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FOOD AND NUTRITION BULLETIN
Published the United Nations University Press, Tokyo, Japan.
Food and Nutrition Bulletin
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The Food and Nutrition Bulletin incorporates and continues the PAC Bulletin of the former Protein-Calorie Advisory Group of the United Nations system and is published quarterly by the United Nations University Press in collaboration with the United Nations ACC Sub-committee on Nutrition.
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Food and Nutrition Bulletin
Editor: Dr. Nevin S. Scrimshaw
Assistant Editor: Ms. Edwina B. Murray
Editorial Consultant: Ms. Sarah Jeffries
Senior Associate Editor-Clinical and Human Nutrition:
Dr. Cutberto Garza, Director and Professor, Division of Nutritional Sciences,
Cornell University, Ithaca, N.Y., USA
Senior Associate Editor-Food Science and Technology:
Dr. Ricardo Bressani, Instituto de Investigaciones, Universidad del Valle de
Guatemala, Guatemala City, Guatemala
Dr. Abraham Besrat, Senior Academic Officer, United Nations University,
Dr. Hernán Delgado, Director, Institute of Nutrition of Central America and
Panama (INCAP), Guatemala City, Guatemala
Dr. Joseph Hautvast, Secretary General, IUNS, Department of Human
Nutrition, Agricultural University, Wageningen, Netherlands
Dr. Peter Pellet, Professor, Department of Food Science and Nutrition,
University of Massachusetts, Amherst, Mass., USA
Dr. Zewdie Wolde Gebriel, Director, Ethiopian Nutrition Institute, Addis
Dr. Aree Valyasevi, Professor and Institute Consultant, Mahidol University,
Food and Nutrition Bulletin, vol. 16, no. 4
(c) The United Nations University, 1995
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The papers contained in this special issue were presented initially at a Colloquium on Care and Nutrition of the Young Child, sponsored by UNICEF and Cornell University's Division of Nutritional Sciences, and held at Aurora, New York, USA, in October 1994. The planning of the Colloquium grew out of UNICEF's recognition of the need for a systematic review and integration of available knowledge concerning the question of how variations in the quality of care received by infants and young children may either enhance or compromise their nutritional status, growth, and behavioural development. Considered equally important was the analysis of various factors in the family and of the larger ecological setting that may affect caregivers' ability to provide good care, as well as the availability of resources essential for it. It was hoped, also, that a review of this knowledge base would provide guidelines for proposed strategies that might be employed in a variety of settings for protecting, supporting, and promoting good child care in the interest of improved nutrition and development. The articles that follow include most of the papers presented at the Colloquium.
The first two papers provide an overview of the relationship between care and nutrition, and a summary of the planning process leading to the Colloquium, including the conceptual framework and rationale for selecting the topical issues addressed. The third paper discusses ethical issues related to nutrition policies in the context of UNICEF's Nutrition Strategy.
The next six articles review the research literature dealing with various aspects of early child care that may have an impact on nutrition, growth, and behavioural development: breastfeeding as care, sustained breastfeeding, complementary feeding practices, the role of appetite, nutritional care during illness, and the role of psychosocial care. Some factors that may significantly influence the quality of care young children receive are discussed in the final four papers: cultural setting of care and caregiver roles, health and nutrition status of caregiver, modernization and urbanization, and coping with emergency or refugee situations.
Suggested strategies for protecting and enhancing the quality of various aspects of care are touched upon in many of the papers in this issue. In addition, at the close of the Colloquium, several work groups drafted preliminary recommendations for research aimed at improving care practices and for action strategies that might be employed to improve child care and nutrition at the policy and planning levels. These recommendations have been made available to UNICEF for further consideration and review.
On behalf of the editorial committee, I wish to thank UNICEF for its sponsorship of this activity, which underscores the importance of creating new knowledge and scholarship in determining courses of action. It also served as a valuable chance to bring biologists, social scientists, and practitioners together to examine a topic that goes beyond child survival. I also wish to acknowledge the valuable help of the other two members of the editorial committee, Henry Ricciuti and Michael Latham.
