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Functional effects of iron deficiency: Cognition*
The following is the summary report of the Conference on Iron Deficiency and Brain Function, held at World Health Organization headquarters in Geneva, Switzerland, 10-12 October 1988, sponsored by the United Nations University and the Sub-committee on Nutrition of the UN Administrative Committee on Co-ordination (ACC/SCN) in collaboration with the WHO and the International Nutritional Anaemia Consultative Group (INACG).
Four main questions were posed at the beginning of the conference:
The meeting focused on a critical evaluation of seven experimental human studies of iron interventions on infants and schoolchildren (in Chile, Costa Rica, India, Indonesia, and Thailand). Presentations were preceded by reviews on behavioural developmental theory, the neurochemistry of iron deficiency, and animal models assessing impacts of iron deficiency on brain function. Two papers on methodological issues followed the presentations. A background paper included an algorithm to evaluate the degree to which causality can be inferred from the relationship between iron deficiency and behaviour.
The human studies assessed the effects of iron deficiency on measures of psychomotor development. attention, learning, and school achievement. None of the individual studies contained all the elements required to establish causality. Most were randomized, double-blind, iron-treatment trials. Results consistently showed that iron-replete children obtained better scores than iron-deficient anaemic children. Two studies (in Bandung, Indonesia, and India) reported that following iron treatment there was a significant improvement in test performance among anaemic children.
The following summary statement was approved at the end of the meeting:
Many studies have shown an association between iron deficiency and less than optimal behaviour in infants and children, as demonstrated by lower scores on tests of development, learning, and school achievement. A problem with interpretation of past studies has been that iron-deficiency anaemia is associated with other adverse environmental and nutritional conditions.
More recent studies using randomized designs with appropriate controls of variables have shown that iron therapy in children with iron-deficiency anaemia results in improvements in learning and achievement tests. This evidence in humans and a number of animal studies suggests that iron-deficiency anaemia is causally associated with less than optimal behaviour. For this reason it is important that iron-deficiency anaemia be prevented and treated.
Since the specific mechanisms and functional significance of these behavioural changes are not completely understood, further studies are essential bath to clarify the effects of iron-deficiency anaemia itself and to determine the importance of lesser degrees of such deficiency.
The inference made on causality was based on both statistical probability and biological and behavioural plausibility.
Critical questions raised during the discussions fall into three general areas for further investigation: (1) development of better measurement tools, (2) the search for mechanisms by which iron deficiency affects brain function and behaviour, and (3) con tinned research into the causal relationship between iron deficiency and behaviour.
Development of better measurement tools
Better infant tests are needed, especially for the use of measures for specific information processes (e.g. attention and memory) and for social and emotional development. Discussants recognized that the Bayley Scales of Mental and Motor Development have contributed to early identification of the effects of iron on infant behaviour, but questioned the construct validity of global scales of mental and motor development. Progress in this field might be accelerated by convening a workshop of development psychologists and neuroscientists to examine the problem and lay out research guidelines. Stops in this direction were taken by conference participants and officials from the Mental Health Division of the WHO.
Investigation of mechanisms
Participants recognized considerable progress in recent years in the study of brain neurochemistry as it relates to iron deficiency, illustrated by the experimental evidence presented on the effects of iron deficiency on the dopaminergic system and the reports suggesting that these effects may lie behind behavioural alterations. Neurochemical and behavioural research should be co-ordinated to draw more specific hypotheses on processes, loci of the effects, and mechanisms. Research should also assess the possible involvement of peripheral biological systems. Further research using animals was considered urgent; however, the relevance of animal models to the human organism must be established. Animal research should include: (1) cross-species verification, (2) development of models that mimic the type and severity of iron deficiency found in humans, and (3) recognition of development from concurrent biological, social, and behavioural perspectives. The relevance of currently available indicators of iron nutriture in the progression of iron deficiency should also be investigated.
Continued research into causality
While most of the investigations used a randomized, double-blind, iron-treatment trial to establish causality, substantial differences in the application of this design suggest that some standardization in methodology is needed to facilitate the evaluation of future research and strengthen conclusions about the generalizability of findings. Some co-ordination of research might be facilitated through multi-centre collaboration and communication.
Following are some critical issues that research designs should address:
At the meeting's end it was noted that current findings already have direct implications for both clinical treatment and public health interventions. However, treatment of iron-deficiency anaemia should not be justified solely on the basis of current knowledge. Continued research is needed to evaluate the potential importance of this public health problem on other programmes related to education and social/economic development.
Fostering nutrition among countries.
A workshop on Fostering Nutrition among Countries, sponsored by the International Union of Nutrition Sciences (IUNS), was held 26 April 1987 in San Diego, California, USA, at the time of the Third International Symposium on Clinical Nutrition. Attending the workshop were IUNS Council members, members of the US National Committee of the IUNS, and other scientists who had come to participate in the Clinical Nutrition Symposium. The workshop was chaired by Dr. Barbara Underwood (USA), a vicepresident of the IUNS.
There were four major presentations: two expressing views of the less-industrialized countries and two expressing those of industrialized countries. Dr. A. Valyasevi (Thailand) and Dr. J. E. Dutra de Oliveira (Brazil) described their experiences with projects involving collaboration with scientists or agencies from industrialized countries. Dr. J. G. A. J. Hautvast (Netherlands) and Dr. J. A. Olson (USA) spoke on their work in organizing collaborative projects in less-industrialized countries.
The presenters focused on five issues:
Open discussion by all attendees followed the formal presentations.
The key points made by each of the invited speakers were as follows.
Dr. Aree Valyasevi listed seven institutions in Thai land that have been supported by, or have collaborated in, programmes of training or research with international and regional agencies, and institutions in the EEC, the United States, Japan, the Netherlands, and Australia. In some cases support was given to the institution and in others to individual scientists. He found that the most important factors favouring the more successful collaborations were:
Barriers to successful collaborations can be minimized by:
Collaborations are needed to address issues both within and between less-industrialized countries. Within these countries help is needed in the critical analysis of existing research information and the development of strategies/mechanisms to apply research results to actual problems; in the development of concrete national food and nutrition plans; and in initiation or strengthening of networks for interdisciplinary collaborations.
