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Manuel Amador and Manuel Peña
Positive changes in the nutrition and health of the Cuban population have taken place in the last three decades. The strategies developed for their attainment have been mainly in the public health sector. Changes in health indicators closely linked to the nutrition status of the community in the last 20 years indicate that the population's standard of living has risen. However, there has been a tendency to both an absolute and a relative increase in the prevalence of and mortality from chronic non-communicable diseases and in their associated risk factors. On the other hand, moderate or severe protein-energy deficiency is not common, but iron deficiency is still a problem, especially in small children and pregnant women. Several strategies and actions currently are in progress for promoting a positive change in food habits and lifestyle.
Changes in Cuban nutrition and health
The nutrition and health of the Cuban population have shown dramatic improvements in the last three decades. Living standards have been substantially raised by the elimination of illiteracy and unemployment, the permanent availability of education and health services, and the guarantee of basic goods for life regardless of personal income. The mean daily per capita intake of energy increased from 2,552 kcal (10.6 MJ) in 1965 to 2,899 kcal (12.1 MJ) in 1988, and that of protein from 66.4 g to 77.4 g in the same period. The proportion of protein from animal sources represents 46.4% of the total, whereas 25 years ago it was 43.5%. Fat represents 24.1 % of total energy consumed . All these data are recorded through the food balance sheets methodology proposed by FAO. This includes the analysis of food wastage, which yields the estimated amount of food available for human consumption .
More than 3 million portions are served daily in canteens in schools, universities, day-care centres, factories, military units, and other locations, free or at very low prices . This represents an important amount, taking into account the population of Cuba (10,603,200 in 1990). The mean monthly salary has increased 26% in the last five years, whereas the cost of living, especially the cost of basic foods, has changed very little in the last ten years.
The strategies in public health rested originally on the creation of the National Health System, with the development of a preventive and curative network at the primary level of health care which ensured health services for all the population. A new model of health service, based on the family doctor, was initiated in 1984, and in 1990 it covered more than half the population.
The health actions that have made a major contribution to the improvement of the nutrition status of the population have included:
Other measures not directly related to health were undertaken simultaneously, including the elimination of illiteracy, increasing the education level of the population, improvement of water supplies and sanitation, increasing family income, and electrification of small urban and rural settlements.
Indicators of nutrition status
The results of these strategies, which were developed in a step-wise fashion in response to the growing needs of the people, can be appreciated through various indirect and direct indicators of nutrition status.
Changes that have taken place mainly in the last 20 years are reflected in some health indicators closely linked to the nutrition status of the community. They reveal health standards in Cuba that resemble those of most developed countries.
Life expectancy for males has increased from 66.8 years in 1969 to 72.2 years in 1989, and for females from 70.3 to 75.8 years in the same period of time. Eighty per cent of deaths occur in subjects above 50 years of age and more than 62% in those above age 65. The survival of children at 5 years was 98.7% in 1990 compared to 94.6% in 1969 .
Figure 1 shows the changes in selected nationwide indicators from 1969 to 1990: the infant mortality rate decreased from 46.7 to 10.7 per 1,000 live births, under-five proportional mortality from 23.6% to 3.5%, the proportion of deaths due to infectious diseases from 9.5% to 1.5%, and the mortality rate for children 1-4 years old from 1.8 to 0.7 per 1,000. Diarrhoeal diseases are not among the first ten causes of death for all ages, and are only the fourth cause of death among infants (0.5 per 1,000 live births). In the same period, the low-birth-weight (<2,500 g) rate decreased from 10.3 to 7.3 per 100 live births.
