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The prevention and control of diarrhoeal diseases


This article deals primarily with those measures that are designed to reduce the incidence of acute diarrhoeal illness of infectious origin. It should be underscored at the outset that the outcome of diarrhoeal disease may be powerfully influenced by management of the acute case, providing an opportunity to prevent some of the sequelae. These include life-threatening dehydration and serious growth impairmen Therapeutic actions are therefore in some sense also essential components of prevention.

Both the incidence of diarrhoea and the severity of its consequences appear to decline with increasing age. Children under the age of five years bear a major burden of the morbidity, but it is the children under two years on whom the impact of diarrhoea and associated malnutrition is greatest. The preventive strategies outlined here will therefore be strongly oriented toward reducing morbidity, and hence mortality, in this young age group.

Enterotoxigenic Escherichia cold organisms are pathogens of major importance in early childhood. They are commonly found in early weaning foods, introduced by contaminated water supplies, contaminated utensils, and unhygienic food handling. The problem is aggravated by the rapid multiplication that occurs in food if it is not consumed soon after preparation. Because E. cold is such an important pathogen in childhood diarrhoea, interrupting it. mode of transmission assumes particular importance in diarrhoea prevention and control.

Other important pathogens are rotaviruses, shigellae, and Giardia lamblia. These organisms do not usually multiply or even survive in the environment, but they are infectious in relatively small doses, and person-to-person spread is important, Their mode of spread underscores the importance of household and personal hygiene. Campylobacter jejuni and salmonellae, in contrast, infect many animal species besides man. They thus may be spread directly by contact with animal faeces, as well as through contaminated food or water.

Faeces Disposal

It is clear from even this superficial overview of diarrhoeal disease transmission that the safe disposal of human faeces (and the exclusion of animal faeces from the home environment) should logically lead to major reductions in transmission of many, if not all, of the above agents of diarrhoeal disease with a corresponding reduction of morbidity and mortality. In practice, few sanitation schemes have met with success, at least in the short term. Recurring shortcomings of such schemes include failure to assess disease perceptions and culturally entrenched behaviour patterns of relevance in a community, maladaptation between sanitary technology and the needs of a specific community, inadequate education toward optimal use of the facilities, and in general a failure to enlist the active participation of the community in the programme. Particular priority should be accorded to the safe disposal of faeces from active diarrhoeal cases, as they contribute the overwhelming proportion of pathogens in the environment. With the exception of asymptomatic carriers, normal human excrete do not transmit disease.

It should be recognized that in many communities, even where basic sanitation facilities exist and adults use them, young children are often permitted to defecate indiscriminately. Because diarrhoea attack rates are highest among children, it is the defecation in this age group that deserves the most attention.

Water Supplies

Contaminated water plays an important role in the transmission of enteropathogens, and there are usually strong desires at many levels of society for the provision of readily available, potable water. However, improved water supplies have many objectives (including lessening the work burden of women and children), only one of which is improved health. Many major capital-intensive water
improvement schemes have been singularly ineffective in reducing diarrhoeal morbidity. Many diarrhoeal agents are not primarily water-borne. Furthermore, it may be the quality and usage pattern of water in the home, not the purity of water at its source, that largely determines the impact of diarrhoeal morbidity on individual members of the community, particularly the children.

It is specious, therefore, to limit the consideration of water supplies to the provision of plentiful clean water at a common community source. Effective water improvement schemes should be accompanied by a health education component aimed at improving personal hygiene, with special reference to food hygiene and particularly weaning food preparation, as described later. The provision of comprehensive water supplies is often prohibitively expensive in most situations and may consume large resources, compromising possible investments in other equally or more effective interventions.