Training centres and the development of graduate training programmes are needed between LDCs, as well as the creation of networks for information exchange. There are advantages to training schemes provided within the LDC or in a nearby region where the nutritional problems, socio-economic conditions, and environment are similar. Training is needed in nutritional science, in nutrition-related fields, and also in planning and management.
Collaborative projects should be relevant to, and be integrated with, the national development plan. They should analyse existing information or help collect needed nutritional information, and/or develop strategies or mechanisms to utilize research results in programme planning and implementation.
In Thailand, assistance from international agencies and collaboration with developed countries have facilitated the build-up of expertise in nutrition institutes in universities such as his own, Mahidol University. These university nutrition institutes (or departments) are a resource (1) to advise the ministries of Health and Agriculture on nutrition components of the national development plans and (2) to train community health professionals and agricultural extension workers to apply the newer knowledge of nutrition.
Dr. Dutra de Oliveira noted that, considering the large amounts of money and effort generously provided for training programmes in North America and Europe, it was his experience that in Latin America there are very few nutrition centres, very few local nutrition specialists, and correspondingly few nutritional interventions to help malnourished, poor people. There are some exceptions to this general statement, e.g. INCAP. What has happened to most of those from Latin America who have received advanced training in nutrition outside of the region? Why are they not working in nutrition science and programmes within Latin America?
He suggested six reasons:
After a few years of struggling to adapt to conditions back home, most of the young, bright, well-trained nutrition workers give up nutrition and take a position in another field. Among hundreds of Latin Americans trained overseas in nutrition, only a few dozen are actually working in nutrition in their own countries. To overcome this deterrent to advancement of nutrition science in a country, there is great need for continued contact and support of trainees from the parent training institutions when they return to their home countries.
International organizations offer support for training personnel, for conducting intervention programmes, and for food and nutrition research, but with limited success. One reason, Dr. Dutra believes, is that, except for the United Nations University, international agencies deal only with government ministers and officials. In some countries in the region governments are transient; in others they are not very concerned about the problems of poor people. More effective programmes would be likely if international agencies supported those universities with expressed interests in nutrition and the few existing research institutes. These institutions could do much more work if provided with more international support. He urged that international funding for nutrition programmes should go to local universities or similar institutions rather than to governments.
When investigators from developed countries plan a collaborative project, their main objective is to collect data. Naturally, the training of local people and the establishment of a continuing nutrition centre have lower priority. For example, although there have been several collaborative projects with developed countries in north-eastern Brazil, this area remains an area for research in malnutrition. The researchers did not appear to have been interested in developing expertise among local groups.
Unfortunately, also, most international courses in industrialized countries have not adequately prepared trainees for work in Latin America or Africa. They have not developed the needed leadership qualities in their trainees. Alternative courses available within the region have not been adequately supported and recognized. The IUNS could perhaps assist with overcoming this problem.
It would be very helpful if experienced nutrition scientists from developed countries could be supported as visiting professors at institutions in Latin America for a specific length of time. Too often experts from international agencies stay for only a few days in large cities, where they talk to government officials. They are taken to a few chosen persons, but may not meet the people who do the work in nutrition. The experts' contribution to advancing nutrition science in the country, therefore, is limited.
Dr. Joseph Hautvast's first point was that all countries should have formulated nutritional objectives. In less-industrialized countries, these might be to reduce the number of wasted children or to reduce vitamin-A deficiency or iodine-deficiency disorders.
At the international level, targets are set for developing countries by the United Nations ACC/SCN (Administrative Committee on Co-ordination, Subcommittee on Nutrition), which is a focal point for co-ordinating activities for FAO, WHO, UNICEF, the United Nations University, Unesco, the World Bank, the World Food Programme, the World Food Council, the UN Environment Programme, and bilateral donor countries. The priorities of the ACC/ SCN include maternal nutrition, encouragement of breast-feeding, nutrition in primary health care, nutrition for low-income families, and a number of country projects in the developing countries. The ACC/SCN is a close family.
Dr. Hautvast commented that some reports, i.e. short books, were particularly useful for nutrition work in developing countries. He mentioned as examples the FAO/WHO/UNU Energy and Protein Requirements (1985); Cameron and Hofvander's Manual on Feeding Infants and Young Children (1983); Ooments Tropical Leaf Vegetables in Human Nutrition (1977); the World Bank's bock Malnourished Peoples; the FAO/WHO ninth joint expert report, Food and Nutrition Strategies in National Development (1976); the WHO and International Vitamin A Consultative Group (IVACG) report Vitamin A Deficiency (1982); and the International Nutritional Anaemia Consultative Group (INACG) Guidelines for Eradication of Iron Deficiency Anaemia (1977).
In every developing country a first priority should be to strengthen and increase the local manpower of scientists and professionals in human nutrition. Countries need a critical mass of these resource people. Since there are losses from time to time, the minimum effective number (six, twelve, or whatever is considered best) is never sufficient. There is need for institutional strengthening and human-resource development. For nutritionists, improvement in the quality of life is an objective. People are not instrumental means to development but rather the objects of development. These aims differ from those of business, of industry, and of economists.
Dr. Hautvast's institution, Wageningen University, in the Netherlands, is engaged in a number of cooperative projects. Funds for these have come from Sweden and from the Netherlands. The university has several different training courses, more now being conducted in less-industrialized countries than in the Netherlands. These courses are given in English. There is an international course at Wageningen that concentrates on food and nutrition planning and on maternal and child nutrition. Sixty per cent of the participants come from Africa. The university cooperates in courses given in the Philippines and Indonesia, is starting a training programme in Zimbabwe, and has held workshops in eastern and southern Africa. Two newer concepts in collaboration are under way: One is the production of books on regional nutrition - e.g. one on iodine-deficiency disorders in eastern and southern Africa, and another on child feeding in this region. The other is "South-South cooperation" - e.g. nutritionists from the Philippines helping Sri Lanka, with the Dutch serving only as technical support.
Networks can be useful, but Dr. Hautvast thinks they should be more than long lists of names and addresses. It is much better to have in-depth cooperation with a small number of institutions and to share money for training. One advantage of a small network with close institutional involvement is that trainers in one institution are familiar with the background that students come from and the type of work and conditions they will go back to in their own countries.
Sometimes it seems that international agencies are competing to establish training programmes rather than co-operating. Dr. Hautvast thought, for example, that the FAO should not carry out its own training programmes; universities are better equipped to be training agencies.