FIG. 1. Changes in selected national mortality rates, 19681990 (Source: Ref. 3)
FIG. 2. Mortality rates from chronic non-communicable diseases, 1968-1989 (Source: Ref. 3)
FIG. 3. Components of mortality from cardiovascular diseases in Cuba, 1970-1990 (Source: Ref.3)
Conversely, a tendency to increase was shown by mortality rates related to unhealthy food or living habits (fig. 2). In the same period, the mortality rate due to cardiovascular diseases (the first cause of death in Cuba) increased from 149.1 to 200.3 per 100,000 people; that due to malignant diseases (the second cause of death) increased from 96.6 to 128.5; cerebro-vascular diseases (the third cause of death) remained unchanged at 66.2; and diabetes mellitus (the sixth cause of death in 1990) rose from 12.6 to 21.4.
Table 1 shows the five main causes of death for each age group in Cuba in 1990 and their rates. Heart diseases are first among subjects 50 years old or over and third among those 15-49 years old . Figure 3 shows the components of mortality by cardiovascular diseases, revealing an accelerating increase in deaths due to ischaemic heart disease.
All this has a great impact on children's health, since it emphasizes the need to prevent at early ages diseases of adults that have their origin in childhood; thus, strategies have changed as health figures of the population have.
TABLE 1. Mortality rates for the five main causes of death within each age group. Cuba, 1990.
|Age group (years)|
|Influenza and pneumonia||0.7||0.4||300.7|
|Enteritis and acute diarrhoeal diseases||0.5|
|Arterial, arteriolar, and capillary diseases||289.2|
Source: Ref. 3.
a. Rate per 1,000 live births.
b. Rate per 1.000 inhabitants.
c. Rate per 100,000 inhabitants.
Food and nutrition surveillance
The National Food and Nutrition Surveillance System (SISVAN) is one of the sources of knowledge required to ensure the adequate nutrition of the community. Nutrition surveillance implies monitoring and control of the nutrition status of the population in order to make decisions that can lead to its improvement.
SISVAN was begun in Cuba in 1977  with the support of the United Nations Children's Fund (UNICEF) and the Pan American Health Organization for three years. By the beginning of the 1980s its coverage was nationwide. This achievement was possible because of the already existent sectorized structure of the official organizations that attend to agriculture and cattle production, trade, social feeding, public health, etc. related to each of the three organizational levels of the state: nation, province, and municipality . Currently, SISVAN has three components: surveillance of mother's and children's nutrition, dietary surveillance in social feeding, and surveillance of chemical and biological food contaminants.
The system started with surveillance of child nutrition, making use of the primary health care network, which rendered all parallel structures superfluous. It covers the whole population under 5 years of age (885,300 in 1990), whose body weights and heights are measured periodically at out-patient centres established by the National Mother and Child Care Programme. The indicator used is body weight for height, with percentiles of the national figures  as the reference standard. Children classified in the following four categories on the basis of those values are singled out for attention:
Children between the 10th and 89th percentiles are considered normal. For each of the four atypical groups, two factors are considered: the frequency of initial diagnoses (new cases), and the prevalence among the children under surveillance.
Atypical subjects detected at the primary health care level participate in a special care programme at the out-patient clinics with more thorough and specific follow-up. If necessary, they are admitted to the hospital. The prevalence of the four categories from 1984 to 1990 is shown in figures 4 (infants) and 5 (children 1-4 years old). A decreasing trend is observed for all four categories, especially for children with possible undernutrition, the prevalence of which is very low compared to that reported by international organizations for other developing countries . The frequency of new cases has also tended to decrease in all the categories. In 1990 the reported figures for infants were I . I % possibly undernourished, 4.1 % thin, 4.7% overweight, and 1.5% possibly obese. For children 1-4 years old the figures were 0.2%, 0.5%, 0.7% and 0.4% respectively 
FIG. 4. Non-normal status (weight for height) among infants under nutrition surveillance, 19841990 (Source: SISVAN, Ministry of Public Health, Cuba, 1990)
FIG. 5. Non-normal status (weight for height) among children 1-4 years old under nutrition surveillance, 1984-1990 (Source: SISVAN, Ministry of Public Health, Cuba, 1990)
The following indicators are used for the surveillance of the nutrition of pregnant women (186,658 births in 1990, of which 99.8% took place in health care units):
TABLE 2. Pregnant women at risk according to three nutrition-surveillance indicators (percentages)
|Low initial weight/height||Insufficient weight gain||Anaemia at 3rd trimester|
Source: SISVAN, Ministry of Public Health, Cuba 1990.
