those years a marked decline in breastfeeding was reported from some Asian and Latin American countries. By the mid-1990s there was a modest resurgence of breastfeeding in the industrialized countries of the North, especially among, better-educated mothers. In poor Asian, African and Latin American countries breastfeeding rates are often lower in urban areas and higher in the rural areas where people have less education.

Breastmilk myths

Myth: Breastmilk varies from person to person. There is a widely held belief that the composition of breastmilk varies enormously. This is not so. Human breastmilk has a fairly constant composition.

Myth: The milk in one breast is different from the milk in the other breast.

Contrary to some beliefs, the milk in both breasts has the same composition.

Myth: Breastmilk ferments in the breasts in the heat.

When the breastmilk is in the breasts it is perfectly safe.

Myth: Breastmilk can spoil in the breasts.

Just as it cannot ferment in the breasts, breastmilk does not spoil in other ways.

There are many reasons for a decline in breastfeeding or for the unnecessary use of breastmilk substitutes, and the reasons vary from country to country. Aggressive promotion by the manufacturers of breast-milk substitutes is one cause. Promotional practices have now been regulated in many countries, but the manufacturers continue to circumvent the accepted codes of conduct and to promote their products, even though such practices may contribute to infant morbidity.

Actions by the medical profession have also contributed to the reduction in breastfeeding. In general, health care systems in most countries have not adequately supported breastfeeding. Even in many developing countries doctors and other health care professionals have had a negative role and have contributed to reduced levels of breastfeeding. This situation is changing, but many health professionals are still relatively ignorant about breastfeeding

Breastfeeding often declines when rural women move to urban areas, where traditional practices may get replaced by modern ones or be influenced by urbanization. Women who take jobs in factories and offices may come to believe that they cannot combine their employment with breastfeeding, and labour conditions and labour laws may also make it difficult for women to hold a job and breastfeed.

The female breast is accentuated in books and magazines, by the media (especially television) and by manufacturers and advertisers of women's clothes. The breast may become regarded as a dominant sex symbol, and women may then not wish to breastfeed their babies in public, or they may falsely come to believe that breastfeeding will mar the appearance of the breasts. At the same time, a belief may develop that it is superior, chic and sophisticated to bottle-feed. Breastfeeding may be regarded as a primitive practice, and the feeding bottle may become a status symbol. As a result in many areas of the world breastfeeding is declining despite all recent efforts in its favour.

Traditional breastfeeding practices do not fit in with the demands of modern societies in which women have to be absent from their homes and their children for extended periods, usually for work. Although employment legislation in some countries provides for breastfeeding breaks for workers, distance from home and transport problems make it impractical for mothers to take advantage of the breaks. Thus, while it may well be possible for a mother to breastfeed her baby when they are together (usually at home), when they are apart the baby must be bottle-fed with infant formula. The mother could also express her own milk and leave it for someone else to feed to the baby using a bottle or a cup and spoon, but in practice few women do this. Some consider expressing milk a bother (although it is very easy once the technique is acquired) or unpleasant, and many worry about storing the breastmilk safely.

Giving babies breastmilk substitutes at an early age is dangerous even where breastfeeding is continued. The unnecessary very early partial replacement of breastmilk with breastmilk substitutes from a bottle introduces risks and sometimes serious problems for the infant, the mother and the family.

Management of breastfeeding

If at all possible, breastfeeding should begin within minutes of delivery (or certainly within one hour). This early suckling has physiological advantages because it raises the levels of the hormone oxytocin secreted into the mother's blood. As described above, oxytocin causes uterine contractions which first help expel the placenta and then have an important role in reducing blood loss.

Soon after delivery the mother and her baby should be together in bed at home or in the hospital ward. In the past it was considered normal in modern hospitals to take the baby to a nursery ward and the mother to a maternity ward, but this practice is highly undesirable. Wherever "rooming-in" is not the current hospital practice, procedures need to be changed. It is absolutely safe for the baby to sleep in the same bed as the mother. There are very few contraindications (save serious illness in the mother or infant) for rooming-in or breastfeeding.

In the days after delivery, and as the baby gets older, breastfeeding should be done "on demand". That is, the baby should be breastfed when he or she wants to be fed and not,` as used to be common in Western countries, on a scheduled basis, such as every three or four hours. The epic poem "Song of Lawino", by the Ugandan poet Okot p'Bitek, praises breastfeeding on demand, in sickness and in health, and satirizes the mostly Western practice of regulated feeding, now widely acknowledged as harmful:

Feeding on demand stimulates the nipple and boosts production of milk, and it helps prevent breast engorgement.