Finally, he observed that co-operation requires time, patience, friendship, and some "easy" money, i.e. flexible-use money.
He thought that the biggest challenge for the IUNS is to find ways to help Africa meet its needs for trained manpower in nutrition and for nutrition programmes.
Dr. James Olson opened his presentation by noting that developed countries sometimes feel, to those living in them, as if they are declining or disintegrating rather than continuing to develop. Developed countries and their people have their own distinct problems.
In co-operation between institutions in developed and developing countries the personal aspect is very important. Both sides need to care about some part of a project, and there must be ability on both sides. Dr. Olson's formula for successful intercultural cooperation was summarized by three nutritiona ssociated acronyms: MEAT, FISH, and OVOVEG. MEAT stands for the attributes of mutuality, equality, ability, tolerance; FISH represents focus, initiative, sincerity, helpfulness; and OVOVEG stands for organization, vitality, originality, vision, equanimity, and graciousness. These ingredients, carefully mixed and allowed to mature over time, provide a recipe for lasting, mutually satisfying working relationships.
In co-operative activities, education can be the catalyst, i.e. working with bright young people. The types of activities in nutrition where education can prevail are research projects or surveys, training courses or conferences, or planning exercises and development of policies. Projects can be limited in size, e.g. lecturing for six months, or of medium size (several years), or large and extending over a long period. The bigger the project, the more time required. In the first two years, you and your counterpart(s) are just beginning to relate to one another. Unfortunately, few agencies fund projects far enough in advance to allow the time needed for their completion. Dr. Olson noted a number of ambitious projects that were cut off by the granting agency after only four years - too soon to expect sustained, successful collaboration to have developed.
Dr. Olson suggested appropriate objectives for guest scientists planning to work in a developing country:
Among the joys of working in another country may be that more varied problems are encountered and can be studied, and broader resources can be applied. Professional interaction can be rewarding, and the intercultural ties that emerge may be lasting. There is also the possibility of benefiting more people from one's work than would be possible if one stayed at home.
Against this, the personal limitations for scientists going from a developed country to work in a developing one may be the higher costs of research equipment and consumables and the probability of poorer funding. In addition, they are isolated from their own society and from what is happening on the frontiers of their science. Productivity is likely to decrease and career development to be slower.
Dr. Olson listed nine special concerns for a developed-country scientist working in a developing country:
At present the most needy developing or least-developed countries are in Africa and parts of Asia. Dr. Olson thought that international and bilateral agencies have over-focused on basic studies underlying applied programmes. More useful approaches might be support of a university nutrition programme or the survey-intervention-evaluation triad. Public education and policy change are much more difficult. What might be the role of the IUNS? He suggested support for conferences, training, and advisory work.
Points from the discussion
Speakers from developing countries spoke of the danger of visiting scientists coming with patronizing attitudes. Collaborative projects should aim for some social and economic payoffs within the country. India has stopped the export of blood samples for research analysis on the grounds that it is better for the equipment, method, and knew-how to be established in the country where the project is.
Foreign experts often do not take the time to understand the people or to become familiar with the extent of variations within the country. For example, people in developing countries would like to have healthy food habits but do not want to lose their traditions. It is very difficult to have the same food and nutrition policy nationwide. What is needed is to have more general guidelines that can be adapted to local circumstances.
On the subject of international courses, the chairman observed that students away from their own backgrounds often become less inhibited and more prepared to interchange with colleagues from other countries. Another speaker suggested that training should not be one-dimensional. There should be an exchange of students from developed to developing countries as well as in the more usual direction, and an exchange of teachers. The course in Uppsala will probably soon be given in English, like the international course in Holland, to facilitate student exchange.
Many scientists are deficient in programme management as well as in data management. Short courses on elementary management, financial management, and labour relations would be helpful, and basic computer courses would also be desirable.
There were several suggestions as to what the IUNS might do to help:
In addition, it was suggested that the IUNS should explore the potential for co-operation with food-related industries or other agencies on one or more of these desirable activities. The key to doing many of these things is finding money. There were good ideas discussed at this workshop that should appeal to industry or foundations for funding.
Fifteenth session of the ACC Sub-committee on Nutrition
The Fifteenth session of the Sub-committee on Nutrition of the UN Administrative Committee on Co-ordination (ACC/SCN) was held in New York, 27 February-3 March 1989. The following is from the official report of the session.
Objectives for Fourth Development Decade and proposed international conference on nutrition
The ACC/SCN strongly strongly advocates that the Fourth Development Decade should focus on human development. Nutrition is a fundamental part of human well-being. Improving nutrition requires effective action in many sectors.
Malnutrition still affects perhaps one-third of the population of developing countries. More serious, in the 1980s trends in malnutrition prevalence are rising in many countries, in contrast to the 1970s. In most regions of the world, the number of malnourished children continues to increase with population growth.
Malnutrition is a central constraint in human development. It contributes to increased sickness and deaths, particularly in children, to lowered educational performance and to reduced productivity. Vitamin and mineral deficiencies cause blindness, mental retardation, and physical exhaustion. Malnutrition results from poverty, and can be overcome through the process of economic and social development in such areas as education, income, provision of health services, household food security, and others.
Better nutrition is a measure of progress and an important objective of development policies and programmes. Achievement of nutritional objectives will be a measure of the success of the Fourth Development Decade.
The ACC/SCN noted that malnutrition, including micronutrient deficiencies, can be reduced through vigorous and sustained efforts, as has been recently seen in some developing countries. Enough is now known, with available technology, to bring about a major change in the world nutrition situation, if there is adequate commitment and available resources. The UN system could be in the forefroont of a new drive for this goal.
The ACC/SCN recommends consideration of a major effort by governments, organizations of the UN system and bilateral agencies, including financial institutions, and non-governmental organizations, to:
For this purpose, the ACC/SCN proposes to the ACC that a broader dialogue should be initiated, through the mechanism of an international conference involving governments, organizations of the EN system including financial institutions, bilateral partners, non-governmental organizations, and others concerned, to address the above objectives.
Nutrition in times of disaster
The ACC/SCN noted with concern the prospect of continuing need for food relief for very large numbers of displaced people - who have lost access to productive resources - and the likelihood that this situation, which affects some 20 million people at present, will continue and probably worsen.
