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Book reviews

Malnutrition and behavior: Critical assessment of key issues.


Malnutrition and behavior: Critical assessment of key issues.

Edited by Josef Brozek and Beat Schurch. Nestle Foundation Publication Series, vol. 4. The Nestle Foundation, Lausanne, Switzerland, 1984.650 pp.

Originally, the symposium that provided the basis for this volume was to be traditional one and was intended "to provide a fresh appraisal of the significance of current research findings and identify needed further research on nutrition, mental development and behavior." For financial and other reasons, it was decided to hold a symposium indirectly by correspondence, rather than through direct interaction among scientists. Thus, the book is organized in six sections, each with chapters followed by comments or addenda to retain the interchange among participants that is characteristic of a symposium. In all, there are more than 60 presentations by as many distinguished participants

The central goal of the book is indicated by the subtitle, "Critical Assessment of Key Issues." The key issues, as described in the Introduction and thoroughly explored in the book, are the concept of energy-protein malnutrition (EPM), anthropometric evaluation of chronic EPM, functional dimensions and measures of the effects of EPM, the underlying mechanisms and factors, advantages and limitations of animal models, interventions under conditions of chronic malnutrition and rehabilitation of children with chronic malnutrition, research design and data analysis, and the problem of the significance of the effects of malnutrition from an applied perspective.

The prologue sets the stage by raising many issues that reappear throughout the remainder of the book, including the etiology and definition of malnutrition, the concept of malnutrition as a dynamic process, and the biosocial nature of behaviour

Most of Part 1 of the book is concerned with nutritional anthropometry and the definition and measurement of energy-protein malnutrition. This part includes discussions of the classification of EPM, the theoretical basis and methodological issues in the use of nutritional anthropometry, and the use of reference values and cut-off points and their practical use in Third World countries.

Part 2 is the largest section since it is on the assessment of function. Following an introductory chapter on measuring outcomes, it is divided into four areas: electro-physiological procedures, psychometrics, motor function, and social emotional development. Part 3, entitled "Mechanisms," includes discussions of the current theories and models for understanding the effects of malnutrition, including neural and animal models and models that emphasize social, familial, and environmental factors. Issues involving nutritional intervention are considered in Part 4, which includes papers on specific supplementation and intervention programmes as well as papers that consider some of the theoretical, methodological, and practical issues involved in effecting social change in nutrition and related areas.

Part 5 is a short section on design and data analysis that includes discussions of general methodological issues, critiques of existing intervention studies, and the use of data banks and existing data bases. The last section, Part 6, on criteria of significance, addresses important questions about the significance of nutritional research. How to assess the impact of nutritional research is considered in terms of statistical significance, magnitude of effects, and social and economic change. For example, the important point is made that effects that are statistically reliable but small may have substantial impact on a national scale. There is also an epilogue to provide some closure for the volume.

The strengths of the book are that it is a comprehensive and thorough treatment of most of the current issues in the field of malnutrition and behaviour. In a field that is often over-reviewed, this text provides some new ideas and perspectives and thus serves as a state-of-the-art statement of the work in this area There is a healthy balance of well-known contributors and newer investigators, and there is a broad interdisciplinary perspective. One gets a clear understanding of the complexity land, to some extent, the frustration) of the issues in the study of malnutrition and behaviour, and also of their overwhelming importance. Academic issues, theoretical, and methodological concerns are well integrated with applied, social, and economic issues They are inseparable, part of the "web of causes and consequences" described in the text A strong social consciousness is evident throughout this volume that supports the idea that basic research can and must be applied to social action

A nice feature of the book is the symposium-like atmosphere that the editors have maintained. The comments give a feeling of dialogue among the participants. Many of the comments provide additional information or perspectives that increase understanding of the presentations; in a sense, the book contains its own reviews. For example, in considering the cultural context of behaviour, a discussant asks, "What is the message, then, behind the anxious expressions and lowered involvement of the unsupplemented Guatemalan children?" Much of the dialogue is provided by editor Josef Brozek; his expertise and experience help provide a solid base for an integration of the many topics covered.