Michael C. Latham
The three underlying causes of malnutrition in children are inadequate food, inadequate health, and inadequate care. Of these three, inadequate care has been the feast investigated Actions to ensure adequate care of children include the protection of good caring practices in a society; support for mother and families to help them maintain good caring practices when these are threatened or otherwise difficult; and promotion of those caring practices likely to improve the nutrition and health of children. Three actions in favour of good care include service delivery, capacity-building, and empowerment. These can operate at different levels in society and may be interdependent. In this Colloquium, special attention was addressed to young children, and how care may influence their nutrition.
For the very young child, good nutrition depends on good care. But for nearly all humans, of all ages, other than those who choose to live as hermits, "caring" can help to ensure their well-being. Good nutrition and health are essential parts of a good quality of life. The relationship between care and nutrition is stronger for those who depend on others for feeding and for other actions that contribute to nutritional well-being. Very young children, certain older people, some sick people, and those who are insane especially depend on care.
In this Colloquium special attention is addressed to young children and how care may influence their nutrition. Care is also of value for pregnant women, for older children, and in some respect for most people. However, the infant and the young child up to age three years almost totally depend on others for food and therefore for good nutrition. Children three to five years of age have some ability to gather food, to select a diet, and to feed themselves, but in most societies children up to about age six years, or school age, are considered to need feeding care. Thereafter care is highly desirable but not essential for survival. But good care will positively influence nutrition status and well-being.
The conceptual framework suggests that the two most proximal causes of malnutrition are inadequate intake of nutrients and disease . The three underlying causes are inadequate food, poor health, and deficient care. Each of these is essential to good nutrition . Of these three, the least investigated and the least understood is care. Few programmes designed to improve nutrition include a set of actions to address problems related to care.
The English word "care" is both a verb and a noun. In the Oxford dictionary the verb is defined as "feel[ing] concern or interest, provid[ing] food, attendance etc. for (children, invalids, etc.) . .. " and the noun as "solicitude, anxiety, serious attention, heed, caution, charge, protection ..." Other definitions of the verb include "to look after, to provide for."
Patrice Engle , who has written about care and nutrition, provided a working definition describing the care of young children as follows:
Care refers to caregiving behaviors such as breast feeding, diagnosing illnesses, determining when a child is ready for supplementary feeding, stimulating language and other cognitive capacities and providing emotional support.
In most developing countries, the mother is usually the main caregiver for the infant and very young child, but in the common extended family, grandmothers, siblings, fathers, and other family and non-family members often also contribute to child care. As the child gets older, care may be provided increasingly outside the home, for example, in day care facilities.
For the child, adequate care is important for survival but also to ensure optimal physical and mental development, and good health. Care also contributes to the child's general well-being and happiness, or what we term a good quality of life. It needs to be recognized that care influences the child, but also that the child influences the care.
The basic causes of inadequate food, health, and care that lead to malnutrition include those at the international, national, local, and family levels. Poor child care may be influenced by war, blockade, or other international factors that keep nations in poverty; national factors such as those related to equity, to availability of good health and education services; local factors such as land distribution, climate, water supply, and primary health care; and finally, family factors such as presence of other family members, type of house, availability of water, household hygiene, and mother's knowledge.
Protection, support, and promotion of good caring practices
Care giving behaviours that contribute to good nutrition, health, and well-being of the child vary enormously from society to society, from culture to culture. A first assumption can be made that almost all societies value children and that they wish to see children grow to be healthy, intelligent, and productive adults. A second, more debatable, assumption is that societies in general have traditional or culturally determined caring practices, most of which are good and contribute to good nutrition.
I believe that in Africa, as well as most of Asia and Latin America, an erosion of traditional caring practices in the 1990s has contributed more to malnutrition than wrong or inappropriate caring practices. Traditional caring practices have been altered or eroded, often for the worse, as a result of modernization or westernization, as well as increasing urbanization . The decline of breastfeeding is an example of this. Breastfeeding was a traditional practice almost everywhere, and its decline has been influenced by modernization, including medical practices of Western-oriented health professionals and promotion by infant formula manufacturers.