The duration of feedings will vary and in general should not be limited. Usually a baby feeds for 8 to 12 minutes, but there are fast and slow feeders, and both types usually get an adequate quantity of milk. Some mothers believe that the milk from the left breast is different from that from the right, but this is not so; the baby should feed from both breasts more or less equally.

Babies in the first few days after birth usually lose weight, so a baby with birth weight of 3 kg may weigh 2.75 kg at five days of age. A loss of up to about 10 percent is not unusual, but by seven to ten days the baby should have regained or overtaken the birth weight.

Almost all experts now agree that the infant should be exclusively breastfed for the first four to six months. An adequate gain in weight is the best way of judging the adequacy of the diet. No water, juices or other fluids are needed for a baby getting adequate breastmilk, even in hot humid or hot arid areas of the tropics; the baby will simply feed more often if thirsty. If the baby has diarrhoea breastfeeding should continue, but other fluids such as oral rehydration solutions or local preparations may be needed.

Experience from countries in East Africa, Asia and Latin America suggests that most mothers living in extended families in traditional societies are very successful, often very expert breastfeeders, and failure of lactation is uncommon. Traditional family life is undoubtedly of great importance to the beginning breastfeeder. Other women in the family provide the support and comfort - especially if there are difficulties - that people in Europe and North America have to seek from organizations such as La Leche League.

At clinics, time is often wasted on lessons on Western textbook ideas about breastfeeding, including insistence on burping, timing of feeds or frequent washing of the nipples. This emphasis on rules and strictures rather than on relaxation and pleasure is not good for anyone anywhere. It has been known to have grave psychological effects, often resulting in failure of lactation. The low rate of successful breastfeeders in North America and Western Europe is an indication of how inadequate Western-style breastfeeding has been, except in Scandinavia.

Breastfeeding should not be a complicated, difficult procedure. It should be enjoyable for both mother and child, and given the right circumstances of security, support and encouragement it can be. Some women in all societies do have problems with breastfeeding, but many of these are solvable or can be relieved. It is important that mothers have easy access to good advice and support. Many books dealing with lactation and related problems are available, and they should be consulted.

Common breastfeeding problems include:

Breastfeeding problems

Complete lactation failure

Very few mothers - fewer than 3 percent-experience complete or nearly complete lactation failure. If the mother has serious difficulties, seeks help and really wants to breastfeed her very young baby, then some heroic methods may be necessary. The mother may need to be admitted to hospital and placed in a ward where other women are successfully breastfeeding. She and her infant should be examined for any physical reason for inability to breastfeed. The mother should be given plenty of fluids, including milk. These are mainly psychological inducements aimed to encourage lactation. In some societies local foods or potions are considered to be lactagogues, or substances that stimulate breastmilk production. There is no harm in trying these substances. A knowledgeable doctor or senior health worker may prescribe one of two drugs which are sometimes effective in improving or stimulating milk production: the tranquillizer chlorpromazine, 25 mg three times a day by mouth, or the newer drug metoclopramide, 10 mg three times a day.

In general, the important basis for treatment is to help the mother relax, to assist her in getting the baby to suck at the breast and to make certain that, while the breast is relied upon as much as possible, the baby is not losing weight. The dilemma is that the more the infant suckles at the breast, the greater the stimulation to production and let-down of milk; while the more the supplementary foods given, the less the infant will want to suckle.

If breastfeeding remains unsuccessful in an infant of up to three months of age, the mother should be taught to feed infant formula or milk to the baby either with a cup and spoon or with a feeding bowl. A cup and spoon are easier to keep clean than a bottle and teat. Some means should be found to provide the mother with adequate infant formula, fresh milk or full-cream milk powder if she cannot afford to buy it, which will often be the case. The infant should attend a clinic regularly.

This method of feeding also applies to the infant of a mother who dies in childbirth. It is then desirable to admit to hospital both the child and the female relative or care-giver who is to be responsible for the infant's feeding. An alternative is to find a lactating relative or friend to act as a wet nurse and to breastfeed the infant. Sometimes a friend or relative will be willing and able.

Failure of lactation or death of the mother after the infant is four months of age calls for a different regime. The child can be fed a thin gruel of whatever is the local staple food, to which should be added adequate quantities of milk or milk powder. It is advantageous to provide some extra fat in the infant's diet. A relatively small quantity of groundnut, sesame, cottonseed, red palm or other edible oil will markedly increase the baby's energy intake without adding too much bulk to the diet. If milk or milk powder is not available then any protein-rich food such as legumes, eggs, ground meat, fish or poultry may be used.