Child-Rearing Practices

Irrespective of the quality of the water and sanitary environment, it is the immediate physical environment to which the child is exposed, determined in large measure by personal hygiene, child care, and feeding practices of the mother, that is crucial in influencing transmission of diarrhoea among infants and children. These aspects of the immediate environment of the child are strongly influenced by individual behaviour. While relatively under-investigated, personal behaviour represents the most creative and potentially effective area for intervention to prevent diarrhoea. This kind of intervention does not depend upon major, capital-intensive investments and thus supports the self-sufficiency of poor families. Two such behaviour patterns that might be influenced favourably by intervention are breast-feeding and weaning practices.


Any measures to promote breast-feeding in communities where it is not universally practiced and to support and sustain the lactating mother and her milk output are likely to reduce both the prevalence and the impact of diarrhoea in infants. These measures might include strong efforts at the national level to limit the promotion and inappropriate use of commercial infant formulas. At the community level, health and nutrition interventions during pregnancy may influence birth weight and subsequent milk production and may delay the time at which other foods are required to complement the diet of the breast-fed infant. In this effort to maximize the quantity of breast milk as a safe supply of appropriate nutrients, it should be recognized that it may be possible in the future to boost the anti-infective properties in breast milk through specific interventions.

In terms of protection against diarrhoea, breast-feeding probably has an important direct role for up to six months and an indirect effect, by its contribution to the nutrition of young children, into the second year of life. There is, however, little doubt that even breast-fed infants enter the high-risk category, both in terms of the frequency and impact of diarrhoea, as soon as any kind of supplementary food is introduced.

This introduction of foods should therefore not begin unnecessarily early. The common practice of regular administration of drinks of water, juice, etc. to otherwise exclusively breast-fed infants should be critically examined and eliminated if no demonstrable benefits are documented. Advice on the most appropriate time for the introduction of supplementary foods should ideally be given to individuals on the basis of longitudinal monitoring of infant growth, incorporated into primary health care programmes. Attempts at blanket recommendations on the timing of supplements are correctly controversial. They will probably be inappropriate for entire communities, let alone individuals, and may be ignored by mothers.

Weaning Food Technology

Contaminated weaning foods of all sorts have been identified as major vehicles for the transmission of faecal pathogens during early infancy. This contamination appears to be worst in the earliest weaning foods, often dilute cereal gruels, cow's milk, or formula. Three aspects of weaning food technology should be examined for possible preventive interventions:

1. Preparation of dry ingredients. Bacterial contamination and multiplication can be reduced by developing and using weaning foods prepared from dry ingredients, which are subject to fewer risks of contamination and do not facilitate bacterial growth as readily as wet preparations do in tropical climates. Food preparation utensils, even when ostensibly cleaned, are commonly faecally contaminated in poor communities. Often, the foods themselves are contaminated with infectious organisms A further input of pathogens results from food handling, which could presumably be reduced by improved personal hygiene. A major source of contamination may be the quality of domestic water, reflecting water contaminated either at its source or during subsequent collection and storage in the home. Water for food production should be treated with the same care as drinking water. Much of the bacterial input could be reduced by dry storage and preparation of grains.

2. Cooking. More complete cooking of foods would reduce or eradicate pathogens. Constraints on cooking may be cost (fuel availability), time, and the effect on the final consistency of food (e.g., boiled cereal gruels become too glutinous). Village technology to reduce this gluey quality
already exists in some societies (e.g., germination and malting), thus permitting boiling of the gruel, and incidentally increasing bioavailability of nutrients. However, if the stages prior to cooking result in a "cleaner" product that can be stored safely, there may be little additional virtue in complete cooking.

3. Delays in consumption Usually, traditional foods are time-consuming to prepare, and a mother's time is hardpressed by other work demands. Thus, weaning foods are often made in bulk and fed to young children over the course of one or two days. Under such circumstances, high levels of enteropathogens in food are almost inevitable, because of rapid proliferation under tropical conditions. Every effort should therefore be made to reduce the standing time of already cooked weaning foods. Again, village technologies exist in some areas to ensure good shelf-life and reduce the need for cooking, as in the case of traditionally made yoghurts.