A strategy for ensuring good nutrition status should first protect the good caring practices in a society. In a society where most mothers breastfeed their babies with no or few other foods introduced until the child is four to six months of age and where breastfeeding continues for 18 months or longer, protection of breastfeeding should take priority over its support and promotion. Similarly, if a society traditionally provides a lot of stimulation to children; if the infant is seldom left alone but is carried on the mother's back; if fathers, grandmothers, older siblings, and other relatives frequently help in child care; and if traditional weaning foods of peanuts, green leafy vegetables, and legumes with a local cereal gruel are the norm; then these caring norms deserve protection. These practices may be threatened by modern or Western influences. A new television set in the family may result in adults' neglecting child stimulation; advertising and promotion of manufactured expensive weaning foods may lead families to poorer diets at higher cost; or work away from home where the mother cannot take her baby may cause long separations of infant and mother.
Support is the next level in promoting good care. Supporting good caring practices is an intermediate approach, between protection and promotion of care. Support includes activities both formal and informal that help women in changing circumstances to practice those good caring practices that are threatened, and that were considered normal in previous times. This may involve restoring confidence in mothers, strengthening their belief that traditional good caring practices may be more desirable than new Western practices. For example, westernization and modernization may suggest that modern women do not breastfeed their baby in a public place or that canned baby foods are superior to home-prepared foods, or that salt and sugar is better treatment for mild diarrhoea than family soups and breastfeeding, or that it is better for a child to stay at home and watch television than to go with the mother to the village market, or that eating with a fork is preferable to eating with one's hands after traditional handwashing.
In many developing countries, paid employment for women away from home is eroding traditional good caring practices. Three months of maternity leave may help support mothers in providing infant care, at least for that period. Later, during the 8 hours mothers are away from home, a crèche or daycare centre at the place of work could be supportive.
Support for good traditional care may include mother support groups or arrangements for adequate child care while the mother is away from home. Staggered working hours for different family members and then a greater role for the father in child care may help.
Promotion of good caring practices is the third level needed. It involves motivation or re-education of mothers, other family members, or whole communities. It is the most difficult and the most expensive of the three strategies. It is important to find what were the most important factors that led to the decline or disappearance of good caring practices. There must be evidence that the new caring practice is less desirable and less beneficial. Lack of such understanding will almost certainly lead to failure of a promotional campaign. The promotion of good caring practices will often involve public education, mass media efforts, and political commitment. Promotional campaigns in Brazil in the 1970s and in Honduras in the 1980s have proved successful . The campaigns might promote such practices as traditional breastfeeding and family feeding for children with diarrhoea; carrying children on their mothers' backs rather than leaving them at home; and the use of good, village-based weaning foods in place of expensive, less nutritious manufactured foods.
How to influence caring practices to ensure good nutrition
Mothers, fathers, families, and communities (and also, of course, governments and international institutions) take actions all the time that influence nutrition. These are actions in the area of food, health, or care. They may have either a positive or negative influence, or they may be neutral. The actions are based on, or arise from, everyday decisions. These decisions are nearly always based on three steps: assessment, analysis, and action. This so-called "Triple-A" approach  is used for the smallest decision (for example, should the mother spend her morning working in the home garden or going to the market to sell produce harvested yesterday) or large decisions (should FAO launch a major programme in an African country to increase the availability of carotene-rich fruits and vegetables in communities). In each case there is assessment of the situation, analysis of the information, and these lead to action.
This triple-A approach is also appropriate for protecting, supporting, and promoting good child care. First, current caring practices affecting nutrition must be assessed. Many countries have fairly good knowledge about the food situation, health status, and health care, but may have very few published findings on child care, especially child care as it relates to nutrition. Gathering data rapidly on child care is an important activity. Often there will be some information on breastfeeding and on weaning practices, but very few data or even descriptions of caring practices influencing psychosocial and motor development, on factors such as mothers' self-esteem and their beliefs and attitudes related to child care, or on household and community factors that greatly influence child care.