Insufficient milk production

Much more common than lactation failure is the belief by a mother that she is not producing enough breastmilk to satisfy her baby. Insufficient milk is very commonly reported by mothers in industrialized countries; perhaps the baby cries a lot or the mother feels that the baby is not growing adequately, or there may be any of a number of other reasons. In medicine this common condition is termed "insufficient milk syndrome". It is often at first a psychological concern rather than a serious condition, but it may rapidly lead to a real problem of milk production. Too often physicians, nurses and friends of the mother provide exactly the wrong advice to the mother concerned about her milk production.

In many studies, especially in industrialized countries, "insufficient milk" is cited as the most common reason given by mothers for their early termination of breastfeeding or for early supplementation with other foods, especially formula. It is all too easy to assume simply that many women are incapable of producing enough milk to feed their young infants. The busy practitioner's answer, when faced with a mother complaining of insufficient milk, is simply to advise her to supplement her breastmilk with bottle feeds. This may be exactly the wrong advice to give.

Suckling at the breast encourages the release of prolactin. The maintenance of lactation is dependent on adequate nipple stimulation by the suckling infant. It is now evident that diminishing breastmilk production results from reduced nipple stimulation. The cause of insufficient milk may therefore often be that alternative feeding has replaced breastfeeding to a variable degree. Therefore, advice to provide or increase supplementation is almost always going to contribute to a reduction in breastmilk production; supplementary bottle feeds are used as a cure for insufficient milk when in fact they are the cause.

The most appropriate treatment for insufficient milk syndrome in a mother who wishes to breastfeed is to advise her to try to increase milk production by putting the infant to the breast more frequently, in this way increasing stimulation of the nipples. The common medical advice, increasing bottle feeds, is likely to worsen the situation, leading to a further decline in milk production and eventual cessation of lactation. This is not to condemn supplementary feeding, especially after the infant is six months of age, but it should be clear that its use will almost inevitably contribute to a decline in milk production.

Maternal employment away from home is frequently cited as the most important reason for a decline in breastfeeding. Published surveys, however, seldom cite work as an important reason for not initiating breastfeeding or for early weaning from the breast. Clearly, employment out of the home for more than a few hours a day does place constraints on the opportunity to breastfeed and provides a reason for supplementary feeding. It may therefore contribute to the development of insufficient milk production.

Working mothers can continue to breastfeed successfully and can maintain good levels of lactation. Nipple stimulation from adequate suckling during the time they spend with their infants is particularly important for them. There is a need for labour laws and work conditions that recognize the special needs of lactating mothers in the labour force. If breastfeeding were accepted as necessary and usual practice by governments and employers, then arrangements would have to be made for a woman's baby to be near her for the first six months of life.

Past and present promotional practices by manufacturers of breastmilk substitutes may be an important factor contributing to the problem of insufficient milk. The companies find it advantageous to influence both the public and the medical profession to believe that supplementary bottle-feeding is the answer to insufficient milk.

The best and easiest way to judge whether or not a baby is getting enough breastmilk, when no other feeding is provided, is to weigh the baby regularly. Normal or near-normal weight gain provides the best evidence of adequate breastmilk production.

Breastfeeding, fertility and birth spacing

The traditional wisdom of many societies long included a belief that breastfeeding reduced the likelihood of an early pregnancy. Often this belief was regarded as an old wives' tale. Scientific evidence now proves beyond question that the intensity, frequency and duration of breastfeeding bears a positive relationship to the length of post-partum amenorrhoea, anovulation and reduced fertility. Mothers who breastfeed intensively find that there is a relatively long period after birth before menstruation resumes. In contrast, the interval between birth and the onset of monthly periods is short in women who do not breastfeed their babies. The physiology of this phenomenon is now reasonably clear; it is related to hormones produced as a result of sucking stimulation of the nipple.

This knowledge has important implications in terms of birth spacing and population dynamics. In many developing countries, breastfeeding now contributes more to child spacing and to prolonging intervals between births than does the combined use of contraceptive pills, intrauterine devices (IUDs), condoms, diaphragms and other modern contraceptives. Therefore the fertility-controlling benefits of breastfeeding should now be added to its other advantages.

