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Letters to the editor

Nutrition education and food-sharing within the family
Social ecology and the breast-milk substitutes code


Nutrition education and food-sharing within the family

Thomas J. Marchione, reporting on surveys performed in 1973 and 1975 in Jamaica if food and Nutrition Bulletin, vol. 3, no. 2, pp. 10-14), found that intrafamilial foodsharing was correlated with the nutritional status of pre-school children, the direction of the correlation varying between food groups.

Between the two surveys community health aides had been charged with the explicit task of improving the child's share of food from the family pot. However, despite an improvement in nutritional status of pre-school children over the period, Marchione was unable to show any change in foodsharing within households. He concludes that "sharing patterns do not appear to be readily responsive to nutrition education . "

Marchione suggests, wisely, that more research is needed, but goes on to recommend: "If the patterns are generally as invariant as they seem from this analysis, it would be wise for third-world nutrition policy to focus more on increasing household access to resources than on largescale 'educational' attempts to get a small family pie divided more equitably. Efforts to increase intrafamilial equality should only be emphatically pursued where governments are taking measures to overcome the societal maldistribution both of food and of the means for producing it. To do otherwise is to be blind to the historically created conditions that have pushed families into a cruel contradiction: to survive, they must risk nutritional damage to their young."

I would suggest that the data are insufficient for the conclusion drawn, as the nature and quality of the nutrition education taught, learned, and disseminated by the community health aides is not described. In fact, we have been working very recently on a major revision of the nutrition component of the training of community health aides in Jamaica. This is in recognition of a need for improvement. Having been involved in devising the early nutrition content A. Hoskins, C. Reid, L. Pitters, J. Johnson, H. Fox, and M. Gurney, "Key Concepts in Nutrition for Community Health Aides," Cajanus, 6: 101-110 [ 1973] ), I am aware of some of its deficiences.

The contention quoted above that "to survive [families] must risk nutritional damage to their young" is not supported from the data given for Jamaica and may not be as cruel a dilemma in many countries as is implied. A 300 kcal daily deficiency in a young child is about one third of his requirements, a considerable proportion. But 300 kcal is well under 10 per cent of the average availability in many households except in very severe conditions. To feed the young child well requires quite a small intrafamilial redistribution of resources.

Consequently, while agreeing wholeheartedly with Marchione's plea for improved distribution within society land between societies), I would suggest that this not be done at the expense of efforts to ensure a level of public awareness, understanding, and knowledge of food requirements of infants and young children that enables people to make nutritionally acceptable choices. Nutrition education is vital, and we must find a way to make it more effective.

J.M. Gurney
Caribbean Food and Nutrition Institute


Social ecology and the breast-milk substitutes code

Gretel H. Pelto's "Perspectives on Infant Feeding: Decision Making and Ecology" (Food and Nutrition Bulletin, vol. 3, no. 3) is a veiled apologia for bottle-feeding.

Few of us argue with a woman's right to make a non breast feeding choice based on her perception "of the relative merits and shortcomings of particular actions"- in other words, an informed choice. This has little to do either with a biological or an ecological perspective. It is plain and simple justice.

The rationale behind the new International Code on the Marketing of Breast-Milk Substitutes (I served as special adviser to UNICEF/WHO) is that the decision should be reserved exclusively for each new mother and should not be tampered with by others, especially those whose motives may be questionable or, at best, unclear.

Thus, the aggressive commercial promotion of breast-milk substitutes in competition with mother's milk land breastfeeding practice) is clearly intended to manipulate the "ecology." Under such a circumstance free, not to speak of informed, choice by mothers is obviously not possible. I have spent my career in advertising and marketing and I have never known a promotion effort or a promotion budget that was not intended to develop the business. And that includes so-called "educational" efforts. "Educational" or not, a manufacturer's energy and money are obviously aimed at business development-for that is the enterprise's purpose. The notion of any other would be enough to justify a shareholder rebellion.

Thus, the Code is intended to protect the mother's right to free choice from any untoward interference from enterprises whose primary aim is to promote a product.

It does not restrict the sale or distribution of the product, merely any possibility of undue influence on the mother's decision. That is a matter between her and the health professionals who should be in the best position to help her make it an informed decision. Even with health professionals, the Code seeks to restrain manufacturers from exercising undue "promotional" influence and for the same reason. Professionals should deliver their counsel to mothers on the basis of uncompromising professional responsibility, based on fact and science-and untrammeled.

In a real sense the Code seeks to preserve the "social ecology" of which Dr. Pelto writes and to prevent its spoliation by potentially dangerous practices.

Richard K. Manoff President, Manoff International, Inc.
Dr. Pelto replies:

I am frankly dumbfounded that Mr. Manoff sees my paper as a "veiled apologia for bottle-feeding." This misinterpretation is particularly mystifying in view of his understanding that "in a real sense the Code seeks to preserve the 'social ecology' of which Dr. Pelto writes...." The purpose of my article was to clarify the social ("ecological") context that the Code-or any other action to promote better infant feeding practices - must inevitably encounter.

If only the world were just, and an "informed choice" were a matter of "simple justice." The Code is a very significant step forward, but I am disturbed by the implication in Mr. Manoff's letter that promotional activities of manufacturers are the only barrier to the "mother's right to a free choice." The evidence is clear that decisions regarding infant feeding are constrained and influenced by many factors, including health-care practices, the status of women, and economic circumstances.

While it is often very useful, for the purpose of political mobilization, to focus on one factor, it is tactically naive to lose sight of the larger picture. It is also poor science. Manoff's interpretation of my argument is parallel to the case of someone deeply concerned about the role of saturated fat in heart disease encountering an analysis showing multiple factors in the epidemiology of the disease and charging that it is an apologia for heart disease.

Gretel H. Pelto

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