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TABLE 6. Availability of energy and protein per person per day in Central America and Panama, according to food balance sheets, 1964-1971 and 1975-1983 availability of energy and proteins.

a.Projected figure

These data should be analysed with caution, as they are national averages, and even in Panama and Costa Rica, where the mean availability of protein and energy seems to be adequate, food is not distributed according to what each family requires for optimal health and nutrition. Thus, if a segment of the population is consuming more energy and proteins than it needs, it is to be expected that another group has less food than it requires. Furthermore, the poorest individuals in developing countries are usually engy seems to be adequate, food is not distributed according to what each family requires for optimal national average.

The data show, however, that at least three countries exhibited in their latest food balance sheets lower mean figures of available energy than the total required by their populations. Therefore, even if all available food were distributed according to nutritional requirements, some countries still would require more than is available.

Family food consumption surveys

Table 7 summarizes family energy and protein intake in Central America and Panama in the periods 1965-1967 and 1975-1982 [8, 12-14]. In recent surveys in Costa Rica and Panama, the mean family energy intake was above 2,050 calories. This amount barely fulfils the average energy requirement of the population from which the information was collected.

In El Salvador, Honduras, and Guatemala the mean family energy intake, derived from family food consumption surveys, was well below 2,000 calories.

As with the food balance sheets, only in Costa Rica and Panama do the latest food consumption surveys show adequate mean intake values for energy and proteins. These mean intakes are not necessarily distributed according to requirements, however. Therefore, a significant number of families have energy intake well below their physiological needs, according to these surveys.

Nutritional status

Low intake of energy, protein, minerals, and vitamins, aggravated by frequent severe infections, produces malnutrition in adults and children. The rapid growth of children requires more energy and nutrients per kilogram of body weight than is necessary at other ages. This, combined with less resistance to infections and dependence on others to feed them, makes children more prone than other family members to exhibit symptoms of malnutrition. Therefore, most nutrition surveys carried out in developing nations concentrate on children under five years of age to determine the extent of deficiencies affecting families and communities.

TABLE 7. Family energy and protein intakes per person per day in Central America and Panama, according to food consumption surveys, 1965-1967 and 1975-1982

Sources: Ref.8.
a. ref.12.
b. Ref.13.

TABLE 8. Percentages of children under five years old in Central America and Panama with weights and heights more than two standard deviations below mean weight and height for age of the NCHS reference pattern, 1965-1967 and 1978-1982

a. Rural areas only.
Source: Ref.15.

The following nutritional conditions have been identified since 1965-1967 [14] and confirmed by more recent studies [8, 9] as affecting a large proportion of children and adults in Central America and Panama: protein-energy malnutrition (PEM), and vitamin A, iodine, iron, and riboflavin deficiencies.

Protein-energy malnutrition

Growth retardation in children, as measured by weight and height, reflects a combination of various nutritional deficiencies but, in particular, PEM. Table 8 shows the latest available figures on the prevalence of PEM, expressed as the percentage of children below age 60 months who are more than two standard deviations below normal weight for age and height for age. (In general, in a normally growing, healthy population, one would expect to find around 2.5% of children below this cut-off point.) All surveys used the National Center for Health Statistics (NCHS) percentiles [16] as the reference growth pattern.

There are marked differences between countries in the proportion of children exhibiting weight and height retardation. In 1982, 6% of Costa Rican children were reported below normal for height; in Guatemala the corresponding figure in the early 1980s was 60%.

The changes in PEM between 1965-1967 and 1978-1982 are better reflected by height for age than by weight for age. The table shows important reductions in the proportion of children exhibiting height retardation in El Salvador and Costa Rica. In Guatemala, Panama, and Nicaragua the prevalence of children more than two standard deviations below normal height for age was similar. The figure that should be of concern is Guatemala's, as Nicaragua and Panama in the 1960s already had low national average figures. No recent national-scale information is available for Honduras, which was supposed to conduct its second national food and nutrition survey in 1986.

Vitamin-A deficiency

Table 9 presents the latest information on the prevalence of vitamin-A deficiency as measured by low and deficient levels of serum retinal in children under 60 months of age [8, 10, 17]. The figures from the period 1976-1981 show marked improvements over those from 1965-1967. In spite of a decrease in the number of children with low and deficient levels ofserum retinol El Salvador still reported one-third of its preschool children to have vitamin-A deficiency in 1976-1980. The countries in which marked improvements were observed, except El Salvador, are those that successfully implemented a national programme for fortifying sugar with vitamin A [17-19]. Costa Rica eradicated vitamin-A deficiency in the late 1970s; and, according to a national survey carried out in 1978, Guatemala substantially reduced its magnitude.

|Iodine deficiency

Iodine deficiency is reflected in the data on the prevalence of goitre, shown in table 10 [8, 10]. In the latest surveys El Salvador and Nicaragua still reported 20% or more of their populations with goitre, although all countries exhibited important reductions in its prevalence. In Guatemala, where important reductions of iodine deficiencies occurred from 1954 to 1965, a slight increase in goitre was noted from 1965 to 1979 as a result of lack of control by health authorities of ionization of salt. Nicaragua, Costa Rica, and Panama presently maintain good salt-iodization programmes.