Recent data from Kenya and elsewhere suggest that women who continue to breastfeed for a long time but also introduce bottle-feeding in the first few months of the infant's life may have shorter post-partum amenorrhoea than women who practise breastfeeding exclusively. The use of breastmilk substitutes in the first few months of life reduces sucking at the breast, thus lowering prolactin levels and leading to an earlier return of ovulation and menstruation even in mothers who breastfeed for a year or more. Thus bottle-feeding of babies contributes to a narrower spacing between births.

The so-called lactational amenorrhoea method (LAM) of natural family planning is now being widely and successfully used. If a mother has an infant under six months of age, is amenorrhoeic (with no vaginal bleeding from 56 days post partum) and is exclusively or almost fully breastfeeding her infant, then she is said to be 98 percent protected against pregnancy. She does not need to use any artificial family planning method.

Breastfeeding and AIDS

Human immunodeficiency virus (HIV) infection is now a major health challenge worldwide. Infection with HIV is followed, often some years later, by progressive disease and eventually by immunosuppression. The resulting syndrome, called acquired immunodeficiency syndrome (AIDS), is characterized by the development of various infections, often with diarrhoea and pneumonia, and malignancies such as Kaposi's sarcoma, leading eventually to death. In many developing countries HIV infection is almost as common in females as in males. Increasing numbers of infants and young children appear to be infected from their mothers. The exact mechanisms of transmission from the mother to the foetus or infant is not known. Transmission could occur in utero through passage of the virus across

the placenta; around the time of delivery through exposure to vaginal secretions, ingestion of maternal blood or maternal-foetal transfusion during labour and delivery; and in infancy through ingestion of the virus in breastmilk. In many countries HIV infection has been reported in 25 to 45 percent of infants born to HIV-positive mothers.

Evidence suggests that HIV can be transmitted from infected mothers to their uninfected infants through breastmilk. The virus has been isolated from human breastmilk. It was thought that the fragile virus might be destroyed by gastric acid and enzymes in the infant's gut and that the stomach and intestines of infants might be relatively impervious to the virus. This is probably largely true; by far the majority of babies breastfed by HIV-infected mothers do not become infected through breastmilk. It has been difficult, however, to determine whether a particular infant was infected prior to delivery, at the time of delivery or through breastfeeding. This uncertainty is partly due to the fact that both infected and uninfected infants acquire HIV antibodies passively from their infected mothers, but the presence of antibodies in standard HIV tests cannot be interpreted to mean active infection.

A pregnant woman with poor vitamin A status is more likely than others to pass the HIV infection to the foetus. Transmission from mother to infant through breastmilk is currently thought to be relatively rare. Some apparent differences in rates of transmission among groups of women from different countries may be related to vitamin A intake and other factors.

A consultation of the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) was clear in its recommendation, despite the current evidence of HIV transmission through breastmilk (WHO/UNICEF, 1992):

Many infants in Africa, Asia and Latin America live in settings where gastrointestinal infections are prevalent, hygiene is poor and water supplies are suspect. In these circumstances the many advantages of breastfeeding far outweigh the risk to the infant of AIDS infection through breastmilk from an HIV-positive mother. Only where the common causes of morbidity and mortality in infancy are not infectious diseases should public policy advise the use of bottle-feeding in place of breastfeeding to reduce the possibility of AIDS transmission. The individual mother should, of course, where feasible, be counselled by a doctor or trained health worker and cautioned about the relative risks to the infant of breastfeeding or alternative feeding methods in terms of disease and survival. This counselling will allow the mother to make an informed decision.

Control of infant formula promotion

Two factors stand out as the major reasons for a decline in breastfeeding: first, the promotion of breastmilk substitutes by their manufacturers, particularly the multinational corporations; and second, the failure of the health profession to advocate, protect and support breastfeeding. In the 1950s and 1960s a small group of physicians, paediatricians and nutritionists working in developing countries drew attention to the dangers of bottle-feeding and decried the role of industry in the decline of breastfeeding. In the 1970s public outrage arose over the aggressive promotion of infant formula using advertising, free supplies and other "hard sell" tactics. Most doctors and health workers in countries of both North and South were at best unsupportive of the growing public pressure to rein in the promotional activities of the corporations; at the worst, doctors sided with the manufacturers against the critics of the corporations.