A conference on "Nutrition in Times of Disaster" was held under the auspices of the ACC/SCN and the International Nutrition Planners Forum, organized by WHO and UNHCR, 27-30 September 1988. The SCN endorsed the statement issued by the conference see page 64].
The SCN requests the ACC to bring this tragic situation urgently to the attention of donor governments.
The significance of small body size in populations
There is a debate about the concept of "small but healthy" concerning whether small body size is in itself significant for leading a normal life. The implications of this for policies could be far-reaching, because of the widespread failure to reach genetic potential among populations of developing countries. The SCN examined the issue and approved the following statement to the ACC.
"The human response to adverse conditions during early life is a slowing of normal physical growth and development. When this failure of growth occurs in early childhood, it can persist throughout life, as smaller stature and weight in comparison to values seen in unconstrained populations.
"It is the factors associated with the process of becoming small, not the state of being small, that are the real concern, albeit both are marked by achieved size. Although the small individual may be healthy at a particular time, the conditions that have caused this smallness are basic deprivations, including poor diet and ill-health, frequently due to poverty. The reason that economic disadvantages and poor social performance are observed to be associated with smallness is that these frequently occur in conditions where health and diet are poor. But the resultant smallness itself - with two exceptions noted below - is not a primary factor perpetuating these conditions. Small achieved body size is often an indicator that conditions have detrimentally affected human development and may be continuing to do so in the population.
"With two exceptions it is not considered that 'being small' - as opposed to becoming small - is in itself harmful to the individual. One exception lies in the relationship between body size (lean body mass) and maximal physical working capacity as well as perhaps the capacity for sustained work (endurance). The other exception lies in the linkage between maternal size and infant birth-weight - the intergenerational linkage of smallness and risk.
"Failure of growth in the individual may be symptom of an underlying diet or health problem warranting intervention. It can also be seen as a marker of a high-risk environment.
"Smallness seen at the population level is explicit evidence for a generalized public health problem calling for policies and programmes designed to alleviate social and economic deprivations, in addition to direct public health interventions."
The ACC/SCN proposes that this position be drawn to the attention of UN member agencies and other interested parties, to contribute to the correct interpretation of conditions in developing countries.
Nutrition in times of disaster
A conference on "Nutrition in Times of Disaster" was held at the headquarters of the World Health Organization, in Geneva, 27-30 September 1988, under the auspices of the UN ACC Sub-committee on Nutrition and the International Planners Forum (a group of senior nutrition planners and managers from developing countries), organized by the WHO and the Office of the UN High Commissioner for Refugees. The conference issued the following statement.
"In the last fifteen years, the continuing problem with famine and disasters, bath natural and manmade, has resulted in unprecedented numbers of people depending for survival upon international food aid, sometimes for prolonged periods of time. The generosity of donor nations has been immense, but, even so, the total volume of emergency resources (food and money), provided bilaterally or multilaterally through organizations such as the World Food Programme, has proved painfully inadequate to meet escalating needs. The food provided has also, at times, failed to reach intended beneficiaries due to severe logistical and security constraints in recipient countries.
"Consequently, the rations provided very often result in a seriously insufficient and unbalanced diet.
"The food shortages, along with other factors, have often had a dramatic effect, increasing disease and deaths among affected populations, particularly in refugee camps. In this context, there are alarming reports of outbreaks of certain nutritional deficiency diseases which have hitherto been considered to be under control, such as such as scurvy, severe anaemia, and beriberi. These outbreaks may, in a large measure, be ascribed to an inadequate quantity and quality of the food available locally and/or provided by international assistance.
"The participants in this conference consider that a minimal standard for food provision for emergency conditions must be maintained. This requires the provision of at the very least 1,900 kcal per person in the daily diet. Furthermore, such a standard diet should contain all essential nutrients at levels that have been determined necessary to maintain health and sustain life.
"The conference urges the populations of donor nations and their Governments to assist the UN family in meeting these goals. Specifically, it urges donor nations to increase their emergency resource allocations and to programme these according to estimates of emergency needs rather than reacting to each situation in an ad hoc manner. It urges that more of this emergency food aid be channelled through multilateral agencies. In order that nutritional standards can be met, it further urges donor nations to diversify the composition of food aid that they provide without reducing the total amount of calories allocated. Finally, it encourages both affected countries and the donor community to intensify efforts to strengthen the capacity of governments to cope with their own disasters and assure the provision of a nutritionally adequate diet to disaster-stricken populations.
"The meeting urges donor nations to assist the UN family in meeting these goals. Such actions are of the greatest urgency if this toll of lives is to be reduced."
For further information, please contact Dr. John B. Mason, Technical Secretary, ACC/SCN, Office No. X-SO, WHO Headquarters, CH-1211 Geneva, Switzerland, telephone (22) 91 33 23; Dr. Abraham Horwitz, Chairman, ACC/SCN, Pan American Health Organization, 525 Twenty-third Street NW, Washington, D.C. 20037, USA, telephone (202) 8163181; Dr. John Rivers, Department of Human Nutrition, London School of Hygiene and Tropical Medicine, Keppell Street, London WC1E 7HT, UK, telephone (01) 636-8636.
International Dietary Energy Consultancy Group.
The International Dietary Energy Consultancy Group (IDECG) was established in Geneva on 3 September 1986, under the sponsorship of the United Nations University (UNU) and the International Union of Nutritional Sciences (IUNS) and with the endorsement of the ACC Sub-committee on Nutrition (ACC/ SCN) of the United Nations.
Aims and objectives of IDECG
IDECG has been established for the study of dietary energy intake in relation to the health and welfare of individuals and societies. Its specific objectives, as defined at the foundation meeting in Geneva, are:
(1) The compilation and interpretation of relevant research data on functional and other consequences of deficiency, change or excess of dietary energy.
(2) The identification of related research needs and priorities and the promotion of needed research.
(3) The publication of scientific and policy statements and other information on the significance of chronic deficiencies and excesses of dietary energy.
(4) The identification and promotion of appropriate and practical means of corrective action.
To meet these objectives, IDECG seeks to bring together scientists engaged in relevant research with representatives of international organizations concerned with the problem. It also seeks to involve in its work bilateral agencies, foundations, and governments interested in relevant research and policy actions.
