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Mortality levels and patterns in the oral therapy extension programme areas of the Bangladesh rural advancement committee

M. Kabir
Jahangirnagar University, Dhaka, Bangladesh
M. Moslehuddin
University of Dhaka, Dhaka, Bangladesh

INTRODUCTION

The Bangladesh Rural Advancement Committee (BRAC) is a private voluntary organization established in 1972. Its main objective is to improve the socio-economic condition of the rural people in Bangladesh, and its programmes cover a broad spectrum of development activities. This paper deals with the question of mortality in the Oral Therapy Extension Programme (OTEP) areas. The present population policy of the government of Bangladesh is particularly concerned with this problem, since the mortality level, particularly the infant mortality level, is still very high: about one in every ten children born in developing countries dies of diarrhoea before reaching the age of five. The OTEP programme can substantially reduce this high rate, Many children in Bangladesh are malnourished, and malnutrition is an important element of diarrhoea; diarrhoea interacting with malnutrition is a major cause of death among infants and young children [4] . The aim of this paper is to present the mortality levels from the baseline survey of the eight thanas, of which four are comparison thanas and the other four OTEP programme thanas.

Methods and Procedures of Data Collection

A detailed study design for this study has already been published as a working paper of ICDDR,B; however, in this section we shall briefly describe the design used.

A two-way classification was used to study the impact of the oral rehydration programme on mortality, one based on geography and the other on famine liability. In the first phase of the Oral Therapy Extension Programme (OTEP), five districts, Sylhet, Jessore, Paridpur, Kushtia, and Khulna, with a total of about 3.9 million households, were visited up until 1983 to teach the preparation and use of lobongur oral saline. These five districts were categorized by location, Sylhet on one side and the other four districts on the other. The second classification, based on the susceptibility of these areas to food shortages and famine, was carried out according to the method of B. Currey, who divided the populations into three groups: thanas very liable to famine (stratum 1), thanas liable to famine (stratum 2), and thanas least liable to famine (stratum 3) (see table 1).

TABLE 1. Classification of study areas

TABLE 2. Selected unions and thanas by district

Str¹=Stratum

The above-mentioned four groups of thanas formed the basis of our study. Two thanas from each of the four categories were randomly selected; in each category one thana was considered as the programme than a and one as a comparison thana. One union from each of the sampled thanas was selected on the basis of the following criteria:

• The union should have a total of about 3,000 households.
• The proportion of Muslims and Hindus should be more or less that of the nation at large.
• The distance of the union from the thana headquarters should be at least three miles.
• About 80-85 per cent of the people in the union should be engaged in agriculture.
• There are no modern non-governmental health services available.

Following the above-mentioned procedure, the selected unions and thanas are shown by district in table 2.

A baseline survey of each union was followed by a six month retrospective multi-round survey, or follow-up survey. This report presents findings from the baseline survey and the first follow-up survey. The selected unions were considered as clusters for our study; each household in the selected union was interviewed. The total number of households studied is shown in table 2.

RESULTS

Mortality Level

The mortality level of both programme areas and comparison areas appears to be reasonable, although mortality level in the comparison areas was slightly lower than that in the programme areas. For instance, the crude death rate was 12.3 per thousand population in the comparison areas, compared with 12.7 in the programme areas.

Neonatal, Post-neonatal, and Infant Mortality

Table 3 shows the neonatal, post-neonatal, and infant mortality for two areas The neonatal mortality in the programme areas was considerably higher than in the comparison areas, while the difference in post-neonatal mortality between the two areas was not as great. The post neonatal mortality in the programme areas was 46 per thousand births, compared to 48 per thousand in the programme areas.

TABLE 3. Crude death rate, neonatal, post-neonatal, and infant mortality rates, by area

TABLE 4. Indirect estimates of infant and child mortality for baseline and first follow-up survey

Indirect Estimates of Infant and Child Mortality

To corroborate the direct estimates, infant mortality was also estimated by indirect techniques (table 4). It is well known that the proportion of children born against those who have died is an indicator of child mortality. The estimates of child mortality shown here are based on the Trussell technique [7]. Because of fluctuations in the estimates, the rates are graduated by logit system [1].

