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Alberto Pradilla. World Health Organization, South-East Asia Regional Office, New Delhi, India
An analysis of the variability of the prevalence of growth retardation among and within the countries of the WHO South-East Asia Region and its relation with some of its associated factors (food intake, poverty, education, and mortality) points to the need for problem-oriented action. The intersectoral approach requires a focus on the problem to be solved and only then the definition for the role of each sector or discipline can be determined. A description of some of the health sector activities that influence growth is presented and discussed.
All the governments of the WHO South-East Asia Region have committed themselves to the goal of health for all by the year 2000, and it is now well recognized that health is the result of an interaction of factors at the individual, family, community, and national levels. No single sector or discipline has the capability of acting on the wide range of conditions determining health or on other factors ranging from individual behaviour to overall development policies aimed at reducing the socio-economic inequalities present in every society. From this recognition, the so-called multisectoral actions have resulted, apparently as a panacea to solve all problems. These actions, however, have been difficult to implement, as there are many conceptual, administrative, and political constraints in this type of co-ordinated effort.
Very recently, during a consultation meeting of countries in the region, the food and nutrition strategies of each one were presented and discussed. It was clear that ways and means to approach a solution to the problem were still being viewed with a strong sectoral and professional bias. This has resulted in a myriad of programmes, as many as there are professional disciplines, many of them not fully related to the reality of the problem and its determinants. The agricultural sector has concentrated heavily on food production, with impressive successes in improving the food balance sheets but with limited effect in improving the diets of lower income groups, unable to compete with the richer farmers, for example, in improving productivity (International Centre for Tropical Agriculture 1974). Also, there have been many experiments on developing proper foods through food technology research, but very few of these formulae have had any impact on the dietary intake of low income groups except in developed countries (Behar et al. 1971). Within the health sector, there have been several types of intervention, including education, rehabilitation, and food distribution, without regard for the fact that those most in need are not usually reached and do not take part in these programmes (Ghassemi 1980). In the area of education, many attempts have been made, with significant results in getting information to the populations but with very limited effect on changing behaviour.
Many of these programmes have failed through lack of proper implementation, and many by disregarding the intrafamily, interfamily, and interregional processes normally taking place for the benefit of some and to the detriment of others, or as a social response for survival. Indeed, individual and social behaviour is a product of adaptation for survival and not necessarily that of ignorance and backwardness (Nabrarro 1982). Apparently, the intersectoral approach requires that we focus on the problem to be solved, understand its various aspects, and only then define the role of each sector or discipline. As the processes may be different for different population groups, in differing ecological regions, and under different political circumstances, a different set of sectors may be called upon to help solve the same problem in different locations.
Countries in the WHO South-East Asia Region (Bangladesh, Bhutan, Burma, India, Indonesia, the Democratic People's Republic of Korea (DPRK), the Maldives, Mongolia, Nepal, Sri Lanka, and Thailand) contain roughly 25 per cent of the world's population, most of the ethnic groups, a large representation of religions and languages, several types of governments, and a full range of ecological systems. These variations occur not only from country to country but within countries, making any mean average almost worthless. However, it is possible to establish qualitatively some comparisons of the magnitude of the problem of malnutrition as well as of some of the conditioning factors.
The growth process of children from conception to puberty has been an accepted indicator of nutritional status. It must be recognized that it is not a specific indicator of nutrient intake although it may be specific for tissue nutritional status and, as such, may reflect the adequacy of nutrient intake, or nutrient absorption and/or nutrient uptake. Furthermore, growth is of use only as it reflects the individual development and function as well as that of the family and the community in which the individual lives. By using this indicator combined with age-specific mortality figures for infants and children one to four years of age (Aranda-Pastor et al. 1975) derived from official documents and published data, it is possible to stratify the region by the severity of the problem in three groups as shown in figure 1 (see FIG. 1. Magnitude of Malnutrition in Selected Asian Contries (Based on the Mortality Rates of Children Aged One to Four)): Group 1, mild (DPRK, Sri Lanka, and Thailand); Group 2, moderate (Burma and Mongolia); and Group 3, severe (Bangladesh, India, Indonesia, Maldives, and Nepal).
TABLE 1. Prevalence of Malnutrition (Children Below Two Standard Deviations (SD) of Reference Weight For Age) and Other Associated Factors in the Countries of South-East Asia
|Country||Area km2||Population density per km2||Crude death rate||Infant mortality rate||Percentage of children with weight bellow 2 SD||Available calories as % of RDAs*||Mean energy consumption as % of RDAs||Relative GNP (%)||Literacy as % of RDAs||Out-patient morbidity: %of cases of enteric infections|
* Recommended dietary allowances.