National child-growth studies
The first national child-growth study was carried out in 1972. A total of 56,00 subjects, constituting a representative sample of the Cuban population 0-19 years old, were measured [10, 11]. A second study was carried out in 1982: an equiprobabilistic sample of 29,759 subjects 0.01-19.9 years old were examined to obtain a description of the characteristics of their physical growth, neuromotor development, somatotype, and functional capacity. The somatic growth data were compared with those obtained in 1972  The results of these comparisons showed that in 1982 the subjects were heavier and taller for their ages, especially at the 50th and 97th percentiles (particularly those above 10 years of age), and were also heavier for their height [12, 13]. The body dimensions of infants, children, and adolescents from rural areas showed greater increments than those from urban areas. Fatness indicators such as skinfold and fat areas of the upper arm showed increments both in males and in females. All this points to a positive secular trend in 10 years, but also to a tendency to increased obesity in the population.
The World Health Organization has proposed as a goal to be reached by the year 2000 a group of indicators, among which are three directly related to the nutrition status of the population : weight for age, height for age, and weight for height. This goal proposes that 90% of the children of the member countries of WHO should show results for those dimensions above the mean or median minus two standard deviations of WHO reference values  This goal was reached in Cuba almost two decades ago, since the values of the 10th percentile of the Cuban 1972 sample are higher than those proposed by WHO for the year 2000 
TABLE 3. Elementary school children (6-11 years old) and adolescents (12-18 years old) in SISVAN weight-for-height risk categories. Cuba. 1986
|Age group (years)|
a. <3rd percentile of national
b. 3rd-9th percentiles.
c. 90th-96th percentiles
d. >=97th percentile
Weight-for-height survey in elementary school children and adolescents
In a study carried out in 1986 in a sample of 19,428 children from elementary schools (6-11 years old) and 11,450 from high schools (12-18 years old) , it was found that the proportion of thin and possibly undernourished subjects (according to the SISVAN criteria) was low, whereas the proportion of overweight and obese subjects was higher among the younger students (table 3).
These figures, together with the results of a survey carried out at the National Institute of Endocrinology in which the estimated prevalence of obesity (body mass index > 30 kg/m²) in subjects above 15 years of age was estimated at 21.8% , show that obesity starts to be important at school age and is particularly significant in young adults.
Indicators of iron deficiency
Iron deficiency is the most common nutritional deficiency in Cuba, though its degree and severity do not reach those found in other developing countries. In 1973 haemoglobin values below the WHO cut-off line for anaemia (110 g/L) were reported in 45.2% of infants 6-12 months old in the city of Havana . In 1985 anaemia was observed in 33.9% of 484 children 6-23 months old attending day-care centres in Havana province (excluding the capital city); in 78% of these the anaemia was mild (haemoglobin between 100 and 109 g/L)  In the same sample. 42% showed serum iron concentrations below 10.7 umol/L  Other studies carried out in several regions of the country found that the proportion of children with haemoglobin below 110 g/L ranged between 45% and 63% [21, 22].
Iron deficiency in pregnant women is also important: in samples obtained in the city of Havana, 22% had haemoglobin values below 110 g/L and 6% below 100 g/L; 35% exhibited transferrin saturation figures below 15%. Conversely, no folic-acid deficiency was found [23, 24]. As shown in table 1, according to SISVAN, the national rate of anaemia in the third trimester of gestation was 11.4 per 100 pregnant women in 1990.
Indicators of other specific nutrient deficiencies
Besides iron deficiency, no other specific nutrient deficiencies are significant enough to constitute health problems in Cuba. In studies carried out in groups of schoolchildren and adolescents and in pregnant and lactating women, a relatively low proportion of subjects had serum vitamin A classified as deficient (<10 g/dl) or low (10-19 ug/dl) [25, 26].