In 1979, WHO and UNICEF organized a meeting in Geneva, Switzerland, at which a number of experts met with representatives of industry and of non-governmental organizations (NGOs) and delegates from selected countries to discuss possible regulations to control the promotion of breastmilk substitutes. At this conference participants took a decision to develop a code of conduct and agreed upon some of its main principles. Several meetings followed to develop wording for the code. On 21 May 1981 the World Health Assembly overwhelmingly adopted the International Code of Marketing of Breastmilk Substitutes. In 1994 the United States Government finally decided to support it. The code applies to the marketing of breastmilk substitutes, and its most important article states: "There should be no advertising or other form of promotion to the general public of products within the scope of this Code." Other details concern provision of samples at sales points; contact between marketing personnel and mothers; the use of health facilities for the promotion of infant formula; and the labelling and quality of products.

The code was a compromise between industry and those who believe that all promotion of infant formula should be barred, and it surely represents the minimum requirements. Its major provisions include:

The international code is not binding on individual countries, but it suggests that governments should take action to give effect to its principles and aims. Many countries have introduced legislation based on the code. The use of samples has declined but has not been halted. Many ministries of health are now more supportive of breastfeeding than in the past. However, it is often forgotten that the code was a compromise agreement, that it is the very minimum needed to address a small part of a large problem and that all codes have loopholes.

Although advertising to the public has ceased, manufacturers continue to advertise to health professionals; and companies are increasingly advertising to the public the use of their manufactured weaning foods for consumption by very young babies. Free formula is still provided by many manufacturers to hospitals in many countries. In exchange, the hospitals hand out free formula together with company literature to new mothers as they leave the hospital. This offering gives the mother the impression of medical endorsement of formula feeding.

Passage of the International Code of Marketing of Breast-milk Substitutes and of some other resolutions that are very supportive of breastfeeding has led to some complacency and to a false belief that the problem has been solved. Those who worked for the code knew that it could at best solve only a part of the problem, yet support for actions to deal with other important causes of decreased breastfeeding is now more difficult to obtain. There is currently a need to strengthen and broaden the code, to make it applicable to manufactured weaning foods as well as breastmilk substitutes and to prevent advertising to health professionals as well as to the general public. More support is needed for NGOs involved in monitoring the code and for their work to protect, support and promote breastfeeding.

The attitude of health professionals with regard to breastfeeding has improved over the last two decades. However, there is still much ignorance, and as a result the medical and health profession often has a negative impact on breastfeeding. The first need then is to educate all future health workers about breastfeeding and to reeducate present professionals. It follows that training of doctors, nurses, midwives and other health professionals must be improved. In some countries major efforts are under way, in which seminars and refresher courses are used to educate active health workers about sound infant-feeding practices.

Protection, support and promotion of breastfeeding

A country's or community's strategy to empower women and to assist mothers and their infants regarding the right to breastfeed needs to include three levels or categories of activity:

Although all three categories of activity are important, the relative effort put into each should depend on the current situation in the particular country. Thus, where traditional breastfeeding practices are the norm but infant formula is just beginning to make inroads, protection activities deserve highest priority. In contrast, in a country where the majority of women do not breastfeed at all, the major efforts should concern promotion. To use a health analogy, it can be said that protection and support are preventive measures, and promotion is a curative approach.

Protection of breastfeeding is aimed at guarding women who normally would successfully breastfeed against those forces that might cause them to alter this practice. All actions that prevent or curtail promotion of breastmilk substitutes, baby bottles and teats will have this effect. A strong code, properly enforced and monitored, will help protect breastfeeding. Various forms of formula promotion need to be curtailed, including promotion aimed at health professionals; distribution of samples, calendars and promotional materials; and hospital visits by manufacturers' staff. Legislative measures to curb these practices may be needed. Papua New Guinea has placed infant formula on prescription as a means of protecting breastfeeding. New measures need to be adopted in some countries to reduce the promotion of manufactured weaning foods and items such as glucose for child feeding.

What needs to be done to support breastfeeding in a country depends on the factors or problems that make breastfeeding more difficult. In many urban areas paid employment away from home is one such factor. Actions to allow women both to work away from home and to breastfeed are needed. A second factor relates to maternal morbidity, including breast problems during lactation. Unless health workers are supportive of breastfeeding, it is often found that mothers unnecessarily resort to breastmilk substitutes when they face such problems. A third important issue involves current health facility practices. Doctors need to understand that very few health conditions are absolute contraindications for breastfeeding. In many industrialized and non-industrialized countries, private voluntary agencies and NGOs have very useful roles in support of breastfeeding. La Leche League and other breastfeeding information groups have been important.