Nutrient Density and Quality

In addition to the problem of contamination, many early weaning foods are often grossly deficient in energy and nutrient content. As such, they fail to supply the necessary supplements, while exposing the infant to increased risk of diarrhoea. Some of these problems can be overcome by the incorporation of calorically dense oils and fats in the weaning food. More frequent feeds also increase overall intake while simultaneously reducing the standing time of already cooked weaning foods.

Household Hygiene

Increasingly, epidemiological and microbiological evidence has demonstrated that high levels of household contamination play a critical role in diarrhoeal disease transmission. Environmental surveillance invariably documents positive cultures for faecal coliforms on utensils, vessels, dishes, fingers, and other household sources. One key to the interruption of disease transmission, therefore, is use of household "technologies" and practices that either reduce the overall level of household faecal contamination or prevent the oral ingestion of faecally contaminated fluids and foods. Excrete disposal is obviously critical in this regard. Other means include simple, low-cost technologies such as narrow-necked water storage vessels that prevent hand contamination of drinking water, the use of alkaline lime water to clean child diapers and soiled hands, simple chlorination of water in the home before drinking, and simple gates and fences to segregate animals from living quarters.

Such technologies and practices should be developed to be consistent with specific local circumstances. It is also possible that behavioural changes, such as hand washing, may reduce disease transmission. These behavioural and technologic changes often can be achieved at low financial cost. Thus, within specific geocultural settings, it may be feasible to develop and promote practices that are consistent with the economic and cultural realities confronting individual families.

Access to and Use of Family Resources

There is presumptive evidence that some of the differences in diarrhoeal prevalence and malnutrition between families may be related to the varying efficiency and effectiveness of families, particularly the mother, in the use of available family resources. Promotion of breast-feeding and the preparation, cooking, and serving of uncontaminated nutritious weaning foods, cited above, are two such examples. Other illustrations are improved intrafamilial distribution of food to individual members, particularly to mothers and children. There is some indirect evidence that the educational level of parents, especially mothers, is an important ingredient in effective use of family resources.

Prevention of diarrhoea and malnutrition may also be improved by access to, and more effective use of, public and private social services by a family. Prompt and proper treatment of infections at a health centre, for example, would not only reduce the nutritional impact of disease, but would also enhance host defence systems of the child against the next infection. In this regard, the role and status of women in a society and their access to modern health knowledge may be critical in more effective use of external resources.

Role of the Physician and Other Health Professionals

The implementation of many of the preventive intervention at the personal, household, and community levels recommended in this article will require their integration into community-based health programmer. Although not a direct intervention, the training and re-orientation of health professionals, especially physicians, are seen as critical adjuncts to successful implementation.

Arguably, the physician, as typically trained in modern, high-technology, hospital-based medicine, is singularly unsuited to direct community-based programmes of diarrhoea prevention and other elements of primary health care among disadvantaged populations. Furthermore, notions of appropriate diarrhoea management, as transmitted in the leading medical textbooks, are outmoded for both developing and developed societies in light of recent research findings and have been shown to be detrimental to the rapid recovery of the patient. Efforts to re-orient the physician and other health professionals through training courses, seminars, and wider dissemination of current research results should be considered an essential component of fostering the proposed preventive measures.


Questions and answers about weaning

Gretchen G. Berggren Harvard School of Public Health, Department of Population Sciences, Boston, Massachusetts, USA

Field staff and planning officers in less developed countries of ten request up-to-date information about infant feeding, specifically breast-feeding and weaning. In response to their most frequently asked questions, a group of scientists from the International Food and Nutrition Program of the Harvard School of Public Flealth and the Massachusetts Institute of Technology discussed various aspects of infant nutrition about which there is broad consensus. Contributing authors were: Gretchen Perggren, Project Leader, Lindsay Allen, Warren Berggren, Richard Cash, Susan Colgate, John 0. Field, Hans Guggenheim, Kendall King, Richard Levins, Robert W. Morgan, Peter Pellett, Gretel Pelto, Pertti Pelto, David Pyle, tan Rawson, Nevin Scrimshaw, Noel Solomons, John Wyon, and Marion Zeit/in.


