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The results of this study show that malnutrition is tightly linked to health, well-being, and educational opportunities in the community. Malnutrition is both the cause and the effect of the limited opportunities for socioeconomic development of the study population.
Malnutrition begins at birth, as illustrated by the finding that newborns of unsupplemented mothers were 180 g lighter. Almost 40% of these children were born with low birth weight (< 2.5 kg). During the first two to three months of life, the unsupplemented children experienced only a partial recovery from in utero malnutrition. This is because they had access to adequate nutrition after birth, since their mothers had an initially adequate milk supply until this age. However, the maternal milk supply was soon no longer sufficient, and the children's nutritional status deteriorated. However, because this deterioration took place slowly it was not obvious to the parents or even the physicians. This is unfortunate, because this is the period when the functional deficits associated with malnutrition begin to appear (Chávez and Martínez, 1979a). It can be detected by periodic weighing.
From three to eight months the children were hungry, as evidenced by their demand to be breast-fed 20 or more times per day, and they began to change their morphology and general appearance, as illustrated by changes in skin texture and adipose tissue. During this period the children began to be insecure and unhappy. However, the mothers and the physicians were unable to interpret these signs correctly, as illustrated by the practice of prolonged exclusive breast-feeding.
The period between 8 and 20 months of age is the valley of death, when malnutrition becomes apparent. During this period, when the transfer of maternal immunity decreases, there is a synergism between malnutrition and infection, resulting from the unsanitary environment in which the child lives, and lower resistance due to malnutrition. The valley of death is also characterized by many behavioral deficiencies, some of which may be triggered by lower levels of physical activity and a more timid and apprehensive personality, both traits that lead to reduced interaction between the child and his mother, family, and environment (Allen et al., 1992).
The interaction between malnutrition and poverty is apparent throughout the life cycle. Maternal malnutrition, as reflected by low weight gain during pregnancy, and poor health are related to low birth weight (Allen et al., 1992). Afterwards, the mother influences the nutritional status of her child through her breast-feeding practices. The consequences of an inadequate maternal milk supply in this population, for satisfactory development after the infant reaches about three months of age, are far more serious than is currently accepted.
Breast milk is the first "push" for the development of the child, but among malnourished women this push is short-lived and not as strong as it should be. The maternal production of breast milk in Tezonteopan is enough to meet the nutritional requirements of the infant only for the first two to three months of life. During this period, the mother increases her milk supply, but it suddenly drops to a level of 500 to 600 ml and remains at this lower level. It is likely that this is a common phenomenon throughout the disadvantaged areas of the world. The decreased milk supply is not enough to continue "pushing" the child in his development and is responsible for a deterioration of his nutritional status. By eight months of age, the milk deficit together with inadequate complementary feeding and the increased nutritional needs for physical activity and recovery from infection, worsens the situation of the child. The survivors in communities like Tezonteopan grow less, spend less energy, and interact less with their environment than well nourished children (A Chávez and Martínez, 1979b).
The sudden stabilization in nutritional status and reactivation of growth and development that takes place at 20 months of age is surprising. However, this reactivation takes place at a pace adequate for the chronological, but not for the biological or functional, age of the child. Therefore, there is no catch-up in the developmental processes in this period. Between 20 months and six to seven years of age, the unsupplemented child's appearance and behavior are those of a younger individual. Character and personality are withdrawn, but nutrition problems are not apparent. At the beginning of the school period, the linear growth of the supplemented children is similar to that of the unsupplemented children, but the latter exhibit deficits in weight and in mental and behavioral development. Moreover, the unsupplemented children did not do well in school. More than one-third failed to pass the first year of school, and the remaining perhaps should have also failed because their grades were very low. The poor school performance of these children can be attributed to malnutrition, since the supplemented children passed their first year of school without problems.
Adolescence is usually considered a period of nutritional crisis. in this study, however, the between-group differences tended to narrow during this period. This is related to adaptation mechanisms oft he unsupplemented children, including delayed onset and longer duration of puberty, which allowed them to partially recover from their deficits. In addition, cultural factors that limit the opportunities for progress slowed down the development of supplemented children during adolescence. However, it is important to note that unsupplemented subjects did not reach the levels of performance of the supplemented children during adolescence. Their physical, mental, and behavioral performance was also worse.
From these results it seems likely that certain behavioral and cultural characteristics that have been considered as typical of poor agricultural societies are due to malnutrition. Among them are passivity, lack of motivation for change, and limited decision-making abilities, which together explain the tendencies for the limited progress and development in these communities. It is possible to break the vicious cycle of malnutrition and social development in several ways. The approach adopted has almost always been to promote investment in increased production and create the conditions for savings and reinvestment. This has not worked in the poor rural environment, where it is difficult to save and reinvest. Nutrition is an area that deserves special attention because, as this study shows, it improves the quality of human resources, an essential factor for development. A society with more capable individuals not only can produce more but can improve its technological competence. Improved nutrition is both an instrument for development and an end in itself. Better nutrition improves health and physical and mental capabilities, the instruments and outcomes of development.
This study shows that it is not difficult to improve the nutritional status of individuals. While more material and human resources were expended in this study due to the research nature of the project, than would be required, it shows that much can be achieved with relatively little investment. Applied nutrition programs are needed because they can maximize the benefits per unit of investment. The data from this study show that the target age for nutritional interventions should be three to eight months to prepare the child for a healthy entrance into the valley of death. Children should weigh 8 kg by eight months of age. The second priority of these programs should be the valley of death, because this is the period when the nutritional problem becomes worse. At this age, programs are curative rather than preventive, since the children are already malnourished (VA Chávez et al., 1988).
An important programmatic priority is the care of the pregnant woman. Gestation is an extremely important period because, as this study shows, the deficits in physical development observed in the unsupplemented group at the end of the study are proportional to those present at birth. The issue of how best to improve the nutritional status of pregnant women has not been resolved. Suboptimal nutrition during pregnancy is related to social conditions, the treatment of women in society, employment, age at marriage, birth interval, and many other factors that currently cannot be addressed with cost-effective programs.
Programmatic actions need to address the malnutrition-infection complex with simple measures. These should be driven by a primary health approach involving food and hygiene, sometimes called the "bread and soap" approach. With political commitment, this is a feasible strategy. The implementation of primary health care measures in the communities involving essential nutrition and health interventions at the household level is within the reach of most Latin American countries. These measures should include immunization, provision of essential micronutrients, elimination of parasites, and educational messages regarding the need for complementary feeding beginning at three months of age. Measures that will improve nutrition during pregnancy are also needed.
These and other studies have documented the nature of the malnutrition problem and its consequences. Furthermore, the technology to combat the problem of malnutrition is available. It is hoped that the findings of this study will help to mobilize the sociopolitical will to solve the problem that is still lacking in many developing countries.
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1 The authors are affiliated with the Division of Community Nutrition in the Instituto Nacional de la Nutrición "Salvador Zubirán," in Mexico, D.F., Mexico.