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The effect of urbanization and western foods on infant and maternal nutrition in the South Pacific
Julian Lambert
National Food and Nutrition Development Programme, Suva, Fiji
When Europeans first made contact with the South Pacific, they frequently commented on the health and vigour of Pacific islanders and the abundance of food to be found. Captain Cook made many references to this in his diaries. At this time self-sufficiency in food was taken for granted, and health problems such as degenerative heart disease and diabetes were practically unknown.
Today the situation is very different. Throughout the Pacific white bread and rice, cassava, and cabin crackers have replaced sweet potato, taro, yams, and breadfruit. Fruits and vegetables such as guava, mango, and paw-paw and local dark green leaves have been replaced by nutritionally inferior foods like apples, tinned fruits, European cabbage, lettuce, and cucumbers. Canned fish has replaced fresh fish, shellfish, and other products of the sea, and tinned corned beef, high in salt and fat, has replaced fresh meat.
In addition, a number of entirely new products have been introduced into the diet of Pacific islanders, such as beer, sugar, soft drinks, and expensive snack foods, all of which contribute little or nothing to food needs. This, unfortunately, does not stop their popularity from spreading.
This process starts at birth for many islanders. In the past, all infants were breast-fed, and it is still the norm in most rural areas. Regrettably, in urban areas throughout the Pacific islands bottle-feeding is becoming more and more common.
The consequences of this trend are most disturbing. In a survey carried out in Port Moresby in 1975, 23 per cent of bottle-fed infants were clinically malnourished compared with 3 per cent of breast-fed infants (1). In Apia, Western Samoa, Quested found that 17 per cent of bottle-fed infants were malnourished compared to 5 per cent of the breast-fed (2). In Suva, Fiji, the percentage of wholly breast-fed infants of all races fell from 44 per cent in 1977 to 31 per cent in 1980 (3). Over the same period the reported number of cases of infantile diarrhoea in Fiji increased from 9,442 to 12,830 (T. Bavadra, personal communication). In Apia, Brewster found that bottle-fed infants were seven times more likely to be hospitalized with gastroenteritis than breast-fed infants (4). Throughout the Pacific region diarrhoea is a major cause of morbidity and mortality among infants.
The cause of these problems is well known. In order to prepare a bottle-feed properly, a mother needs a reliable supply of water of good quality, facilities to be able to sterilize feeding bottles and nipples, and to store the milk (i.e., a refrigerator), and sufficient income to be able to buy the necessary formula, bottles, nipples, and fuel. Few mothers in the Pacific area have all of the facilities required to bottle-feed their infants. In Fuji it costs F$4.50 {approximately US$ 5.30) a week for the infant formula alone for a three-month-old baby. All too often health workers see babies who have been given formula that has been over-diluted (to save money), made with contaminated water, and put into an unsterilized bottle.
The advantages of breast-feeding are too numerous to mention in this paper and cannot be over-emphasized. Breast-milk is clean, free, and always available at just the right temperature. It contains antibodies that protect infants from diseases like diarrhoea, polio, and ear infections, and it promotes a close mother-child relationship. Infant formula, despite the claims of the manufacturers, is different in practically every respect from mothers' milk. Only the water content and milk sugar are comparable. Despite the concerns of many women about their milk supply, research in several developing countries has shown that up to 98 per cent of all women can lactate satisfactorily. This fact is demonstrated by countless mothers in rural areas throughout the Pacific region. Even when a mother is malnourished herself, she can generally produce enough milk for her child for the first four to six months of life.
After four months, breast-milk alone is not adequate for these infants. Infants are very vulnerable to malnutrition because of their rapid rate of growth (tripling their birth weight in the first year), low disease resistance, and minimal nutrient reserves in their bodies. In several parts of the Pacific it is customary for mothers to delay the introduction of supplementary food until a child is 10 or 12 months old and has several teeth. Recent data indicated that 52 per cent of infants in urban Apia and 19 per cent in rural Savai'i in Western Samoa (2). Similar trends have been observed in Fiji and Guam (1). Moreover, the interaction between nutrition and infection leads to a vicious circle that, if not broken, often results in the death of the child (5).