Q. What is weaning?

A. "Weaning" means more than removing the child from the breast. It includes the long critical period when the child slowly adapts to other adult foods while continuing to breast-feed.

Q. What is the appropriate period for weaning?

A. At four to six months the rapidly growing child normally needs his first supplementary food, usually a calorie-dense porridge or gruel. Over the next months pureed foods from the family diet should gradually be introduced, provided they are not too spicy. By the second year, the child should be eating most items from the family table. Even then, breast-feeding continues to make a nutritional contribution and can usually continue for two or more years.

Q. To what extent is breast-feeding a/one insufficient for the very young child?

A. Breast milk is the single best food a child can get and breast-feeding for two years or longer is desirable. The average infant who is fed on demand thrives on beast milk alone until about the fourth to sixth month. At that time he begins to need supplementary nutritious food to get enough calories and protein to grow properly and to resist disease. If the infant consumes a sufficient quantity, breast milk can supply enough high-quality protein to meet most of his needs for another year or so. However, hard-working and undernourished mothers may produce only enough breast milk to supply about 500 calories per day, which is insufficient. Starting at about four months, the additional calorie and nutrient needs can be supplied by appropriately prepared grains, legumes, oils, fruits, and nuts. In developing countries in which breast milk is not supplemented when necessary, research shows that by six to nine months infants are likely to become malnourished, to become vulnerable to common childhood diseases, to suffer growth problems that may be irreversible, and sometimes to die.

There is great individual variation in the amount of breast milk produced and in the metabolic needs of individual infants. For this reason the amount of supplementary food given to an infant should depend on how well he is growing.

Q. How frequently should children be fed?

A. Compared to adults, children have a smaller stomach capacity combined with a higher nutrient demand relative to their weight. They need to eat several small meals spread out during the day. In many countries constraints on food availability, mothers' time tar cooking, and the cost or inaccessibility of fuel have produced a household feeding schedule appropriate for adults but inadequate for children. The mother may find it extremely difficult to incorporate frequent infant feedings into her busy work schedule, but they are essential. The recommended weaning diet should include some foods that do not .require cooking ledge. mashed banana) and continued frequent breast-feedings.

Q. Are there genera/ principles about food types that can be applied widely in less-developed countries nerd,

A. Yes. A good weaning diet must provide enough calories (energy), protein, essential vitamins, and minerals. Starchy staple foods supply calories, but the semi-liquid, starchy porridges, gruels, or paps mothers give infants are sometimes too dilute to meet a child's full energy needs. If calorie needs are not met, growth will be retarded, and the body will break down its own protein to supply energy. Protein-energy malnutrition can result. Calorie density of weaning porridges can be improved by the addition of small amounts of sugar and/or oil. High calorie density means that a smaller volume can provide more calories; the child needs to eat less, and his protein requirements will be less.

Most starchy staple foods supply inadequate protein. Where protein of animal origin (meat, fish, eggs, milk, etc.) is costly or in short supply, legumes (beans, peas, or nuts) can complement cereal or tuber staples to increase the protein available from vegetable sources. A good rule of thumb for weaning foods used to supplement breast milk in most LDCs is that the mother combine three to four parts cereal flour (wheat, rice, corn, maize, millet, sorghum) with one part dried legume flour, or dried milk, to make an adequate weaning food mix. Dry cassava flour is of generally poor protein value and needs a mixture containing two parts cassava flour to one part legume or protein supplement. The weaning food mix (bimix = two ingredients; multimix = three or more ingredients) should be served several times a day as a thick, spoon-fed porridge to assure adequate nutrient intake.

Fresh fruits and vegetables supply necessary vitamins and minerals.