TABLE 9. Prevalence of vitamin-A deficiency (<20 g/d) of serum retinol) in children under five years of age in Central America and Panama, 1965-1967 and 1976-1980

a. The latest information from Honduras reported 2.8% of cases below 30 g/dl of serum retinol therefore, no more than 2.8% of cases are below 20 g/dl.
Source Ref.10.

Iron and riboflavin deficiencies

Table 11 summarizes the latest available information (1965-1967) on iron and riboflavin deficiencies identified in the Central American isthmus [10, 20]. Anaemia, as measured by a level of saturation of transferrin below 20%, affected from 42% of the population in El Salvador to 60% in Panama. Riboflavin deficiency ranged from as low as 10% in Nicaragua to 55% in El Salvador. Unfortunately, there are no recent national-scale data. Moreover, no marked improvements are expected, given the nature of these two conditions, the changes seen in other nutritional deficiencies, and the lack of specific control programmes geared to tackle them.

Variations of nutritional conditions

The national figures already discussed do not reflect differences in nutrition between various political administrative units or types of families. For example, periodic censuses of schoolchildren's heights in Costa Rica and Panama [21, 22] have shown dramatic differences in nutritional status by provinces, by counties or districts, and by smaller units such as villages. Five of Costa Rica's 82 counties had a rate of height retardation (less than 90% of standard height for age) above 22%, while in five other counties the percentage was closer to that expected in a normal, healthy growing population. Living conditions, as indicated by poor housing, lack of access to potable water, and poor disposal of excrete and garbage, are also dramatically different in the two groups of counties.

TABLE 10. Prevalence of endemic goitre in Central America and Panama, 1954-1967 and 1973-1983

Source: Ref.1 0.

TABLE 11. Prevalence of anaemia and riboflavin deficiency in Central America and Panama, 1965-1967

a. Percentage of population with loved of saturation of transferrin below 20%
b. Percentage of population with low and deficient levels of riboflavin in their red blood cells.
Source: Ref.1 4.

A census of schoolchildren's heights was carried out in Panama in 1982 using the criterion of less than two standard deviations from the mean. Analysis of the data for the political-administrative units with the highest and lowest figures shows that, the smaller the units, the greater the differences there are in children's nutritional status. The data show striking differences in the prevalence of height retardation between the smaller units within the same district, whether the district exhibits an overall high or low level of malnutrition.

Panama and Costa Rica are the two countries in the isthmus in which nutritional status is relatively good and where severe, overt malnutrition is unlikely to be found. Thus, larger differences in nutritional status by political-administrative units probably occur in Guatemala, El Salvador, and Honduras.

Variations in the infant mortality rate by county were reported from Costa Rica in 1978, and maps were prepared showing the counties where the rate was above 35 per 1,000. Panama reported similar differences in the infant mortality rate by district for 1982 [24]. The geographical identification of such pockets of high infant mortality can help in targeting programmes to address the problem.

Differences in the nutritional status of children according to the occupation of the head of household were reported from Guatemala, Costa Rica, and Panama [25-27]. The national nutrition survey carried out in Guatemala in 1980 [25] determined that 57% of children from families whose heads of household were farmers with less than 0.7 hectare of land were affected by height retardation, compared with only 35% of children from families whose heads of household were skilled labourers.

Ecology is another important factor for malnutrition. Reports from Costa Rica, El Salvador, Guatemala, and Panama show that poverty and malnutrition are likely to be concentrated in rural communities and, to a much lesser extent, in the cities [2, 21, 25, 26, 28]. Within the rural areas, the children of agricultural labourers living on coffee plantations and of very small subsistence farmers (with less than 1.4 hectares of land) are likely to have the poorest nutrition [26, 28]. Data gathered through the school systems of Costa Rica and Panama [22, 29] and the national survey conducted in Guatemala in 1980 [25] show conclusively that the areas with a significant proportion of Indian groups also have high levels of malnutrition. These areas are the most deprived and isolated, and few government services are likely to be available for the population.