Unfortunately, in many urban areas in Pacific countries malnutrition in infants and Young children is becoming more frequent. At the Colonial War Memorial Hospital in Suva, Fiji, which contains over 30 per cent of all hospital beds in the country, the number of cases of clinical malnutrition seen in the paediatric ward increased from 68 in 1975 to 178 in 1980. Over the same period, the number of deaths from malnutrition increased from 4 in 1975 to 12 in 1980.
In Western Samoa, research by Jensen in 1969 (6) showed that 6 per cent of children under five years of age in Apia were underweight (below 80 per cent of normal weight for age). By 1979, a similar survey by Brazil showed that 30 per cent were in that category (7). In rural Savai'i no change in nutritional status was recorded over the same period. The main reasons for the increased rate of malnutrition in Apia included low incomes, a shortened period of breast-feeding, bottle-feeding, and a reduction in the consumption of traditional, high-energy, nutrient-rich foods.
In Papua New Guinea malnutrition is a serious problem in some resettlement schemes. At an oil palm production plant in Hoskins, West New Britain, a survey in 1975 revealed that 41 per cent of children under five from the settlers' block were underweight, compared with 23 per cent of children under five in the surrounding villages (8). A programme was introduced to encourage the settlers to grow food crops, but a follow-up survey in 1978 revealed that, while the number of underweight children in the villages had been reduced to 15 per cent of the survey population, on the settlement blocks the percentage had increased to 51 per cent. It appeared that, although the programme to promote home gardens among the settlers had been a success, much of the produce was being sold in the nearby town of Kimbe.
The problem was found to be more severe at the Gavien rubber resettlement scheme near Angoram, in the East Sepik Province. In this scheme, people living on the banks of the River Sepik, whose land was flooded for at least six months of every year, were resettled on blocks of land away from the river to grow rubber trees. Unfortunately, it takes from five to seven years for rubber trees to become established and produce a reasonable return. A survey of the settlers' children in 1975 revealed that 66 per cent of those under five were underweight compared with 52 per cent of children in the disadvantaged area from which they had come. Two years later, 80 per cent of the settlers' children were underweight.
On other islands in the Pacific malnutrition is also being seen more frequently. The author has personally seen kwashiorkor (protein malnutrition) in Vila and Raratonga; and last year Tonga, generally thought to be free from the extremes of child malnutrition, reported its first death from kwashiorkor in Nuku'elofa.
However, an overall shortage of food remains the main problem, rather than a deficiency of protein per se. In both Fiji and Papua New Guinea, marasmus (caused by an insufficiency of calories) is between ten and twenty times more common than kwashiorkor.
A critical factor in determining the general level of health in infants is the nutritional status of the mother. Poor diets in pregnancy lead to an increase in the number of low-birth-weight babies, and a rise in morbidity and mortality for both mother and child.
In Fiji up to 40 per cent of mothers attending the antenatal clinic in Suva are anaemic (Saroj Nandam, personal communication). The main cause of this anaemia is iron deficiency. It has, in the past, been associated mainly with the Indian population, but it is becoming more and more common among Fijian women. Between 1975 and 1977 the amount of anaemia seen in the Fijian population rose from 9.4 to 16.4 per cent (9). Experience in several Pacific countries has shown that where food is in short supply, usually because of low incomes in the urban areas, it is most often the women in the family who do without.
In many Pacific countries urbanization has resulted in a breakdown in traditional methods of family spacing. In the past, a birth interval of between two to three years was common. Now many women have a child every year. As a result, the health of both mother and child is compromised.
Poor maternal diet also results in an increase in the number of babies whose birth weight is below 2.5 kg. In Fiji this problem is more common in the Indian population.. However, improvements in diet and socio-economic status can dramatically reduce the number of low-birth-weight babies, as shown by data from the maternity unit at Suva's CWM Hospital, where 24.6 per cent of Indian children born in the public ward are low-birth-weight compared with 11 7 per cent in the private wards used by the higher socio-economic group (10).