Q. How should a child's nutritional status be evaluated?

A. During the weaning period, weight-for-age is a simple, satisfactory measure of the adequacy of dietary intake. This should be assessed about every two months and remedial and corrective measures taken with the mother when growth is seen to be faltering. Weight-for-age becomes somewhat less reliable after two years of age, but for the critical "weaning age" it is the most sensitive single measure.

Q. Why distribute the so-called "Road to Health" tweight for-age J cards to mothers of weaning-age children?

A. The absolute weight-for-age reading is of less significance than satisfactory and steady gain over time. The weight for-age graph, usually printed on a card, is the most reliable indicator to mothers and health workers as to whether the child's diet is adequate during the weaning period. As long as the growth curve rises at a steady rate within a given "channel," the child is probably doing
well, even if relatively small for his age (i.e., in the lower weight-for-age percentiles). At many clinics, the mother keeps the card and brings it to the clinic with her child for monthly weight readings that are entered onto the card. The shape of the "growth curve" thus recorded on the card tells mother and health worker if the child is doing well. If the growth curve levels off or dips, this is a warning signal that the child's diet is inadequate, or that a serious infection is present.

Q. How can nutritional status be assessed when children's ages are not accurately known?

A. Weight for height, which is age-independent, can be used and does give a measure of the adequacy of dietary energy, particulary beyond the second year. Mid-arm circumference is a good predictor of mortality risk across the weaning age. It is a simple age-independent screening tool that can be used by the community to identify malnourished children.

Sometimes a mother can link her child's birth to events in the annual planting/harvesting/crop rotation cycles. If she remembers such an associated event, the child's approximate birth can be reconstructed. For children under two years of age, weight-for-age is the only satisfactory indicator of dietary adequacy for growth.

Q. What is the relationship of weaning practice to diarrhoeal disease and oral rehydration therapy?

A. Breast milk is clean and contains valuable antibodies that protect the child against diarrhoeal disease and other infections in his environment. As long as breast milk is the only food, diarrhoea is less common and not as severe. When weaning foods are introduced, they must be hygienically prepared and stored and easily digestible or else they will cause diarrhoea.

A weaning-age child actively explores his environment with hands and mouth. Teething distress makes him chew on any convenient object. For these reasons, he is very likely to ingest pathogenic organisms and develop diarrhoea. His environment should be kept clean, and breast-feeding should be continued as long as possible, so that the passively acquired antibodies can help prevent serious illness.

A child with diarrhoea loses his appetite and also absorbs nutrients less efficiently. Thus prolonged diarrhoea leads inevitably to malnutrition. In the short run, a child whose diarrhoeal fluid losses are not promptly replaced can die from dehydration. Oral rehydration therapy (ORT) using water, salt, sugar, and fruit juice found in the home should be taught as part of a comprehensive nutrition education program for mothers who are weaning their children.

A well-nourished child bounces back rapidly from a cold or intestinal illness, but malnutrition impairs the body's resistance to infection. Children who are not properly weaned get sick more frequently than well-fed ones, they suffer more serious bouts with illness, and are more likely to die of disease. Moreover, recovery is impaired when nutrient intake during convalescence is suboptimal. For these reasons, infant mortality rate is a useful indirect measure of the nutrition status of the children in a community.

Q. How important is water purity in weaning food preparation and in reducing the incidence of diarrhoea and ma/nutrition?

A. Research in Bangladesh and in the Gambia has shown the relationship between infant food contaminated with Escherichia co/i organisms and the high incidence of diarrhoea. Dirty water can contaminate weaning foods, but water is not the only source of contamination. Soiled hands, dirty utensils and storage vessels, and food that is contaminated before preparation are all sources of bacteria. The longer the food is kept before being eaten, the greater the chance of significant bacterial growth, especially in hot tropical climates. This means increased likelihood and severity of intestinal infections.