There are a number of themes and concepts that appear in various forms throughout the text that represent important advances in the study of malnutrition and behaviour. One theme is the continuing trend away from linear, static, main-effect models toward more dynamic, bidirectional, interactive models. Much of this thinking is embodied in the concept of synergy, which appears throughout; there is even an attempt to apply systems theory. This trend reflects an appreciation for the complexity of the study of malnutrition and behaviour. This complexity with its multiple interactions is apparent in all areas, whether one is discussing animal studies, nutritional anthropometry, behavioural assessment, intervention, or sociopolitical or world hunger models, and is symbolized by the concept of a web. As Brozek points out, the distinction between independent and dependent variables is difficult, at best. Some dynamic models include characteristics of the child as mediators of developmental outcome, the theme that the child affects the environment. The question is raised as to why a specific child in a family becomes a target for malnutrition, Unique behavioural characteristics of the infant (the cry, for example), organismic variables such as the sex of the child, and the mother infant relationship were mentioned among other factors as potential mediators of developmental outcome.

Related is the question of why some children living in the most adverse conditions do not suffer the consequences of malnutrition, and here the theme of coping was raised. What are the coping strategies and adaptive behaviour patterns that enable some individuals to appear "invulnerable"? Strain-specific effects of malnutrition in rats, described in one chapter, suggests the role of constitutional factors. The theme of adaptation also appears from a biological perspective. The discussion of the self-righting capacity of the human organism following insult recognizes the maturational forces that determine the canalization of development. The ability of the infant to recover from nutritional and related insults reflects a new understanding of the plasticity of the nervous system.

One can sense, in several papers, dissatisfaction with the deficit model of nervous-system insult in favour of a model that appreciates the recovery capacity of the nervous system. In this context, it is interesting to note the call for behavioural measures that indicate the processes of behavioural development. Process-oriented measures (the "how" of development) will probably be more sensitive to the capacity of the nervous system to recover from nutritional insult. Similarly, there is the recognition of the importance of multiple measures and an increasing emphasis on measures of the functional rather than structural integrity of the nervous system. The latter is reflected, for example, in the interesting controversy over the use of neurometrics and related EEG procedures and the implications of measures such as acoustic cry analysis.

The notion that social and cultural factors play a major role in determining developmental outcome and mediate the effects of nutrition is well explicated. The application of the concept of risk to the study of malnutrition and behaviour, also mentioned in this volume, is an advance that captures many of the themes described above. Nutritional insult can be viewed as a risk factor to be studied against the backdrop of social, cultural, biological, physiological, and other factors that combine to shape development and that can exacerbate or attenuate the effects of malnutrition.

Some of the strengths of this book are also its weaknesses - for instance, the symposium-like quality, which, while it does have its virtues, contributes to a certain looseness. There is too much redundancy and too little critical evaluation. There is a broad range in the style and content of the papers; some are cursory reviews, others contain detailed data and statistics as if for journal publication. The book lacks a broad integrative chapter in which the major issues and themes, some of which are mentioned above, are described, evaluated, and given perspective from the viewpoint of the study of malnutrition and behaviour.

Despite these weaknesses, this is a valuable work, which provides an update of the field as well as new directions for the study of malnutrition and behaviour.

Barry Lester
Child Development Unit
The Children's Hospital
Boston, Massachusetts, USA

Brief Reviews

Nutrition Education - State-of-the-Art: Review and Analysis of the Literature. R. C. Israel and J. P. N. Tighe. Nutrition Education Series, no. 7. Division of Science, Technical and Vocational Education, Unesco, Paris, 1984.(ED-84/WS/27 )

This is a 96-page annotated bibliography with a 5l/2-page introduction. It is not a state-of-the-art review and analysis of the literature as claimed in the title. The annotated bibliography draws heavily on consultant reports for the

AID-funded International Nutrition Communications (INCS) Project, managed by the senior author. Indexed by country and topic, it provides the Unesco readership with a wealth of useful information that does not appear in established journals.