As mentioned previously, there is also a significant variation within countries. The same criteria, when available, demonstrate extreme variations in the magnitude of the prevalence of malnutrition within country boundaries (see FIG. 2 Magnitude of Malnutrition within Asian Country Boundaries (Based on the Mortality Rates of Children Aged One to Four)). Some factors that have been identified as associated with malnutrition (growth deficit) such as nutrient availability, nutrient consumption, income, education, and morbidity, were also collected and analysed in relation to their contribution to the problem. Table 1 summarizes the average values for these variables in the countries of the Region. For this analysis, the available unconsolidated data were utilized to determine the strength of the association with nutritional status. Though no strong association was expected, on the assumption that the average for an area or a country represents a large number of universes, each of which has a different set of conditions determining the effect of a given variable, the results in figure 3 (see FIG. 3 Correlation of Malnutrition and Conditioning Factors:) are none the less disturbing, and contradict present views (Beaton and Taylor 1981; Berg 1981). The strongest association with nutritional status appears to be literacy and income.
A more detailed analysis of one of the factors, energy intake, was undertaken using published data supplemented by personal communications. The mean value and standard deviation for energy intake were derived for Bangladesh (Mostafa 1979, Institute of Nutrition and Food Science 1976), India (NNMB 1976-1980; Panikar 1980), Indonesia (Djumadias 1979; Goan-Hong Lie 1976), Sri Lanka (MRI 1976), Thailand (Nutrition Division 1981), the Philippines (FNRI 1980), Colombia (Fundación para la Educación Superior 1976), and the United States (PHS 1979).
Wherever possible the data (sometimes not consolidated) available with countries were used. Figure 4 (see FIG. 4. Energy Intake: Mean Value and One Standard Deviation for Different Developed and Developing Countries or Areas) shows in graphic form the lack of significant differences between energy intake in the United States and that in developing countries or areas within countries. In figure 5 (see FIG. 5. Frequency Distribution of Energy Intake as Percentage of an American recommended Daily Allowance.) the frequency distribution of energy intake in the slums of Cartagena, Colombia, and in Bangladesh, expressed as a percentage of recommended allowances in the United States, emphasizes this observation. This finding might not have any significance if other similar contradictory observations were not available. The state of Kerala in India has had the lowest per capita intake of energy and proteins in the country and, on the other hand, the best growth performance and infant survival rates (Panikar 1980). A field experience, in Candelaria (Colombia), shows a decline of nutrient consumption with a simultaneous improvement of growth performance and child survival (Pradilla et al. 1975, unpublished). Also the area where nutrient consumption is the lowest in Thailand has the best nutritional status. In the United Kingdom, Nelson (1980) has also reported unexpected differences in growth with an equal intake of energy and proteins. From these observations, one can draw several general and specific conclusions of regional interest:
The WHO programme for the South-East Asia Region includes support within the health system of those activities known to have an impact on the growth of children, e.g. their nutritional status, from conception, and of the mechanisms necessary to determine necessary action by other sectors. It is recognized that every country is developing its own programme, that many of the activities may already be under way, or that the interest in them is not as yet sufficient for them to have been included in national priorities or policies. For this reason, the programme is directed essentially toward promoting/strengthening/supporting appropriate mechanisms within the countries to facilitate a multisectoral analysis of the problem and its determining factors, and the development, testing, and evaluation of solutions in line with each country's socio-political reality, to help in attaining the following objectives:
TABLE 2. Intra-uterine Malnutrition
|Problem||Indicator||Associated factors||Determining conditions|
|Intra-uterine malnutrition||Low birth weight for gestational age intervals||1. Preconception|
|Mother height age, pregnancy||Her own childhood: growth and development.|
|Maternal nutritional status||Energy expenditure|
|Infections or other diseases|
|Placental status||Genetic, metabolic|
|Infections or other diseases|
|Foetal factors||Genetic, metabolic Infections|
TABLE 3. Increased and Decreased Food Intakes
|Increased food requirements and losses, during disease and convalescence||1. Frequency of disease||Susceptibility Environmental conditions: housing, excrete disposal and water supply|
|Hygiene: personal, household, food handling|
|Large weight loss without weight gain after recuperation||2. Duration of disease||Awareness of need, health behaviour, access to services, quality and cost of services.|
|Dietary beliefs and behaviour during disease and convalescence|
|Decrease intake during disease and convalescence||Cultural||Food patterns, beliefs, withdrawing food when sick.|
|Low density diets and impossibility to increase intake for recuperation|
|Lack of awareness of water, salt, and energy needs during disease|
|Metabolic and symptomatic||Inappropriate treatment of disease resulting in increased duration|
TABLE 4. Insufficient Food Intakes
|Food intake insufficient to cover the requirements||As measured by dietary surveys||Poor intra-family distribution||Inadequate food availability to the family|
|Cultural patterns, food taboos for certain ages|
|Inadequate food choices||Purchasing power|
|Production of cash-generating crops|
|Insufficient family production|
|Food habits and socio-cultural patterns limiting utilization of available food items|
|Food and nutrient losses during preparation and/or storage|
|Unavailability of proper foods||Low awareness of and access to welfare mechanisms|
|Unavailability of food items by low production or marketing imperfections. leading to high prices|
TABLE 5. Deviations from Normal Growth
|Nutritional objectives not included in developmental plans||Lack of awareness of the
Vulnerability to developmental policies
Budgeting for operations, not for specific outputs?