A workshop on diarrhoeal diseases held in Haiti in 1977 concluded that water impurity is probably less important than other factors such as faecal contamination of the environment. Adequate quantities of water are necessary to improve the general level of personal hygiene, and easy access to water is essential. If water must be carried several miles, hard-working villagers cannot spare the time or energy to make many trips. They will save their precious water for drinking and cooking, and dispense with handwashing, dishwashing, and proper laundering of clothing and bedclothes soiled with faeces.

In many countries fuel is too scarce and expensive to make boiling a realistic home purification method; and as indicated above, using boiled water does not insure an uncontaminated weaning food. Although water quality is obviously important, we should not overestimate its potential in reducing the incidence of diarrhoea. It must be coupled with education, handwashing, and the proper preparation of foods.

Q. How do food storage practices effect weaning?

A. Limited time and fuel supply make it impossible for most LDC mothers to cook several times a day. They may prepare one large meal and set the leftovers aside to serve later. Since refrigeration is generally unavailable, the food is often simply covered and stored in a cool, shady spot. Problems arise because many important protein foods (fresh meat, fish, milk, eggs) spoil rapidly without adequate protection. The danger of eating spoiled food may explain traditional taboos against feeding highly perishable protein food to intents. Food storage problems can also cause mothers to postpone weaning their children since they know-that weaning foods bring diarrhoea.

In some areas, large percentages of the food crop are lost to insects, rodents, mould, or rot because the farmers or householders do not know adequate storage techniques. Sometimes food is wasted because storage facilities are inadequate for the seasons when road transport is impossible. Thus improved storage techniques and facilities can decrease post-harvest food losses and eliminate seasonal and regional food shortages.

A "pre-cooked" home-made weaning food that can be stored dry and reconstituted "instantly" with potable water or milk would seem ideal. In some countries there are traditional foods that begin to meet these criteria, and with enrichment or other modifications, they could meet the requirements for a good weaning food. Traditional food preservation methods such as sundrying, smoking, salt-curing, and fermentation rely on low-cost indigenous technology and are most appropriate.

An alternative solution may be for local vendors to sell weaning food that they prepare freshly several times a day.

Q. Assuming an appropriate weaning food can be formulated, how do we get the community to adopt and utilize the new recipe in combating malnutrition?

A. New foods or food preparation methods have always spread rapidly if they provided a better adaptive strategy for the survival of a large population than did the foods they displaced. Marketing strategies were not needed to persuade people to adopt new foods that required less energy to produce, resisted drought or pests better, or were easier to store or process. Commercially processed modern infant formulas have spread rapidly because they appear to consumers as a labour-saving device. In the family's cost-benefit analysis, reduced energy and time input by the mother may be the critical variables. In contrast, better home-processed weaning foods may require increased effort by women or a change of habits, and provide little if any immediate gratification.

It might not seem difficult to tell people about good weaning foods and to persuade them to adopt sound weaning practices, but it is. A woman will not abandon traditional weaning practices for new ones unless she is convinced that they provide a reward-better health for herself and her children-and the reward must be demonstrated. She must be convinced that the reward will not result from a single action but only from continuous adherence to a new method-which requires a long-term commitment. She must also be convinced that change will not bring negative results such as derision from her family or peers.

Participatory teaching and demonstrations allow mothers to observe directly the results of new practices: They can see whether or not their infants accept new food, and they can see when weight gain improves. Constant and intensive reinforcement of the message helps sustain a long-term commitment to change. Peer group involvement helps prevent negative feedback, and encourages mothers to share new knowledge with others. The primary health worker's personalized and community-supported approach is the optimum strategy for illiterate rural populations. Radio (and television in urban areas) can only reinforce the personal contact.