Table 4 shows the estimated infant and child mortality from the baseline and first follow-up survey. The mortality levels based on 12, 13 and 15 in the West model I if e table are also shown [3] . The estimated mortality as derived by the indirect technique suggests no significant difference between the two surveys, although it seems that mortality in the follow-up survey is slightly lower than in the baseline survey [5]. The overall infant mortality as shown by 12 in the West model life table is considerably higher than in the direct estimates.

Causes of Death

The causes of death for infants and children below the age of five years by sex are presented in tables 5 and 6. Malnutrition is the major cause of death for both infants and children (0-4 years): about 43 per cent of the male children and 39 per cent of the male infants died of malnutrition. The second and third major causes of deaths were diarrhoeal and other diseases. The "other" category includes murder, suicide, jaundice, and unknown causes. The causes of death for females followed the same pattern as the males.

Discussion and Conclusion

Detailed investigation of the results suggests that both neonatal and post-neonatal mortality is still high in both areas, and neonatal mortality accounts for about two-thirds of the infant deaths,

TABLE 5. Causes of deaths for males (baseline survey)

a 1 = tetanus; 2 = drowning; 3 = malnutrition; 4 = tuberculosis; 5 = diarrhoea;6 = old age; 7 = delivery; 8 = fever; 9 = others.
b. Excluded deaths under age one month.

TABLE 6. Causes of deaths for males (baseline survey)

a.1 = tetanus; 2 = drowning; 3 = malnutrition; 4 = tuberculosis; 5 = diarrhoea;6 = old age; 7 = delivery; 8 = fever; g = others.
b. Excluded deaths under age one month.

The infant mortality in the programme areas was 125 per thousand live births, while in the comparison areas it was only 113 per thousand births. The statistical Z test suggests that this is not significant. From the above findings it is difficult to ascertain that OTEP has any effect on infant mortality; but it is too early to draw any conclusions, since the information shown here was collected only six months after the OTEP programme was introduced. More time is probably required. The programme may have synergistic effects with other interventions, such as pure drinking water, environmental hygiene, sanitation, and general health education programmes.

The more important question raised by the study concerns the appropriateness of the intervention strategy to the task of reducing diarrhoeal mortality among children. Given the prevalence of diarrhoeal disease, the concentration of health education on mothers and on the home management of diarrhoea was appropriate; clearly, death rates may be high or low at given levels of mortality depending upon the availability of effective care for the sick. However, the scope for lowering death rates is likely to remain limited as long as the factors that generate disease remain unchanged.

In the case of diarrhoeal disease, these factors can be eradicated by better environmental conditions, safe drinking water, hygienic practices, and improved feeding habits by the household members.

REFERENCES

1. W. Brass, Methods for Estimating Fertility and Mortality from Limited and Defective Data, occasional publication (International Programme of Laboratories for Population Statistics, University of North Carolina at Chapel Hill, 1975).

2. R. E. Black et al., A Two Year Study of Bacteria, Vital and Parasite Agents Associated with Diarrhoea in Rural Bangladesh (Baltimore, Md., 1980).

3. A. J. Coate and P. Demeny, Regional Model Life Tables and Stable Populations (Princeton University Press, Princeton, 1966).

4. S. D'Souza et al., "Socio-economic Differentials in Mortality in a Rural Area of Bangladesh, unpublished MS. (ICDDR, B. Dhaka, 1979).

5. M. Kabir, "Levels and Patterns of Infant and Child Mortality in Bangladesh," Social Biology, 24(2) (1977).

6. Oral Rehydration Therapy for Childhood Diarrhoea, Population Reports Series L, no. 2 (1980).

7. T. J. Trussell, "A Re-estimation of the Multiplying Factors for Determining Childhood Survival," Population Studies, 29(1) (1975).

Nutritional aspects of obesity and diabetes and their relation to cardio-vascular

T. Tashev
International Union of Nutritional Sciences, Sofia, Bulgaria

INTRODUCTION

The workshop from which this article is drawn was devoted to the nutritional factors in the etiopathology and pathogenesis of obesity and diabetes and the interaction of these metabolic diseases as risk factors for cardiovascular degenerative processes. These diseases are among the crucial health problems which are attaining global proportions today, and are the subject of intensive studies and numerous scientific symposia and workshops. Cardiovascular diseases occupy a priority place in the programmes of WHO and other international organizations.

The IUNS also considers this problem important. Having organized several meetings in the past on the subject, it was considered appropriate and timely to review the field within the framework of Committee IV/2 of Commission IV' "Health Problems of Special Nutritional Importance." The purpose of the workshop was to assess nutrition as a factor in metabolic and degenerative pathology and to formulate recommendations for preventive health strategies and programmes.