The present situation and future prospects for food and nutrition programmes

Several national programmes and activities are aimed at improving the food and nutrition conditions of the populations of Central America and Panama directly or indirectly. Other regional or national-scale programmes and activities operating in different government sectors, if properly targeted and executed, will also exert a positive impact on the groups most affected by low purchasing power and poor access to health and nutrition services.

Food and nutrition education programmes

Food and nutrition education programmes are carried out in Costa Rica by the ministries of Health, Agriculture, and Education, the National Institute of Learning, and the Social Security System. The Ministry of Health recently reinforced its activities through national teaching campaigns using communications media. These programmes are expected to contribute to improvements in the nutritional status of the poor by strengthening, modifying, or changing existing food habits.

In El Salvador, the ministries of Health, Agriculture, Education, and International Affairs are implementing community-level food and nutrition education programmes under the co-ordination of the National Commission for Food and Nutrition of the Ministry of Planning, with the goal of reaching the entire population of the country. They are carrying out the following short-term actions: (1) evaluating the present operation of such programmes, (2) establishing a national study on food habits and beliefs, (3) developing mass-communication campaigns, training activities, and teaching materials to re-orient food and nutrition habits if necessary, (4) developing the teaching component of supplementary and emergency feeding programmes, and (5) developing food and nutrition education activities within primary health care programmes.

Programmes in Guatemala are carried out by the Ministry of Health, the Bureau for Community Development, the Bureau for Agricultural Training, the Secretariat for Child and Family Welfare, the National System for Extrascholastic Education, and the Social Security System. The activities of the Ministry of Health are geared to training teachers and the staff from the health services who will orient the population in the use of the most commonly available foods of high nutritive value. These activities will be reinforced by a mass-media programme.

In Honduras, the ministries of Natural Resources and Education, the National Agricultural Institute, and the National Agrarian Institute carry out food and nutrition education programmes directed toward improving the patterns of food consumption in the population. The Ministry of Health has identified as a priority the establishment of a programme supporting the development of activities in different sectors. The proposed system entails the revision, modification, and elaboration of the food and nutrition content of the formal education curriculum, and the design, development, and evaluation of extensive food and nutrition materials for nonformal education.

Activities in Nicaragua have been carried out within the formal education system by the Ministry of Education and within the non-formal education system by the ministries of Health, Agrarian Development, and Internal Commerce. These actions are supported by the mass media and by the production of teaching materials. A Five-Year Food and Nutrition Plan for 1984-1989 is being implemented and coordinated by the Ministry of Agriculture with the participation of different sectors. The education component of the plan includes (1) developing workshops to train personnel at the regional, area, and community levels, (2) elaborating and producing teaching and training materials, and (3) elaborating and diffusing food and nutrition messages using the communications media. Two salient characteristics of the programme are (1) the development of basic knowledge related to new animal and vegetable food resources to increase the consumption of high-quality foods, an activity coordinated by the Ministry of Industry, and (2) educational activities aimed at promoting the consumption of nutritious foods and at improving their biological utilization through the use of mass media and popular participation, co-ordinated by the Ministry of Health.

Several Panamanian institutions are implementing food and nutrition education programmes, such as the ministries of Health, Agrarian Development, Education, Labour, and Industry and Commerce, and the Social Security Bureau. These institutions designed a national food and nutrition education plan under the co-ordination of the Ministry of Health. In November 1983 a National Commission for Food and Nutrition Education was created to establish a permanent policy for such education, with multisectoral participation through which the use of available government and external resources will be improved. The objective is to reinforce and modify food-consumption habits to improve the nutritional conditions of the country. This plan will be carried out through the formal and non-formal education systems and the use of mass media.

As of 1984-1985, all countries of Central America and Panama had revised their national food and nutrition education activities and prepared five-year plans (1985-1989) within the Bridge for Peace Initiative promoted by the Pan American Health Organization and UNICEF 1301. The Institute of Nutrition of Central America and Panama (INCAP), at the request of its member countries, prepared a regional project to support with technical assistance, research, and training activities the national food and nutrition education programmes prepared by all the countries of the isthmus, which are expected to be carried out in the next five years.

Promotion of breast-feeding practices

After a regional workshop on the promotion of breast-feeding was held in Panama in 1983 [31], all the countries of the isthmus have been strongly promoting breast-feeding and adequate infant-feeding practices through several activities.

First, national commissions, including professionals from the health and other social sectors, are being organized to coordinate promotional activities carried out by different private and government groups in each country. Before 1983 Guatemala was the only country with a national commission promoting breast-feeding.