The introduction chronicles the rapid expansion in the concept of nutrition education in recent years to encompass all aspects of social marketing. Technically rigorous communications and marketing approaches have yielded significant improvements in dietary practices and in nutritional status and have elevated nutrition education/communications to the status of an intervention that attracts multi-million-dollar investments. Israel's claim that more resources have been allocated to combat the problems of undernutrition in developing countries than to prevent overnutrition in industrialized countries is incorrect.

This document makes reference to most of the recent, innovative developing-country projects. The references in the introduction are not all accurate. Finding three of my own works cited and attributed to three other writers makes me wonder how many other authors were similarly represented.

Marian F. Zeitlin
Tufts University School of Nutrition
Medford, Massachusetts, USA

Everyday Indian Processed Foods. K. T. Achaya. National Book Trust, New Delhi, India, 1984.184 pp.

This book outlines the chemistry, technology, and nutritional quality of the entire range of foods consumed in India, from the primary rice, wheat, and vegetable oil to the more sophisticated processed foods such as bread, biscuits, nanaspati, chocolates, pickles, cheese, and other milk products. The chain of transformation, preparation, sterilization, and packaging is presented according to scientific processing with a dash of history, geography, and sometimes and exotic description; for example, the appetizing cheeses and wines, justified by the inherent fascination of their science and technology.

The author combines information on the chemical, biological, and engineering principles that go into Indian food processing with the traditional and ancient practices that very often gave rise to the more sophisticated techniques of the new technology, and presents this mixture in an interesting and lively way to the lay reader. A departure from the routine presentation of food categories and groups makes the book more readable, even for specialists in the field, who will have no problem understanding that the "foundations" of the diet means the staple foods, the "cups that cheer" means tea and coffee; the "tastes that differ" refers to sugar, honey, and salt; and the "living foods" are the products of animal origin such as eggs, fish, and meat.

The book is written simply and is suitable for both nutrition professionals and lay persons. However, it is missing a chapter that relates the various food preparations and local recipes to consumption at specific ages and in different physiological states.

Mohamed Mansour
Tufts University School of Nutrition
Medford, Massachusetts, USA
(UNU Fellow)

A Study in India's Food Policy: Institutions and Incentives in India's Food Security Structure. B. M. Bhatia. Asian and Pacific Development Centre, Kuala Lumpur, Malaysia, 1983. 129 pp.

This small paperback monograph undertakes to describe and analyse the role that the government institutions and the incentives or disincentives they have created have played in India in promoting food production and the food economy over the 36 years since independence. A historical perspective is applied to the current food situation and the key issues it raises for current policy-makers and planners.

Even though the mean rate of food production has kept ahead of population growth over this period, the per capita growth rate trend is downward, posing a threat for India's future leaders. The book traces the policies and factors that led to the peak years of 1964l65 and 1970l71 and the virtual stagnation since 1978l79. It examines not only the production of food but also the public food distribution and procurement systems as well as the growth of consumption, and includes very useful statistical tables. The conclusions and policy implications will be of interest to persons concerned with food and nutrition policy and planning in all developing countries.

The Diet and Health of Isolated Populations. George Wadsworth. CRC Press, Boca Raton, Fla., USA, 1984. 215 pp.

Valuable epidemiological lessons about nutrition and health are to be learned from populations that have been isolated from the effects of Western development. Unfortunately, such information is fragmentary and difficult to obtain. This book brings together such information as may be available on the mode of life of isolated groups from both the dry and humid tropics to the Arctic, with a review of their foods, diet, lactation and weaning practices, growth rates, and disease distribution.

After introductory chapters on the nature and causes of health and disease and what is known of ancient man from archaeological evidence, the book examines a series of peoples, obviously not totally isolated, or the information would not have been obtained: the San of the Kalahari in Africa, the indigenous people of Papua New Guinea, the Australian Aborigines, and the Arctic Eskimos. The next six chapters use this information and that available for some other isolated societies to discuss growth, form, and size; physical prowess and physical performance; infective disease; child mortality; cardiovascular disease; and cancer.