The reports and discussions confirmed the enormous complexity of the factors and interactions involved in the metabolic diseases and their nutritional aspects. It was the group's opinion that this complexity should not be an obstacle to reaching a consensus on some general pathogenic nutrition-related mechanisms and to formulating relevant recommendations. Three drafting groups prepared the recommendations, which were discussed and adopted at the closing session of the workshop.

NUTRITION AND OBESITY

Obesity is the most prevalent nutritional disease in developed countries. It is apparent from all the reports presented that it has assumed alarming proportions during the last decade, affecting 20 to 40 per cent of the adults and 10 to 20 per cent of the children and adolescents in these countries. Hyperalimentation is a general feature of the contemporary nutritional pattern in Europe, USSR, North America, Japan, New Zealand, and Australia, as well as for affluent groups in Africa, Asia, and South America. Accumulation of excessive adipose tissue in obesity is the leading component in the complex of metabolic syndromes that includes deviations in the insulin and cortisol metabolism and in lipoprotein, glucose, cholesterol, and triglyceride plasma levels. The metabolic disturbances have a common pathogenic origin whenever hereditary factors play an important role; however, environmental conditions are of decisive significance for the development of obesity and its complications. Modern lifestyle, together with excessive food intake and reduced physical activity, are the main contributive factors to the increasing frequency of these diseases. A high energy intake, involving excessive consumption of sugar, sweets, refined foods, and fats, is common practice in the industrial countries and some developing countries; at the same time there is a decreasing tendency to consume complex carbohydrates and fibre-rich food. During the discussions the speakers unanimously stated that obesity increases the risk of diabetes, gout, various types of hyperlipoproteinemias, cholelithiasis, and liver steatosis, arterial hypertension, atherosclerosis, cardiovascular diseases, locomotor system diseases, etc.

The following recommendations were made:

1. There is a strong need for a standardized definition of obesity, and also for a common nomenclature and classification of different degrees, types, and forms of obesity.
2. It is now necessary to standardize and recommend methods for the measurement and assessment of body mass.
3. The following dietary principles for preventing and treating obesity should be adopted: the ratio of energy dense foods such as simple carbohydrates and fats should be reduced; the fibre content in the diet should be increased through the consumption of common unrefined foods; adequate levels of essential nutrients in the low-energy diets should be ensured by the appropriate variation of food items; and reducing diets should be as close as possible to existing nutritional patterns.
4. Particular attention should be paid to the children of parents with obesity and/or diabetes.
5. National and regional programmes for education and the promotion of favourable changes in nutritional habits and physical activity in the general population should be implemented.
6. Closer collaboration between nutritionists, health authorities, and the food industry in producing foods complying with nutritional guidelines should be encouraged, as should the production of low-energy foods for particular nutritional uses.
7. Assistance from international organizations (IUNS, WHO, FAO, etc.) will be necessary to elaborate, implement, and evaluate the above programmes.

DIABETES AND OBESITY

Obesity and diabetes are one of the most frequent pathological associations. Over 70 per cent of diabetics are overweight, while more than 50 per cent of patients with advanced obesity have reduced glucose tolerance.

The pathogenic mechanisms of the diabetes-obesity association can be considered in several aspects. It is known that a relative insulin resistance takes place in obesity in peripheral tissues, mainly adipose tissues, while the insulin excretion is normal or increased. The demonstrated reduction in the sensitivity to insulin of the large adipocyte can be attributed to the decreased affinity of the insulin receptors or to a reduction in their number in the cell membrane Though a feedback mechanism the insulin excretion is stepped up, thus leading to a state of hyperinsulinism.

There exists, however, other evidence which suggests that primary hyperinsulinism can arise as a result of hyperenergy nutrition with a secondary stimulation of the adipocyte growth. In this case, hyperinsulinism through a down regulation leads to a reduction in the number of insulin receptors and, through the mechanism of negative co-operativity, decreases the sensitivity of these receptors to the hormone. Thus, again, a state of relative insulin resistance is brought about.