A good general indicator of the level of health of women in a society is mean life expectancy at birth. Where health standards are good, the life expectancy of women is four or five years longer than that of men. Where they are not so good, these figures are equal, and where it is poor men live longer. As is well known, the term "malnutrition" includes over-nutrition as well as under-nutrition. In many parts of the Pacific, diabetes, heart disease, and obesity are becoming major health problems. While males are usually affected more by heart disease, obesity and diabetes are more commonly seen in women. The decline in breast-feeding may contribute, in part, towards a greater incidence of obesity in women. This is because during pregnancy a well-nourished woman will gain approximately 4 kg of fat as an energy reserve to help meet the needs of milk production. If a woman does not breast-feed her baby, this extra fat can be very hard to lose. The custom of not allowing a woman who has had a baby to do any work for a period of several months after the birth of the child exacerbates this problem, particularly if the mother is consuming a diet of energy-dense, refined carbohydrate foods.
SUMMARY
Throughout the Pacific region, infant and maternal nutrition has been adversely affected by urbanization and the introduction of new foods. However, the process of urbanization is probably irreversible, at least for the foreseeable future, and few of us would deny the convenience of many imported foods. What is needed is to select the best of the foods that have been introduced and the most appropriate technology, and to preserve the best aspects of traditional life. For this the general public must be well informed. Therefore, a Pacific-wide nutrition education programme is required, tailored to meet the needs of each country, making fullest possible use of the mass media.
Some of the changes that have already occurred are not necessarily irreversible. In Papua New Guinea the Government passed legislation in 1977 removing infant feeding bottles and nipples from general sale, allowing them to be available only on prescription. This legislation, coupled with a campaign to promote breast-feeding, led to a reduction in the percentage of bottle-fed infants in Port Moresby from 35 per cent in 1975 to 12 per cent in 1979 (10). Over the same period, the number of cases of diarrhoea in infants less than six months of age seen each year at Port Moresby General Hospital dropped from 83 to 28.
In Micronesia a campaign to replace imported soft drinks with coconuts resulted in a drop of over 50 per cent in such imports (11). In Fiji, a Feed Fiji First-campaign, through the use of radio programmes, newspaper articles, the sale of T-shirts, and a nation-wide school garden contest, has succeeded in reviving interest in traditional crops.
The superiority of breast-milk and many other traditional foods compared to imported foods is self-evident to those who know the facts. Consumer education must therefore be the main goal. Military records from New Caledonia and Tahiti show that in 1905 the average height of Polynesians recruited into the armed forces was 4 cm greater than that of Europeans. BY 1950 there was no difference, and by 1970 the Europeans were taller than the Polynesians. Apparently our grandparents could teach us a lot about good nutrition!
REFERENCES
1. J.N. Lambert and J. Basford, "Port Moresby Infant Feeding Survey,'' PNG Med. J., 20: 175(1977).
2. C. Quested, "Breast-feeding and Artificial Feeding Practices in Western Samoa" (mimeographed paper, Ministry of Health, Apia, Western Samoa, 1978).
3. J.N. Lamber and V. Yee, "Suva Infant Feeding Survey," Fiji Med. J., 6:5 (1981).
4. D.R. Brewster and K. Kuresa, "Infant Feeding, Malnutrition and Gastroenteritis in Western Samoa" (paper presented to the International Paediatric Congress, Kuala Lumpur, Malaysia, 1979).
5. J.E. Gordon, M A. Guzman, W. Ascoli, and N.S. Scrimshaw, "Acute Diarrhoeal Disease in Less Developed Countries. 2. Patterns of Epidemiological Behaviour in Rural Guatemalan Villages," Bull. Wld Hlth. Org., 31: 9 (1964).
6. A.A. Jansen, "Malnutrition in Western Samoa" country report, World Health Organization, Manila, Philippines, 1969).
7. H. Brazill, "Socio-economic Factor Contributing to Malnutrition in Western Samoa" (mimeographed paper, Ministry of Health, Apia, Western Samoa, 1979).
8. J.N. Lambert, "The Relationship between Cash Crop Production and Nutritional Status in Papua New Guinea," History of Agriculture (Working Paper No. 33, University of Papua New Guinea, Port Moresby, 1979).
9. Cema Bolabola, "Anaemia in Fiji" (unpublished paper, NFNC, Suva, Fiji).
10. Ministry of Health, unpublished data, Suva, Fiji.
11. J.N' Lambert, "Bottle-feeding Legislation in Papua New Guinea," J. Human Nutr., 34: 23 (1980).
12. N. Rody, "Things Go Better with Coconuts," J. Nutr. Ed., 10: 19 (1975).