Q. What is the importance of maternal nutrition during pregnancy and lactation?

A. Women with low pre-pregnancy weight and low pregnancy weight gain give birth to infants of reduced birth-weight, which means higher risk of stillbirth, illness, or death in the newborn period, and subsequent malnutrition. In countries where women usually gain 10 to 15 kg during pregnancy, birth-weights average about 3.5 kg, and low birth-weight affects about 6 to 10 per cent of the babies born. Where average pregnancy weight gain falls closer to 5 kg, average birth-weights tend to drop below 3 kg, and the number of low birth-weight infants may rise to 25 per cent or more. Preventing low birth-weight is an important, often overlooked, means of reducing infant mortality.

Nutritionists believe that mothers of low socio-economic status generally need supplementary nutritious food during pregnancy and lactation. Dietary intake during pregnancy and lactation must suffice to meet both maternal and infant needs. If the mother's diet is inadequate, her reserves are drawn upon until they are exhausted, at which point nutritional deficiency diseases (such as iron-deficiency anaemia) appear. Because hard physical labour increases their caloric needs, most women who practice subsistence farming in LDCs are at high risk for nutritional inadequacies. Closely spaced pregnancies prevent them from rebuilding their reserves, and their nutritional status deteriorates further as they bear more children.

Lactating women who have low weight for height, indicating poor caloric intake, produce less breast milk than do adequately nourished women; however, the fat and protein density of their breast milk is only marginally reduced. Their milk is adequate in quality but the quantity produced is insufficient to satisfy their infants' needs. This will be reflected in poor growth rates and slower mental development.

Q. Why do we need home/village-processed food supplements in addition to or instead of centrally processed or imported food programmes?

A. Effective centrally processed weaning foods exist and reach large numbers of people in less developed countries, but broad segments of the populations in these countries live outside the areas served by commercial food concerns and, in any case, cannot afford to buy processed foods. Their food needs must be locally met. Moreover, a project that introduces better home or village food processing methods offers a means of teaching people about maternal and child health matters in general. It can go far beyond nutrition education per se to mobilize interest in general community development projects. However, there is also a need for relatively low-cost, nutritious, centrally processed weaning foods for the convenience of urban populations.

Q. What general principles should be followed in designing supplementary feeding programmes?

A. Weil-designed programmer typically feature the following four attributes, though they will differ greatly in other respects because they should be adapted to specific local conditions. - The food supplements are targeted to "vulnerable" groups, especially pre-school children in the 6-36month age cohort. An effort is made to ensure that they, not other family members, are the principal beneficiaries and that the food provided is supplementary, not substitutive, in effect. Explicit and careful targeting is a cost-effective way to obtain nutrition goals. - Supplementation is provided to the same children over an extended period of time, perhaps as much as a year or more. Distribution to recipients takes place at regular intervals during this period. Continuous contact with beneficiaries is essential to success. - Supplementation is accompanied by the close monitoring of child growth and health status. Typically, this includes weighing and the use of growth charts. Allocation of food supplements works best when integrated with other health services. - Supplementation is accompanied by education of mothers about food preparation, diet, health, and
general hygiene. This requires substantial community participation in both planning and implementing the entire package of health, nutrition, and educational activities.

Q. Is cash income the most critics/ factor in ma/nutrition, or are other factors usually more important ?

A. The causes of malnutrition are multiple and complexly interrelated. income, although important, is not usually the limiting factor. Other factors, such as realistic knowledge of food needs during health and illness, food availability, patterns of land or resource use, family support networks, and the presence of endemic diseases, all contribute to the nutritional equation. Cash grants usually will not solve nutrition problems. Unfortunate taboos (such as avoidance of eggs or milk, or withholding food during illness) are not removed by an increase in the family food budget identifying cash income as a cause of severe childhood malnutrition is simplistic and usually inaccurate. Research in many countries has shown factors such as family size, birth rank in the family, and educational level of the mother to be more useful in identifying high-risk children. Nutrition workers should analyze the specific causes of each case of malnutrition so that intervention can be individualized.