Relations between food habits and nutrition and health
We can sum up the current nutrition and health situation in Cuba as follows:
These conditions have a multifactoral origin, food habits being among the most relevant factors. The increased capacity to acquire food has not corresponded with a change in food habits and hence in the quality of life.
Cuba has a higher per capita sugar consumption, 52.7 kg in 1988, than any other country in the world. Sugar represents 19.7% of the total energy intake of the population .
Fruits and fresh vegetables have a seasonal distribution and are not available throughout the year. In addition, people are not used to eating them in sufficient quantities. Less than one-third of the fat consumed comes from vegetable sources. Only a low proportion of the animal fat comes from fish. A national survey carried out by the Cuban Research Institute of Internal Demand, investigating people's proclivity to change their current habits of food consumption, reported a tendency to eat more fruits and vegetables as well as larger quantities of fats and sugar. Twenty-three per cent of households belonged to a class of consumers characterized by high intake of energy-related foods (lard, butter, sugar, rice), and they continue to increase the consumption of these items. The principal characteristics of these families are low income, rural origin, and low socio-economic status 
One common feature of food habits is an unsatisfactory distribution of daily energy intake, with a major proportion ingested at the end of the day. In one study healthy adult men 20-50 years old were grouped into seven categories according to their physical activity. Breakfast represented a mean of only 4.4% of their total energy intake, whereas dinner represented 42.6%; nearly one-fourth of the subjects received more than half of their energy at the evening meal .
A low prevalence and duration of breast-feeding and early introduction of solid foods characterizes infant-feeding practices. In a cohort study of 4,272 infants from birth to 7 months of age, 89.8% were breast-fed at 7 days. This proportion dropped to 45.2% at 3 months, including not only those who were exclusively breast-feeding but also those fed by breast and bottle. In the first month of life, a significant proportion of the infants received fruit juices (16.5%), fruit purees (12.4%), mashed tubers (4.6%), cereals (1.8%), meat (2.0%), and egg yolk (1.4%) . The introduction of solid foods in the first seven months was directly related to the maternal education level . Similar results have been found in more recent reports [31-33].
Strategies for immediate action
Cuba has defined its strategies and actions to preserve and improve the nutrition status of the population through the National Food and Nutrition Programme, established in 1988 . This programme includes four basic approaches: socio-economic, educational, medical, and organizational. It is systematic and multisectoral and is focused on improving the health of the population through the creation of proper food habits. It comprises quantitative and qualitative aspects of food based on interventions in the planning of production, imports, marketing, food elaboration and food distribution. All sectors of the economy and services related to feeding the population are included. Evaluations are made annually, and within one year of its implementation, promising results had been obtained.
The main goals of the programme are as follows:
- decreasing sugar consumption to less than 15% of total energy intake,
- reducing total fat intake, and increasing vegetable-oil consumption to at least 50% of total fat intake,
- increasing fish consumption.
- increasing the availability of fresh vegetables and fruits throughout the year;
- including other indicators (arm circumference) and groups of subjects under surveillance (schoolchildren, adolescents),
- developing software for dietary evaluations;
- increasing the prevalence and duration of breast-feeding,
- reducing the low-birth-weight rate to under 6 per 100 births,
- developing food products for pregnant women, infants, and small children (including the fortification of foods with iron and vitamin C);
- extending the new model of care by the family doctor to all the population,
- establishing detection and special out-patient care for subjects at risk of obesity and chronic degenerative diseases,
- developing programmes for massive physical activities in the community.
The goals for forthcoming years will focus on modifying current conditions and promoting a more healthy lifestyle of the people. Coordinating the activities of agriculture and animal production, the food industry, domestic and foreign trade, education and mass-diffusion media, public health. and mass organizations in the framework of the National Food and Nutrition Programme should make the goals achievable in the near future.
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