Evaluation of the nutritional impact of governmental policies
|Lack of appropriate information for the selection of an order of priorities||Information collected for
intrasectoral operational needs.
Lack of analysis both for intersectoral use and for specific geographical regions
planning in social sectors
Data aggregated for country
|Food and nutrition
monitoring and surveillance systems
Inventory and analysis of quality of sectoral data collection and processing
|Lack of inclusion of nutritional objectives in health activities and plans||In general nutritional status perceived as solely the result of food intake||No participation of nutrition in health planning||Participation of the
technical nutrition unit in health planning
Defining the role of nutrition as the technical body for health programmes
It is clear that most, if not ail, of the activities require a synchronized, concerted effort by different agencies acting in close co-operation to respond to community needs. Most of the hardware, if the term can be used, and sector-specific software are to be supplied by sectors other than health. It is also apparent that unless a network is developed that will include all sectors of society, very few of these activities can be accomplished. This is one of the basic reasons why the development of health services and primary health care, together with community participation, is one of the solid pillars of the strategies that have been agreed upon by governments in the world Health Assembly and later at the sessions of the WHO regional committees held in different regions throughout the world.
Aranda-Pastor, J., G Arroyave, M. Flores, G.A. Guzman, and Rl Martorell. 1975 Indicadores mínimos del Estado nutricional. Publ. No. E 827. Institute of Nutrition for Central America and Panama, Guatemala, Guatemala.
Beaton, G., and L. Taylor. 1981. "Body's Adaptability to Lower Calorie Intake - A Factor in Setting Standards." UNU News-letter, 5: 3. United Nations University, Tokyo.
Behar, M., R. Bressani, and N. Young. 1971. Factors to Consider in the Development of Feeding Mixtures Recursos proteinicos en América Latina. INCAP Guatemala, p. 423.
Berg, A. 1981. Malnourished People: A Policy View. Poverty and Basic Needs Series. World Bank, Washington, D.C.
Djumadias, A. 1979. Nutritional Intakes in Indonesia. Nutrition Research and Development Committee, Ministry of Health. Bogor, Indonesia.
FNRI. 1980. First Nationwide Nutrition Survey. Food and Nutrition Research Institute, Manila.
Fundación Pára la Educación Superior. 1976. Baseline Data for Food and Nutrition Surveillance. Cali. Colombia.
Ghassemi, H. 1980. Can Interventions Make a Difference? The Policy Implications of Field Programmes. United Nations Administrative Committee on Co-ordination. Sub-Committee on Nutrition, UNICEF, New York.
Goan-Hong Lie. 1976. Family Food Consumption Patterns in Indonesia. Symposium on Food and Nutrition. Nutrition Research and Development Committee, Ministry of Health, Jakarta.
Institute of Nutrition and Food Science. Nutrition Survey of Rural Bangladesh 1975/76. University of Dacca, Dacca, Bangladesh, 1976.
International Centre for Tropical Agriculture, 1974. Small Farmers Systems Programme Progress Report. Cali, Colombia.
Marga Institute. 1980. Needs of Children in Sri Lanka. Sri Lanka Centre for Development Studies (MARGA Institute), Colombo, Sri Lanka.
MRI. 1976. Report on Nutrition. Medical Research Institute, Colombo, Sri Lanka. table 4.
Mostafa, G. 1979. "Districtwise Assessment of Food and Nutrition: Use of Available Sources of Data." In: K. Ahmed (ed.), Bangladesh Nutrition Seminar. Institute of Nutrition and Food Science, University of Dacca, Dacca, Bangladesh.
Nabarro, D. 1982. "Social, Economic and Environmental Determinants of Nutritional Status." in: Proceedings of the Workshop on Nutrition Monitoring and Evaluation. world Health Organization, SouthEast Asia Regional Office.
Nelson, M. 1980. "Assessing Dietary Intake and its Relation to Growth in British Children." Proceedings of the Nutrition Society, 39: 35.
NNMB. Reports, for 1976, 1977, 1978, 1979 and 1980 of the National Nutritional Monitoring Bureau. National Institute of Nutrition, Hyderabad.
Nutrition Division, Ministry of Health, Bangkok, Thailand, 1981. Report, 1980.
Panikar, P.G.K. 1980. "Interregional Variation in Calorie Intake: Working Paper." Centre for Development Studies, Trivandrum, India.
PHS. 1979. Dietary Intake: Source Date. US 1971-7X, National Centre for Health Statistics, Department of Health, Education and Welfare, Hyattsville, Md., USA. Publication no. PHS 79-1221.
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