A process is needed to continually adapt the interpretation and operationalization of the organization's objectives to what its potential users and contributors perceive to be their most important and most pressing needs. On request of the steering committee, this process has been initiated by Prof. George Beaton, who has canvassed a broader group of interested individuals for this purpose. From the responses received it is apparent that there is a dichotomy of views about priorities: while some emphasize the need to move ahead and offer advice on current issues related to policy formulation and implementation, others hold reservations about the reliability of available knowledge on which such advice would be based. Prof. Beaton attempts to reconcile the two views and concludes:
It is clear, then that IDECG must accept the reality of a duality of function and embody this within its short-term and long-term goals. It is recognized that, at times, the duality will create apparent conflict and will certainly compete for available resources. That IDECG must accept. There is not a true duality - there are two dimensions of a single purpose - to improve our understanding of the relationship of energy intake to human function and through this understanding to promote policies and activities that may operate for the betterment of human health and well-being.
Organization of IDECG
IDECG is sponsored by the UNU, with the endorsement of the ACC/SCN, and by the IUNS. UNU responsibility for the policies of IDECG is delegated to a steering committee, consisting of a representative of the UNU as chairperson, the secretary general of the IUNS, and the executive secretary of IDECG. Responsibility for the administration of IDECG is delegated to the executive secretary.
The steering committee is guided by an advisory group consisting of nine scientists, appointed for staggered three-year terms, and a representative each from FAO, WHO, UNICEF, and the World Bank. Additional persons may be invited to participate in the advisory group, in meetings, and in other activities of IDECG as needed for scientific or policy reasons.
First scientific IDECG meeting on chronic energy deficiency
Thirty scientists from 15 countries met in Guatemala City in August 1987 for the first scientific meeting of IDECG. The focus of the meeting was on chronic energy deficiency and its effects on behavioural development, stature, work capacity, and productivity. Papers were also presented on the socio-economic consequences of and responses to food deprivation, seasonality in energy metabolism, the effect of energy supplementation, research on metabolic adaptation to low energy intake, and maternal energy requirements. This information was supplemented by reports on studies carried out in Colombia, Egypt, Ethiopia, Gambia, Guatemala, India, Indonesia, Mexico, and the Philippines. Participants later prepared reports on available knowledge, policy implications, and research needs and priorities. State-of-the-art papers and working-group reports were published in a book entitled Chronic Energy Deficiency: Consequences and Related Issues, which is available from the IDECG secretariat free of charge.
Definition of chronic energy deficiency
The presentations and discussions at the Guatemala meeting made very apparent that the term "chronic energy deficiency" has been defined and used in many different ways. Several participants expressed their dissatisfaction with this state of affairs and recommended that "chronic energy deficiency," certainly an important concept in connection with IDECG's preoccupations, should be better defined and used more consistently. The steering committee of IDECG decided to follow this suggestion by appointing a small working group and charging it with the development of a set of recommendations on the operational definition and use of the term "chronic energy deficiency."
This working group, consisting of Professors J. C. Waterlow, A. Ferro-Luzzi, and W. P. T. James, met twice and elaborated a report on the definition of chronic energy deficiency (CED) in adults which has been published in the European Journal of Clinical Nutrition (vol. 42, pp. 969-81). In essence, it recommends defining chronic energy deficiency in adults as a steady state which can be maintained, but at a level at which certain functions and/or health are impaired. A progressively more precise approach to identifying chronically energy-deficient adults involves measuring body weight and height, then energy intake (or expenditure), and finally the basal metabolic rate (BMR). Three cut-off points for body mass index (BMI) = weight/height2) were identified: 18.5, 17.0, and 16.0. Adults with a BMI above 18.5 are to be classified as normal, and adults with a BMI below 16.0 as suffering from grade III CED. A diagnosis of grades I and II CED depends on finding the combination of a BMI of 17.0-18.4 or 16.0-16.9 with a ratio of energy turnover to predicted BMR of less than 1.4. Measuring the individual BMR avoids classification and confirms the diagnosis. These guidelines can be used when assessing the input of aid programmes and for clinical and other studies.
Standardization of the doubly-labeled water method
The study of whole-body energy metabolism in humans requires information on dietary energy intake, energy expenditure, and the body's energy stores. Although it is possible to measure energy intake and expenditure very precisely, this can only be achieved by restricting subjects to a whole-body respiration chamber, measuring the energy content of their preselected diets and correcting for faecal and urinary losses. Unfortunately the techniques available for making such measurements in people living their normal lives have hitherto been very imprecise, and it is a general rule that the less a given measurement interferes with a subject's life-style, the less reliance can be attached to the data. This imprecision, together with probable in-built biases in the methods for measuring energy intake and expenditure, has led to a situation where estimates of energy expenditure almost always substantially exceed estimates of energy intake when both are measured simultaneously. As a result of these uncertainties, nutritionists are still unable to answer some of the most fundamental questions relating to man's energy requirements.
It has been argued that greater reliance should be placed on dietary intake data, on the grounds that it is easier to accurately quantify energy intake, which occurs relatively infrequently during the day, since the technical problems associated with weighing food and calculating its energy content are relatively minor. The counter-argument, however, is that such measurements are subject to an "observer effect" and that people consciously or subconsciously alter their eating patterns when they are recording their dietary intake. Many scientists therefore remain sceptical about the very low energy intakes reported for underprivileged people in the developing world and in such groups of people as the obese, in whom there may be a strong motive for concealing true intake. Measurement of total daily energy expenditure on the other hand is inevitably complex, since energy is expended throughout the day at a level which can vary over a tenfold range from minute to minute. Attempts have been made to integrate these variations by a "factorial method" in order to quantify total daily energy expenditure in free-living people. For this method, subjects are observed, or asked to record an accurate diary of their activities, throughout the period of study. The time-and-motion data recorded in this way are converted to energy expenditure using standard tables for the energetic cost of each type of activity, or using average data collected in the specific population being studied. Even when performed by the most competent technicians, such a method will inevitably be associated with a high level of imprecision, and there are theoretical reasons why it is most likely to overestimate energy expenditure.