Q. What can be done about traditional beliefs and customs that contribute to poor nutrition?

A. Most populations as well as individuals are willing to accept new ideas they perceive as useful and that involve acceptable social risks. Families make their own cost. benefit analyses and adjust their beliefs when the advantages of doing so become apparent.

Most traditional beliefs had useful functions in the past, even if they now appear harmful. For example, priority feeding of men when food was scarce assured tribal survival when men were hunters and warriors. Through the centuries the custom of feeding men first has been woven into the prestige and status system of many societies, even though research shows that infants deserve nutritional priority. To change such a practice means changing a wide range of beliefs about the world and realigning relationships within the family. The entire belief system must be understood before changes are introduced.

Changing a belief involves the consensus of the family (father, co-wives,elders) and the approval of the community. To counteract harmful practices or beliefs, the nutrition worker must work with the society's opinion leaders, who then pass on the message. Often it must be demonstrated repeatedly over a long period that certain foods can be consumed without harm to the mother or child. If members of the society believe that eating eggs causes children to turn into thieves, what mother wants her peers to accuse her of raising a thief?

Q. Is breast-feeding an effective method of child spacing?

A. Breast-feeding normally suppresses ovulation for some time after delivery. In developing countries this period of infertility may last two years or longer, though in developed countries the menstrual periods of nursing mothers are usually re-established after a few months. It is not clear what determines the duration of this post-partum amenorrhoea. The mother's nutritional status and the intensity of the child's suckling may both play a part.

In rare cases, a lactating woman ovulates and becomes pregnant without menstruating. In general, however, until ovulation resumes, a woman cannot get pregnant while breast-feeding.

Q. At what age can a child safety be weaned and the mother start another pregnancy?

A. Poor children in developing countries need prolonged nursing and their mother's full attention during their vulnerable early years if they are to survive. Therefore, a good rule of thumb is to advise women to delay pregnancy until the young child has attained a height of 90 to 100 cm. For the mother's sake, nursing should cease if a new pregnancy occurs, though abrupt weaning is dangerous to the child and ought to be avoided.


Inventory of international and regional training courses in human nutrition

The IUNS Committee on Advanced Degrees in Nutrition Science (Committee V/8), responding to needs expressed by international organizations involved for ten years or more in organizing international food and nutrition courses, has undertaken to prepare an inventory of international and regional courses in human nutrition. The inventory will be designed to serve prospective participants and those responsible for helping the participants select the course which will best suit the candidate's needs in the light of his or her future job requirements.

A preliminary version of the inventory will be published in the Food and Nutrition Bulletin in July 1982.

In order to prepare as complete and comprehensive an inventory as possible, the International Course in Food Science and Nutrition, which is coordinating the compilation of the information, requests the co operation and assistance of those people and organizations who run or plan such courses. The following information is needed on each course:

- Title
- Address
- Director
- Objectives
- Subjects included in the course (please list)
- Institutional affiliation of main course work (institutional setting, collaborating faculties, research or training centres, laboratories, etc.). If field-work is done, a general indication of its location should be given.
- Duration of training, including total course duration and general breakdown by course activities (class work [lectures and discussions]; individual presentation by participants; practical course work [laboratory exercises, workshops, etc.]; applied vocational training [e.g., participation in field work, service delivery, etc. (please specify)]; special project work [individually or by groups of participants]; scientific visits and excursions; individual study time)
- Language
- Degree or diploma offered and type of examination
- Sponsoring organizations If or both financial and administrative matters)
- Contacts with international organizations
- Admission requirements, including countries, professional and educational level (type of diploma/degree), working experience, admission procedures (admission board, entry examination, etc.)
- Chronology of courses since 1975, including dates of the course, main themes (if these differ between courses), number of participants
- Participants admitted since 1975, by country of origin and by function (profession) before the course

Please send all relevant information to:

Dr. Marylou Mertens, Assistant Director international Course in Food Science and Nutrition
Lawickse Allee 11 6701 AN Wageningen, Netherlands

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