The wide range of foods consumed by early hunter-gatherer populations and by most isolated populations today is emphasized. The modern departure from such a diet pattern along with a host of other environmental changes is discussed in relation to differences in health and disease patterns between isolated and contemporary industrialized societies. It remains to be seen whether humankind will survive as well and for as long under these new conditions as it has for a million years or more in the past.

Iron Nutrition in Infancy and Childhood. Edited by Abraham Stekei. Nestle Nutrition Workshop Series, vol. 4. Raven Press, New York, 1984. 204 pp.

As the preface to this book states, "This volume will be of interest to pediatricians, obstetricians, internists, and general practitioners, as well as specialists in nutrition and epidemiology." The subject is of pressing importance, because, as the book points out, iron deficiency affects hundreds of millions of people throughout the world, especially those in developing countries, where its causes include dietary deficiencies and parastic infestation. Although precise estimates of prevalence are not available, one chapter presents the following statistics, among many others, on the prevalence of anaemia among infants and children: 82 per cent for children four years of age and under in Bangladesh, a range of 37.8-73 per cent among children between six months and six years of age in a low socio-economic but well-nourished group in Indonesia, and 23 per cent among kindergarten and nursery school children in China (pp. 61-74).

Recently the many functional consequences of iron deficiency, with or without anaemia, have begun to be documented, including impaired immunocompetence, cognition, physical work capacity, and other functions (pp. 45-59). The book contains chapters on iron requirements, laboratory diagnosis of iron deficiency, functional implications of iron deficiency, prevalence of nutritional anaemia with emphasis on developing countries, iron nutrition in low-birth-weight infants, iron and breast milk, availability of iron from infant foods, bioavailability of different iron compounds used to fortify formulas and cereals, and prevention of iron deficiency. There are workshop discussions at the end of almost all chapters.

An Agromedical Approach to Pesticide Management: Some Health and Environmental Considerations. Edited by John E. Davies, Virgil Freed, and Fred Whittemore. University of Miami Press, Miami, Fla., USA, 1984.320 PP.

This book states that it is "designed to assist agromedical planners and supervisors of food production and humanhealth programs as well as the lower echelons of the agromedical infrastructure in the developing countries." It advocates an "agromedical approach" to the problems of pesticide use which are of mutual concern for agriculture and health: pest resistance to pesticides, human and animal poisonings, persistence of certain chemicals and chronic pesticide exposures (occupational and incidental), and disposal of pesticide containers as well as disposal of outdated stocks of pesticides.

The need for effective means of pest control is very great. As the book's first chapter points out, "A variety of pests reduce agricultural productivity by as much as 50% or more and are also carriers of human disease" (p. 3). However, the use of pesticides has been a two-edged sword. The book's foreword makes this point eloquently:

The impact of the stark contrast of competing needs must surely be one of the most vivid impressions encountered in tropical areas. The ever present threat of vector-borne and parasitic diseases, the obvious manifestations of kwashiorkor, marasmus, and blindness stand side by side with human and environmental suffering wrought by the very agents used to fight these scourges. It is this tragic paradox, largely the result of inadequate safety technology transfer, which has prompted us to develop this training program. [p.xi]

The book is written clearly and has a convenient format, including summaries at the beginning of each of its 21 chapters, which have been divided into three parts. The first part, "The Agromedical Approach - General Considerations," contains material on the nature and extent of the problems with pesticide use, epidemiology of pesticides, and toxicological and environmental implications of pesticide resistance. The second part, "Prevention, Diagnosis, and Treatment of Pesticide Poisonings," covers a wide range of topics of interest to many groups, including medical-care personnel, agricultural extension workers, and those immediately concerned with the well-being of workers who may be directly exposed to pesticides. Among the chapter topics are pesticide toxicity and mode of action, firstaid procedures, clinical aspects of acute poisoning, laboratory verification, and worker protection.

Planners and members of government agencies will be among those most interested in the third part of the book, "Agriculture, Public Health, and Environmental Considerations," in which pesticide application, transport, storage, and disposal are discussed as well as regional differences in agromedical problems and implementation of agromedical concepts.

Reader are invited to submit appropriate new, notes, and announcements for the "News and Notes" section of the Bulletin.

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