There is, therefore, a need for the development of an accurate and non-intrusive method for measuring energy expenditure in free-living people, and the doubly-labelled water (DLW) method is rapidly becoming established for doing just that. It is based on calculations taking account of how the body metabolizes hydrogen and oxygen. At the beginning of the measurement period, the subject drinks a glass of water enriched with two stable isotopes (2H218O). The hydrogen isotope deuterium (2H) equilibrates throughout the body's water pool, and the oxygen isotope (18O) equilibrates in both the water and the bicarbonate pool, which consists largely of dissolved carbon dioxide in the blood stream that is the end product of metabolism and passes to the lungs for excretion. The rate constants for the disappearance of the two isotopes from the body are measured by mass spectrometric analysis of a series of samples of urine, saliva, or blood.
In July 1987, the British Nutrition Society hosted a symposium on "Stable Isotopic Methods for Measuring Energy Expenditure," at which all laboratories actively involved in DLW studies in humans were represented. The meeting left little doubt about the great potential of this new method, but no consensus could be reached yet on two important issues: the best method of calculating energy expenditure from isotope disappearance curves and the best way of dealing with isotopic fractionation.
At the IDECG meeting of 3-7 August 1987 in Guatemala City, Dr. Prentice, from the Dunn Nutrition Laboratory in Cambridge, England, proposed to organize a workshop for the standardization of the DLW method. IDECG decided to support this initiative, and the Nestlé Foundation agreed to fund the workshop, which took place in Cambridge 26-29 September 1988.
All the eight research centres using the method in humans and two which have done pioneering work in animals were represented at the Cambridge workshop. Data sets and position papers on various aspects of the method were exchanged among centres prior to the meeting. The main issues presented and discussed at the workshop were isotopic pool sizes and flux rates, estimates of error, fractionation effects, isotope exchange, effects of changes in isotopic background, the energy equivalent of CO2, problems of mass spectrometry, and problems arising when the method is used in special groups of humans like premature babies and certain categories of hospitalized patients.
The discussion was very open, and consensus could be reached on all important issues.
It is planned to publish the conclusions reached by the workshop participants in two formats: firstly, as a detailed and comprehensive technical report for users of the method, and secondly, in the form of a shorter, more general paper for persons who need to be able to correctly interpret data obtained by the DLW method.
Energy requirements of infants and children
The next IDECG meeting will take place late this year to review the energy requirements of infants and children, considering all the new information which has become available since the latest edition of FAO/ WHO/UNU recommendations was published in 1985.
Conceptually a new feature of that report was that, for adults, it based energy requirements on energy expenditure, including energy expenditure for physical activity as an important factor to be considered. At that time it was not possible to adopt the same position in the formulation of energy requirements for infants and children. Because the necessary information on energy expenditure in that age group was not yet available, energy requirements continued to be based on information on energy intakes of infants and children growing normally. Thanks to the development of the doubly-labelled water method and renewed interest in that area, a considerable amount of new information has become available on children's energy expenditure, so that it appears useful and timely to reanalyse the energy requirements of infants and children from that new perspective.
For further information, write to: Dr. B. Schurch, Executive Secretary, IDECG, c/o Nestlé Foundation, PO Box 518, 1001 Lausanne, Switzerland.
Codex Committee on Vegetable Proteins: Vegetable protein production.
The fifth, and probably last, session of the Codex Committee on Vegetable Proteins was held in Ottawa, Canada, 6-10 February 1989, and was attended by 40 representatives and observers from 14 countries. The committee has now proposed guidelines for the utilization of vegetable protein products in foods and international general standards for such products and for soy protein products and for wheat gluten. These documents will now be treated by the Codex Commission at its meeting in Geneva in July 1989.
Dr. Walter Wolf of the US Northern Regional Research Centre in Peoria, Illinois, presented a review on current international trends in the production and utilization of processed vegetable proteins. The following are some excerpts from his report.
Development of new vegetable protein products and spectacular growth of markets that were forecast in the past 20 years have not occurred. Nonetheless, progress has been made in specific areas.
Soybeans
The United States soybean processing industry is the acknowledged leader in the development of edible proteins from soybeans. Flours, concentrates, and isolates have been commercially available for 30 years or longer and are no longer considered new or navel. At present, soybean proteins and wheat gluten are the only significant vegetable proteins available commercially. Others are used on only a small scale (e.g. peanut and pea) or are still in the development stage (e.g. glandless cottonseed and sweet lupine). There was a rapid growth in traditional Oriental soybean foods, particularly tofu, miso, and tempeh, beginning in the late 1970s. Soymilk has been slower to attract the attention of Western consumers than was tofu.
Although soybean proteins are well established, concerns have remained about certain nutritional aspects of their use. In the past decade nutritional studies have focused on four major areas: the effects of trypsin inhibitors on the pancreas, adequacy of methionine in soybean proteins for human diets, the effects of soybean proteins on the bioavailability of dietary iron, and the cholesterol-lowering effects of soybean proteins.
Trypsin inhibitors are widely distributed in nature, and consequently they occur in many common food items such as the legumes, cereal grains, potatoes, and eggs. Because normal moist-heat processing inactivates most of the soybean trypsin-inhibitor activity, many experts agree that properly processed soybean protein products do not pose a hazard to human health at practical levels of consumption.
It is well known that methionine is the first limiting amino acid in soybeans as determined by rat assays. Recent studies show that, for humans, the limitation of methionine is not as serious as formerly believed and depends on the age of the subjects. Based on these studies, it was concluded that when the isolates are consumed as the sole source of dietary protein, at a level of 0.8 g of protein per kilogram of body weight, protein nutritional status can be maintained adequately. The methionine content of soy proteins appears adequate to meet the nutritional needs of preschool children and adults, but there may be a need to supplement soy-isolate-based formulas for infants. In the early 1980s several research groups reported that addition of soybean protein products to experimental diets depressed absorption of dietary iron. An extensive study was therefore designed to test the long-term (six months) effects of extending beef with soybean protein in men, women, and children under practical conditions. Results indicated that soybean protein at the levels used does not impose a risk of iron deficiency.
Studies with experimental animals and humans have shown that dietary protein can influence the level of cholesterol in the blood. For example, feeding of casein in a cholesterol-free diet to rabbits causes hypercholesterolaemia, and on continued feeding artherosclerosis develops, but these effects are prevented when soy protein replaces the casein. The mechanism by which say protein lowers blood plasma cholesterol is unknown but is under active investigation in a number of laboratories.