Second, health personnel and the staff from other sectors are being trained in topics related to the promotion of lactation and the clinical management of breast-feeding and infant feeding. Courses on the clinical management of lactation have been held where professionals from the countries of the isthmus have had the opportunity to receive specialized training, initially outside the region (in California, USA) and now on a regional and national basis within the isthmus. These regional activities have provided an excellent forum for the sharing of information among the countries about the constraints and successful experiences they have had. In addition to the training activities, all the countries have revised their norms for prenatal and postnatal care, rooming-in, milk banks, and infant feeding. Thus, the countries are implementing changes, when these are deemed necessary, in the traditional procedures that have been followed for decades.

Third, mass-communication programmes on breast feeding and infant feeding are being developed. Finally, analysis and strengthening of promotional breast feeding activities is being carried out by the ministries of Health, Labour, Education, and Agriculture, and by private groups.

Group feeding programmes

In Central America and Panama in 1984-1985 there were a total of 65 group feeding programmes of regular or emergency nature [32]. The foods distributed amounted to 200,000 metric tonnes per year, with an estimated economic value, excluding administrative costs, of more than US$120 million per year. The present objectives of governments are to make more rational use of these resources as part of their social development strategies and to plan, operate, and evaluate such programmes more effectively if they are identified as necessary to supplement the income of the poor. Details are available from the authors on request.

Child survival and development programmes

The main specific health problems in Central America, particularly for children living in rural areas, are (1) infectious diseases preventable by vaccination, (2) diarrhoeal diseases, (3) perinatal problems, (4) acute respiratory infections, and (5) protein-energy malnutrition.

Technical groups within the Ministry of Health of each country drew up five-year plans for child survival and development as part of the Bridge for Peace Initiative. Also, INCAP has the human and economic resources to support its member countries in such activities by providing technical assistance and supporting and developing research and training activities for collecting and interpreting information on health conditions and programmes. The support of INCAP to its member countries will also entail planning, developing, and evaluating national activities on child survival resulting from the plans prepared by each country.

Fortification of foods

Vitamin-A and iodine deficiencies were reduced by implementing technologies that were developed and tested in the Central American isthmus to incorporate these nutrients into widely consumed foods. The government of Costa Rica began fortifying sugar with vitamin A in 1974-1975 but discontinued the practice in the early 1980s because field nutrition surveys conducted in 1979 indicated that vitamin-A deficiency had been eradicated.

Similar fortification programmes were operated in Guatemala and Honduras in 1981-1982 but were discontinued in 1983-1984 for financial reasons and lack of supervision. Nicaragua and El Salvador have never added vitamin A to sugar on a national scale.

All the member countries of INCAP fortify salt with iodine. As with the fortification of sugar with vitamin A, a major constraint to making this a permanent, efficient operation is the lack of supervision and control by government offices. Government involvement is important because fortification with both nutrients requires material imported from developed nations that must be purchased with US dollars.

The fortification of foods is one of the priority regional projects of the food and nutrition component included in the Bridge for Peace Initiative. All the countries have prepared their national programmes for 1985-1989 and are expecting to obtain external financial support to perform the process efficiently, and particularly to control it. In addition, INCAP prepared its own five-year project in support of these food-fortification activities. food and nutrition surveillance systems

The concepts of and approaches to setting up efficient food and nutrition surveillance systems in the isthmus are based on experiences from 1976 to 1984 in the region. These were reviewed in a meeting held in Antigua, Guatemala, in 1984 attended by technical groups from Central America and Panama, INCAP staff, and external consultants [30].

Costa Rica has continued with its Nutrition Information System (SIN) that has maintained up-dated reports on conditions in the country since 1979. The Ministry of Health has also implemented a Nutrition Surveillance System based on the anthropometric and other information gathered by the programmes under the responsibility of the Department of Nutrition. The country is now reviewing the possibility of integrating all its food and nutrition data collection and analysis efforts into a national multisectoral food and nutrition surveillance system. Costa Rica has one of the best existing systems in any developing nation to provide timely information for making decisions in food and nutrition planning [3].

El Salvador has had a food and nutrition surveillance system operating in the Ministry of Health since 1976 [5]. However, no progress in its structure or operations took place during 1981-1984. No important practical activities occurred in the health sector in Honduras or Guatemala in the same years. These three countries were scheduled to carry out nationwide censuses of schoolchildren's heights in 1986, however. A technical group in nutrition has prepared a plan for the development of surveillance activities for 1985-1989. Some of the proposed activities will operate with government funds, while others are expected to be financed as part of the external support requested through the Bridge for Peace Initiative.