From a practical point of view all hypotheses concerning the mechanism by which the association between obesity and diabetes takes place could be put down to over nutrition, to a hyperenergy food intake. This is a sound basis for preventive and therapeutic recommendations aimed at countering the effect on health of the combined obesity and diabetes:

1. Maintaining a normal body weight is the most important measure for diabetes prevention in the general population. The group stresses that this measure is of the utmost importance for the subpopulation with a hereditary predisposition.
2. Weight reduction should not be conceived as simply energy intake reduction. Emphasis should be given at the same time to the adoption of healthy nutritional habits including an adequate protein intake, a high intake of fibre, and a reduced preference for sweet things, combined with physical exercise.
3. For obese diabetic patients the normalization of body weight is the most important therapeutic measure.

ATHEROSCLEROSIS AND NUTRITION

The standardized mortality rate for all forms of ischaemic heart disease and cerebral vascular disease has increased in the developed countries since the Second World War as a reflection of changes in life-style, food habits, and environmental hazards. The observed trend to regression of mortality rates from IHD in some countries could be attributed in part to substantial changes in the mode of nutrition of the population.

There is a great deal of evidence to support the diet-lipid heart theory, despite the lack of a conclusive and an irrefutable cause-effect relationship. The coinciding results of different methodological approaches to this problem have imposed the recommendation of broad nutritional preventive programmes in many countries.

The development of the atherosclerosis process involves a great number of risk factors which may initiate, potentiate, promote, and precipitate the pathological process: these include constitutional and demographic factors, exposure to environmental factors, life-style, serum blood indices, health conditions (diabetes, hypothyroidism, chronic dialysis, obesity, gout homcysteinemia, etc.), and dietary factors.

All risk factors are highly interrelated. The effect of diet, especially of alimentary fats, on the lipoprotein metabolism, diabetes, obesity, and thrombogenic activity is supported by several lines of evidence. The abuse of refined sugar may play an important role in widespread over nutrition, diabetes and hypertriglyceridemia. There is a general agreement about the benefits of increasing the quantity of ingested fibre.

Some experimental and clinical data seem to indicate that atherosclerosis can regress with a combination of vigorous dietary and drug therapy. Thus the continuous promotion of a prudent diet directed to the general population has proved rewarding. Strict long-term dietary measures are justified only in patients with hyperlipoproteinemia, severe family history of coronary heart diseases, and other major risk factors—hypertension, diabetes, obesity, etc.

The recommendations were as follows:

1. The general population should be informed about the methods of primary prevention of atherosclerosis in the framework of the national extension programmes. Attention should be paid to hyperlipoproteinemia or elevated plasma cholesterol levels in the younger population for early detection and treatment. The improvement of nutritional habits is crucial to the comprehensive prevention of atherosclerosis.
2. The nutritional policy should be directed to the promotion of a healthy diet, including a reduction in the total energy intake and the intake of fats and cholesterol-rich foods. The consumption of lean meats, skimmed milk and milk products, fish, all-bran products, cereals, beans, vegetable oils, and foods rich in fibre should be encouraged.
3. In the implementation of dietary changes it is essential to provide detailed labelling of foods with a high fat content, and of dietetic and hypoenergy foods, in order to supply better and more relevant information to the consumer.

GENERAL RECOMMENDATIONS

The atherosclerosis-related diseases—obesity, diabetes, and hyperlipoproteinemia—are interrelated through certain common etiopathogenic mechanisms. Thus common preventive methods may be used, such as healthy nutrition, adequate physical activity, and avoidance of alcohol and smoking.

1. The main efforts should be directed to the primary prevention of these diseases, although some aspects of secondary prevention, treatment, and rehabilitation must be considered.
2. Intervention should be focused on physical inactivity, inappropriate nutrition, smoking, hypertension and environmental factors.
3. All relevant organizations and institutions should be involved in the implementation of long-term preventive programmes. Regional organizations should be more actively involved where possible. On the international level the vast experience of the specialized United Nations organizations such as WHO and FAO should be used more effectively.
4. Special attention should be given to the optimal organization of medical care. The development of unified methodological instructions for the medical care network must be adapted to the specific conditions and traditions of each country.
5. The implementation of adequate extended education programmes is indispensable. They can propagate sound knowledge in hygiene, nutrition, and medical principles in schools and universities at all levels. In medical schools co-operation and collaboration between the fields of nutrition, cardiology, endocrinology, and public health should be established within the curriculum. Comprehensive medical education programmes concerning the main risk factors should be elaborated and directed to the community utilizing all available mass media.

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