Cottonseed
In order to circumvent the problems of gossypol, research and development has proceeded with glandless varieties of cotton. In 1986 Yazaki, in the United States, introduced defatted flours made from glandless seeds and began market development for the flours in foods. In early 1988, however, the company ceased its cottonseed protein operations, and at the present there are no edible cottonseed protein products produced in the United States.
Lupines
Newcomers to the vegetable protein field are the sweet lupines, which are low-alkaloid strains of several Lupinus species. Development work on lupine proteins has been conducted particularly in countries where soybeans are not grown,
Sunflower
Pilot-plant quantities of sunflower-seed flour, protein concentrates, and isolates have been available in the United States, Italy, and Canada in recent years. Difficulties in decortication and colours caused by chlorogenic acid continue to be problems limiting development.
Wheat gluten
Wheat gluten is the water-insoluble protein portion of the grain endosperm. Manufacture of wheat gluten involves separation of the protein and starch fractions of wheat flour. Its major use is in bakery products to increase protein content, thereby obtaining dough strength, mixing tolerance, and handling properties. In Europe gluten has found extensive use to fortify low-protein wheats from Canada, the United States, and Australia. Up to 1% gluten is routinely added to bread-making flours in France. Other applications include meat, poultry, and fish products where the adhesive, and film-forming properties are used.
Rapeseed
Appreciable progress has been made to improve the composition of rapeseed. New low-erucic, low-glucosinolate varieties are collectively known as Canola to differentiate them from the older, higherucic type rapeseed. The much reduced levels of glucosinolates in Canola varieties (up to 30 micromoles of glucosinolates per gram of dry, oil-free meal) are still considered too high for incorporation of the meals into food products. Rapeseed meals also contain various phenolic compounds dominated by sinapine which taste bitter and cause discolouration by reaction with other components. Two major obstacles to the commercial production of edible protein concentrate from rapeseed are the lack of efficient methods for dehulling and for reducing the content of phytate to acceptable limits. The economics of preparing rapeseed protein concentrate are not very favourable in spite of the fact that rapeseed protein is of outstanding nutritional quality. No commercial preparations of rapeseed protein fractions are presently produced.
Peas
Processes for production of pea flour and pea protein concentrates have been developed in Canada. The concentrates contain 83%-85% protein and are being used in the baking industry as replacers for nonfat dry milk and as protein supplements.
Other legumes
A number of legumes, including chickpeas, pigeonpeas, common dry beans, Phaseolus vulgaris, and black gram supply a substantial amount of dietary protein, especially to residents of rural Africa and Asia. They are prepared for consumption in a number of ways, including cooking of whole and dehulled seeds, fermenting, germinating, and grinding into flours and meals. They are generally high in carbohydrates (mainly starch) and low in fat. Consequently, even defatted flours are low in protein compared to the minimum of 40% specified in the standard for vegetable protein product. Protein concentrates and isolates have been made experimentally from many of them, but there is no large-scale commercial processing. Faba bean protein isolate was manufactured and used commercially for time in the United Kingdom to produce a spun fibre but was discontinued because the economics were unfavourable. In France, commercial production of air-classified faba bean protein concentrate and starch is reported.
Leaf proteins
A number of countries have conducted extensive research and development work on the recovery of proteins from green leaves, which are the world's largest supply of protein. Because of the high fibre content of leaves, the proteins must be separated from the fibre and concentrated. At present there is no commercial production of edible-grade leaf protein, and near-term prospects for establishing an industry are not encouraging.
Single-cell proteins
Dried cells of micro-organisms such as algae, actinomycetes, bacteria, yeasts, moulds, and higher fungi are included in the category commonly referred to as single-cell proteins (SCP). In technologically developed countries much work has been expended in this field, but at present these products are still minor sources of protein for humans. SCP is used primarily for animal-feed supplements, and in some countries SCP has not been able to compete even as a feedstuff because of cheaper sources of protein, such as soybean meal. Near-term prospects for these products do not look very promising. Yeasts, for example, which have a long history of consumption and acceptance as food, are too expensive to compete with soy proteins as a source of protein but are utilized primarily as flavouring agents. High contents of nucleic acids further limit utilization of yeasts as protein ingredients in foods.
Dr. Wolf's report ends with a review of present market potential and trends, and summarizes regulatory provisions and practices in 26 countries.
Courses offered
The International Training Division of the Nutrition Center of the Philippines, an associated institution of the United Nations University, is offering the following training courses in 1989 and 1990:
Each course consists of five components: (1) teaching sessions on core subjects relevant to the course, (2) field visit and observation of on-going programmes and projects, (3) village field practicum in selected communities, (4) written and oral technical report on training activities, and (5) home-country project development for the participant's re-entry plan.
The medium of instruction is English. Participants must have adequate knowledge of the language for effective participation in the programme.
All correspondence regarding nomination and registration may be addressed to: The Director, Nutrition Center of the Philippines, MCC P.O. Box 653, Makati, Metro Manila, Philippines 1299; cable: NUTRICEN, Manila.
IFPRI report
Consequences of deforestation for moments time allocation, agricultural production, and nutrition in hill areas of Nepal. Shubh K. Kumar and David Hotchkiss. Research report 69. International Food Policy Research Institute, Washington, D.C., USA, 1988.
Although estimates vary widely, most sources agree that 20% to 50% of the forests in the hill areas of Nepal, where agriculture has not benefited from improvements in technology, were cut down in the 1970s. In this report, the authors deal with the development issues facing a relatively poor agricultural area, and the interaction of low agricultural productivity with deforestation in promoting further deterioration in bath.
Deforestation, which stems primarily from the need to expand the area cultivated due to low agricultural productivity, is itself found to contribute directly to declining agricultural productivity via a reduction in household labour, especially moments. This reduction can be traced to the higher labour requirement for collecting fuelwood and other forest products, such as leaf fodder and grass for animals, and is not compensated for by an increase in wage labour. Since outmigration is already high - with one permanent migrant worker in every two households - local solutions are clearly required. Reforestation efforts could assist in rehabilitating existing forests but may not stem the pressure to clear new land.