A useful approach for finding which child caring practices seem to be desirable may be an investigation of "positive deviants" in a community, or a comparison of "negative deviants" and "positive deviants" . Positive deviants are young children who have good nutrition status even though they come from very poor households, have uneducated mothers and limited family access to food and health services, and live in a community where most children are malnourished. If it can be found that mothers and families with positive deviants have a set of good caring practices, ones not usually used by other families and mothers, then it can be assumed that all or some of these caring practices deserve protection, support, and promotion.
Actions in favour of good care
These can be divided into service delivery, capacity building, and empowerment, all three of which may be operative at different levels in society (from national to family) and which may be interdependent. All three will involve triple-A processes of assessment, analysis, action, and reassessment. Delivery of services in support of child care may address the most immediate causes, and some are curative rather than preventive. Examples might include oral rehydration for diarrhoea, deworming, child-feeding targeted to malnourished children, and so on. Others may also be top-down and be preventive, such as immunization and organized day-care centres. Delivery of services may not be sustainable or may have to remain in place for a long period unless other changes prevent or permanently cure the problem in society, not in the individual child. For example, oral rehydration prevents death in a child and treats dehydration but does not reduce diarrhoea prevalence or incidence in society.
Capacity-building is likely to be more sustainable and often is preventive rather than curative, since its aim is to deal not with the immediate causes but more with the underlying causes of malnutrition. It is likely to be most successful if based mainly on bottom-up, not top-down, actions. Capacity-building is important for improved care in relation to nutrition, and may involve protection, support, and promotion. Examples include good feeding practices as the infant moves from exclusive breastfeeding, to mixed feeding, to an age when exclusive home foods are appropriate; child-care practices that are stimulating and influence good psychosocial development; health education to provide knowledge about protection against disease, including immunization or how to use home foods and fluids for diarrhoea; and home hygiene and sanitation to prevent diarrhoea and intestinal parasitic infections.
The third level, empowerment, crosses the boundaries of service delivery and capacity-building. Actions empowering mothers often address the more basic causes of child malnutrition. Empowerment for women includes giving women rights to have an income, not to be overburdened with work, to breastfeed, and to have reasonable access to services, resources, and capacity-building activities. Empowerment can consist of improving mothers' incomes or control of family income, providing good access to health care for women and children, providing water supplies that lessen the burden on women, or reducing poverty and increasing equity (through trade and price policies). It includes both top-down and bottom-up approaches.
Investigating current good caring practices, how they might be threatened by new influences, and how they might be protected in changing, modernizing, urbanizing societies deserves a very high priority. Support for good caring practices is undoubtedly also important, although perhaps not such a high priority for research.
Finally, we know relatively little about which good caring practices should be promoted or how to do this. Where caring practices are inadequate and cause malnutrition, we need studies on appropriate alternatives and investigations.
There is some published research on intrafamily food distribution, meal frequency, energy density of foods, and other practical topics, but we know little about other important factors that influence nutrition related to care.
1. Ramakrishnan U. UNICEF-Cornell Colloquium on Care and Nutrition of the Young Child-planning. Food Nutr Bull 1995;16:286-92.
2. UNICEF. Strategy for improved nutrition of children and women in developing countries. New York: UNICEF, 1990.
3. Engle P. Care and child nutrition. Theme paper for International Conference on Nutrition. New York: UNICEF, 1992.
4. Latham MC. Western development strategies and inappropriate modernization as causes of malnutrition and ill health. In: Latham MC, Bondestam L, Chorlton R. Jonsson U. eds. Hunger and society, Cornell International Nutrition Monograph Series no. 17;1988:7595.
5. Jelliffe DB, Jelliffe EFP. Human milk in the modern world. Oxford: Oxford University Press, 1978.
6. Zeitlin MF, Ghassemi H. Mansour M. Positive deviance in child nutrition. Tokyo: United Nations University Press, 1989.
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