The first census of schoolchildren's heights was carried out in Panama in 1982, and a final report of the 1980 national food and nutrition survey was prepared in 1983. The latter laid out the bases for surveillance systems to be operating in other countries of the isthmus in the following years. The second census of schoolchildren's heights was conducted by the ministries of Education and Health in 1985. It is expected that surveillance activities will be strengthened in 1986, mostly with locally available funds, in the health and agricultural sectors.

In Nicaragua, the WHO/UNICEF-funded Five-Year Food and Nutrition Plan was approved in 1984 and includes the development of a multisectoral food and nutrition surveillance system. Among the activities were a census of schoolchildren's heights and the strengthening of sectoral activities within the ministries of Health and Agriculture.

In 1984-1985 all countries prepared their national projects on surveillance systems, which are expected to be funded and implemented with local and/or external support in 1986-1990.

Other programmes

A summary by country of the different food and nutrition programmes or of other national socioe-conomic programmes with profound nutritional implications operating in the agricultural, health, education, and labour sectors as of 1984 was prepared and edited by INCAP 130]. It is envisaged that if adequate co-ordination and targeting of all these efforts to the most needy groups within countries are achieved, in the next five years this may yield important positive results in the overall conditions of the populations of Central America and Panama.

Dr. Victor Valverde

The Food and Nutrition Bulletin deeply regrets the death of Dr. Victor Valverde, the senior author of this article, who died from a rare fatal reaction to the altitude of La Paz, Bolivia, during a mission for FAO. This is his fifth article to be published in the Bulletin. His death, at the age of 37, is a serious loss to the Institute of Nutrition of Central America and Panama INCAS, the Food and Agriculture Organization, and the entire international nutrition community as well as to his family.

A 1972 graduate of the University of San Carlos, Guatemala, he received his Ph.D. in Human Nutrition, and Food and Nutrition Planning in 1979. He was head of INCAP's Division of Food and Nutrition Planning and served as the UNU Institutional Co-ordinator at INCAP from 1982 to 1986. With more than 40 scientific papers of consequence and presentations of papers at numerous international workshops, seminars, and congresses, Dr. Valverde was a/so responsible for the design and development of nutrition evaluation and surveillance programmes in Central America and Panama and for the formulation of national food and nutrition plans for the countries of the area.

He served as a consultant to FAO, the Pan American Health Organization, and the World Food Programme and was a member of the Subcommittee on Nutritional Surveillance of the US National Academy of Sciences. Dr. Valverde was already recognized internationally for his contributions to food and nutrition policy and planning and was in global demand as a speaker, author, adviser, and consultant. He was much admired and appreciated as a friend and colleague and will be sorely missed.

INCAP is seeking contributions for a fellowship in his name.

Conclusion

It should be a priority for the governments of the isthmus and for INCAP to monitor the extent to which some of the positive trends observed in reducing the magnitude of nutritional deficiencies in certain countries over the past 20 years may have been lost in the last two to five years. Two factors account for such deterioration.

The first is the recent proliferation of man-made disasters, an outgrowth of the wars and other violent acts with which our region has unfortunately been torn. For example, official statistics from El Salvador, which still may contain serious underestimations, showed that in late 1984 more than 500,000 people were displaced from their place of origin by war- that is, approximately 10% of the total population. These people fled their farms or villages, leaving behind crops and all their goods, and moved to rural towns or larger cities where labour opportunities, housing, and government services were not of acceptable quality even for the permanent inhabitants. Most of the displaced families have been fed for several years by government programmes that rely on international and bilateral food-aid programmes.

Costa Rica, Honduras, Panama, Mexico, and Belize, with no internal armed confrontations, are sheltering refugees from neighbouring countries. Honduras has a refugee community of 35,000 persons, and the number has reached 28,000 in Costa Rica. In Panama the number is smaller.

Observations by health and nutrition experts show that levels of infant and child mortality are extremely high in the areas where displaced and refugee families are located. Children exhibit degrees, types, and severity of nutritional deficiencies that had almost been eradicated in some of these countries. Providing health and nutrition services to these groups is a technical challenge for nutritionists, physicians, and nurses, but solving the conflicts and their international ramifications is a political responsibility.

The second factor that has negatively affected the nutritional achievements reached in certain countries up to 1980 is inflation. Since 1980 inflation has reduced even further the purchasing power of those already deprived and malnourished. It also complicates the economic capacity of governments to allocate additional resources or even to continue, at say 1980 prices, investment of the magnitude needed to maintain the quality and quantity of services rendered to the poor through the social sectors.

Thus it is more important than ever to strengthen food, nutrition, and health interventions in the next five years. A first goal is to avoid potential deterioration. If programmes are properly identified, strengthened, planned, operated, and targeted, improvements may be expected to take place.

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