Strategies for raising agricultural productivity, particularly focusing on the higher agricultural potential of the valleys, where lowland crops such as paddy and wheat are grown, should be a useful approach for stemming the pressure to expand the cultivated area in the hills. Current yields for these crops are very low. There is much scope for improvement with the use of improved varieties and fertilizer, which are now virtually absent. Such crop intensification in the lowlands should improve the area's market integration and make it easier to diversify into increased horticulture production, for which the region is ecologically well suited.
Livestock production is an important enterprise in the hill areas. Increased emphasis on rice and wheat could help to meet the fodder requirements, as straw from both these crops is used for cattle feed. This could reduce the need to collect grass and leaf fodder, easing both household labour constraints and the pressure on forests.
The study also highlights the significance of saving moments labour in improving household welfare. Technologies to save labour and enhance its productivity could include, for example, easier access to food-processing mills or improvements in water supply to reduce the carrying of water up and down hillsides. Forestry programmes that improve access to fuelwood and other essential forest products could also be highly complementary to an agricultural intensification effort that requires increased labour output.
Books received
Nitrosamines: Toxicology and microbiology. Edited by M. 1. Hill. Ellis Horwood Series in Food Science and Technology. VCH Verlagsgesellschaft, Weinheim, FRG; Basel, Switzerland; Cambridge, UK; New York, 1988. 169 pages, 20 figures, 25 tables. DM 180; £64.
This book discusses the analysis of volatile Nnitrosamines, their toxicology in animals or in vitro assay systems, and the evidence implicating N-nitroso compounds in human cancer. A final chapter is concerned with prospects for the future.
Statistical exercises in nutrition. Erica F. Wheeler. London School of Hygiene and Tropical Medicine, University of London, London, 1989. £6.
This set of examples of the application of biostatistics to community-based nutrition research, developed for students in the M.Sc. course in human nutrition at the London School of Hygiene and Tropical Medicine, can be used with any introductory course or text in biostatistics. It provides examples for all the methods appropriate to a beginning course in health biostatistics, taken from common and relevant problems of data analysis that are encountered in human-nutrition research.
Problems of endemic goitre in Gangetic belt: Possible measures to control. I). K. Agarwal, S. Srivastava, K. N. Agarwal, and 1. K. Agarwal. Nutrition Section, Department of Paediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. Rs 35.
This 52-page pamphlet describes the apparently successful use of potassium iodate solution for addition to water consumed within the household. This would be a practical alternative to iodinated salt in populations too remote to be reached by iodized salt.
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Recent and Forthcoming UNU Publications on Food and Nutrition
Identification of Food Components for INFOODS Data Interchange
by John C Klensin, Diane Feskanich, Victor Lin, A. Stewart Truswell, and David A.T. Southgate
Intended to help remedy the glaring incompleteness or inaccessibility in many parts of the world of data on the nutrient composition of foods, this book makes available for the first time a comprehensive standardization of nomenclature for international nutrient data exchange. It provides a straightforward set of rules for identifying food components precisely and constructing data bases suitable for transfer between computers.
WHTR-14/UNUP-734 ISBN 92 BOB-0734-x112 pages, 16.4x 23.9 cm, paper bound, US$20
Food Composition Data: A User's Perspective
Edited by William M. Rand, Carol T. Windham, Bonita W. Wyse, and Vernon R. Young
Knowledge of the composition of the foods eaten around the world is of critical importance for research and policy in public health, dietetics, and nutrition. Data on food composition, however, are extremely inadequate. This volume, examining the current problems of the field and what is needed to improve the situation, provides an essential introduction and survey of the subject for anyone who will be involved in gathering compiling, or using food composition data. It will be a useful reference for university courses on food and nutrition.
WHTR-10/UNUP-633 ISBN 92-BOB-0633-5 240 pages, 16.4x23.9cm,paper-bound, US$20
Research Methods in Nutritional Anthropology
Edited by Gretel H. Pelto, Pertti J. Pelto, and Ellen Messer
A comprehensive manual of anthropological methodologies applicable to field studies in nutrition this volume describes strategies of field research in nutritional anthropology, determinants and cultural components of food intake, methods for collecting and analysing data on energy expenditures, and statistical methods for nutritional anthropology.
WHTR-9/UNUP-632 ISBN 9-808- 0632-7 218 pages, 16.4 x 23.9 cm, paper-bound, US$30
Positive Deviance in Child Nutrition - With Emphasis on Psychosocial and Behavioural Aspects and Implications for Development
by Marian Zeitlin, Hossein Ghassemi, and Mohamed Mansour
Children who grow and develop well in environments where most children suffer malnutrition and chronic illness provide valuable examples to guide the design of programmes aimed at the malnourished. The book examines successful interactions between care-giver and child and the social support systems that sustain them and offers goals and guidance for future research.
WHTR-12/UNUP-697 ISBN 92-BOB-0697-1 16.4 x 23.9 cm, paper bound, US$30
Methods for the Evaluation of the Impact of Food and Nutrition Programmes
Edited by David E Sahn, Richard Lockwood, and Nevin S. Scrimshaw
This state-of-the-art discussion of methods for evaluating food and nutrition programmes focuses primarily on determining specific nutritional impact even in circumstances where adequate baseline data are not available. It recognizes also that food and nutrition programmes can have beneficial effects going beyond traditional health impacts and gives specific attention to social, economic, behavioural, and political consequences that may accompany a feeding programme.
WHTR-6/UNUP-473 ISBN 92-808-0473-1 291 pages, 16.5 x 23.5 cm, paper-bound, US$25
Effective Communications for Nutrition in Primary Health Care
Edited by Jean E Andersen and Aree Valyasevi
Concentrating on the experiences of developing countries, this book advocates the effective communication of nutrition and health information as a key component of primary health care. It provides a framework for evaluating nutrition communications needs, methodological guidelines, and suggestions for programme evaluation.
WHTR- 11/UNUP-634 ISBN 92-808-0634-3 220 pages, 16.4 x 23.9 cm, paper-board, US$20
How to Order Publications
A complete list of UNU publications is available from the University. Publications may be ordered by writing to: The United Nations University, FNB/SU, Toho Seimei Building, 15-1 Shibuya 2-chome, Shibuya-ku, Tokyo 150, Japan.
Microform Publishing: All UNU publications can be obtained on microfiche.