Promotion of breastfeeding includes motivation or re-education of mothers who otherwise might not be inclined to breastfeed their babies. In theory, promotion is the most difficult and certainly the most costly of the three options. In some societies, however, promotion is essential if breastfeeding is to become the preferred method of infant feeding. The usual approach involves mass media and education campaigns to make known the disadvantages of bottle-feeding and the advantages of breastfeeding. It is important to know the factors that have led to a decline in breastfeeding in an area and to understand how women regard breast- and bottle-feeding. A lack of such understanding has led to the failure of many promotional campaigns. Social marketing techniques, properly applied, have a greater chance of success. Promotion should address not only the health benefits, but also the economic and contraceptive advantages of breastfeeding. Often it is first necessary for politicians to be educated about these matters.

Both a strong political will and an ability to implement new policies are necessary for any plan to protect, support and promote breastfeeding.

The Baby Friendly Hospital Initiative (BFHI)

In 1992, UNICEF and WHO launched an initiative to help protect, support and promote breastfeeding by addressing problems in hospitals, such as practices that were not supportive of breastfeeding (for example, separation of mothers from their infants) and those that directly influenced mothers to formula-feed (for example, presentation of free formula packs to mothers). The two major objectives of BFHI were to end the distribution of free or low-cost supplies of breastmilk substitutes; and to ensure hospital practices supportive of breastfeeding.

BFHI may be less relevant for countries and communities where most babies are born outside the hospital setting. It may also be less influential in maternity hospitals in large cities in developing countries, where babies are discharged within 24 or 36 hours of delivery.

Breastfeeding and employment legislation

Some countries have made it easier for working women to breastfeed, and some employers of female labour have facilitated breastfeeding for mothers. These are exceptions, however, when they should be the rule. The FAO/WHO International Conference on Nutrition (ICN), held in Rome in 1992, acknowledged "the right of infants and mothers to exclusive breastfeeding". The Plan of Action for Nutrition adopted at the conference states that governments and others should "support and encourage mothers to breast-feed and adequately care for their children, whether formally or informally employed or doing unpaid work. ILO conventions and regulations covering this subject may be used as a starting point...".

Ten steps to successtul breastfeeding

The joint WHO/UNICEF statement Protecting, promoting and supporting breast-feeding: the special role of maternity services (WHO/UNICEF, 1989) spelled out the following practices, termed "Ten steps to successful breast-feeding", which hospitals and all facilities providing maternity services and care for newborn infants are expected to undertake in order to be considered baby friendly.

    1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

    2. Train all health care staff in skills necessary to implement this policy.

    3. Inform all pregnant women about the benefits and management of breastfeeding.

    4. Help mothers initiate breastfeeding within a half-hour of birth.

    5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.

    6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.

    7. Practise rooming-in - allow mothers and infants to remain together - 24 hours a day.

    8. Encourage breastfeeding on demand.

    9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

    10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The Maternity Protection Convention adopted by the International Labour Organisation (ILO) recognizes that women have a right to maternity leave and a right to breastfeed their infants. However, in many countries serious obstacles are placed in the way of mothers' rights to breastfeed. Among the common obstacles are very short maternity leave, or rejection of maternity leave for casual employees; job dismissal for those who do take maternity leave; lack of child care facilities which could be available in places where large numbers of women are employed; failure to provide breastfeeding breaks for women who could breastfeed during a long work shift; and open targeting of working women by formula companies to persuade them to formula-feed rather than breastfeed their infants.

What can be done? First, governments and the general public should ensure that at the very minimum the terms of the ILO Maternity Protection Convention are adhered to and never infringed. These terms include 12 weeks of maternity leave with cash benefits of at least 66 percent of previous earnings; two 30-minute breastfeeding breaks during each working day; and prohibition of dismissal during maternity leave. Other actions can be taken to:

Figure 4, taken from an action folder produced by the World Alliance for Breastfeeding Action (WABA) for World Breastfeeding Week in 1993, illustrates the requirements of time, space and support for mother-friendly workplaces.

International commitments in favour of breastfeeding

The nine years between 1981 and 1990 witnessed many international actions or pledges in support of breastfeeding. These include the adoption of the International Code of Marketing of Breast-milk Substitutes by the World Health Assembly in May 1981; the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, adopted by the WHO/UNICEF policy-makers' meeting Breastfeeding in the 1990s: A Global Initiative, in Florence, Italy in 1990; and the World Declaration on Nutrition and Plan of Action for Nutrition approved at the ICN in 1992.

FIGURE 4. Creating mother-friendly workplaces

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