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Until recently, the nutrition community had few data
to counter those who questioned the impact of nutrition programs. An exhaustive review of
the literature of supplementary feeding programs aimed at mothers and children published
by Beaton and Ghassemi in 1982 is a case in point. The authors concluded that the impact
of nutrition supplements on growth was small. They went on to list the many reasons why
larger effects were not found, including that, often, too little food was provided to make
a difference. They also raised the possibility that growth may not have been the only or
even the most important health benefit. This study has been widely quoted but is often
misinterpreted. Many have abstracted from it the gloomy view that one should not invest in
nutrition because it will not make much difference.
Fortunately, the situation has changed. There are now better-designed evaluations from around the world that provide a more positive outlook Jennings et al., 1991). The programs are also more effective, because much has been learned about management and design features. New research, including the follow-up study reported here, has contributed to the growing consensus that nutrition interventions, when they effectively increase dietary intakes in those who need it, do indeed result in appreciable impact. It should be stressed that these dietary improvements may be achieved through many types of programs and not only through targeted supplementary feeding.
Another development is that although the nutrition community used to worry about justifying the economic returns to nutrition programs, many economists have come to accept the value of nutrition programs even before they have been provided with conclusive results. In the 1960s and 1970s, one often read about trade-offs between development and social services. Allocation of resources to social services was frequently seen as occurring at the cost of more immediately productive investments in rural areas (Lele, 1975). For this reason, many saw the provision of social services as self-defeating in the long run.
The rhetoric has changed. For example, the World Bank's current strategy for reducing poverty adopts a two-part approach (World Bank, 1991). The first approach seeks broadly based economic growth. The second approach concerns the provision of social services in order to increase the capacity of the poor to respond to opportunities arising from economic growth. Rather than a problem of trade-offs, social services, including better nutrition, are implicitly recognized as necessary for economic development.
Some have suggested that the
follow-up study, by examining the links between nutrition and productivity, is examining
issues that should best be left alone. If economists and planners seem already convinced
of these relationships, why bother? Advocates of nutrition also fear that the proposition
that good nutrition is a human right will be weakened by reference to other arguments,
such as those about productivity. None of these views deter us. Fashions come and go, and
this would seem to apply to development policies as well. It is very possible that the
World Bank strategy will differ in 10 years. It remains very important to study whether or
not nutrition in early childhood contributes to human capital formation and economic
productivity. To the degree that these linkages can be demonstrated, they offer a powerful
counterargument to those who view nutrition programs as competing with economic
development. If these links are demonstrated, nutrition may be seen as a necessary and
important component of economic development. Nutrition programs would then be more
appropriately viewed as long-term economic strategies. Demonstration of these linkages can
provide support to those politicians and planners who have come to accept the importance
of nutrition as a human right and for its contributions to economic development. It is
hoped that this demonstration will strengthen their resolve to improve the nutritional
status of needy populations.
Data collection for the INCAP longitudinal study was
supported for the most part by contract HD 5-0640 from NICHD. The study was undertaken by
a large multidisciplinary team led initially by Dr. Cipriano Canosa and, for most of its
history (1970-1977), by Robert E. Klein. The follow-up study was supported by an RO1 grant
(HD22440) to Reynaldo Martorell; coinvestigators included Drs. Juan Rivera, Jere Haas,
Jean Pierre Habicht, and Ernesto Pollitt.
Beaton GH, Ghassemi H. 1982. "Supplementary
feeding programs for young children in developing countries. " Am J Clin Nutr
35: 863-916.
Bergeron G. 1992. "Social and economic development in four Ladino communities of Eastern Guatemala: a comparative description." Food Nutr Bull 14(3):221-236.
Cohen J. 1977. Statistical power analysis for the behavioral sciences, Revised Edition. New York: Academic Press.
Engle PL, Carmichael SL, Gorman K, Pollitt E. 1992a. "Demographic and socio-economic changes in the Guatemalan Oriente families from 1968 to 1987." Food Nutr Bull 14(3):237-245.
Engle PL, Gorman K, Martorell R. Pollitt E. 1992b. "The INCAP longitudinal study: infant and preschool psychological development." Food Nutr Bull 14(3):201-214.
Haas JD, Martínez EJ, Murdock S. Conlisk E, Rivera JA, Martorell R. "Nutritional supplementation during the preschool years and physical work capacity in adolescent and young adult Guatemalans.» J Nutr 1995;125(4S):1078S-1089S.
Habicht J-P, Martorell R. 1992. "Objectives, research design and implementation of the INCAP longitudinal study." Food Nutr Bull 14(3): 176190.
Jennings J. Gillespie S. Mason J. Lotfi M, Scialfa T. 1991. "Managing successful nutrition programmes." United Nations: ACC/SCN State of the Art Series Nutrition Policy Discussion Paper, No. 8.
Johnson CS.1991. "The role of participation with nutritional supplementation during pregnancy: a comparison of data from Indonesia and Guatemala." Master's Thesis, Cornell University.
Krasovec K.1991. Background issues. In: Krasovec K, Anderson MA, eds. Maternal Nutrition and Pregnancy Outcomes: Anthropometric Assessment. Washington, DC: Pan American Health Organization, World Health Organization, pp 93-103.
Krasovec K, Anderson MA, eds. 1991. Maternal Nutrition and Pregnancy Outcomes: Anthropometric Assessment. Washington, DC: Pan American Health Organization, World Health Organization.
Lasky R, Klein RE, Yarbrough C, Engle PL, Lechtig A, Martorell R.1981. "The relationship between physical growth and infant behavioral development in rural Guatemala " Child Dev 52:219-226
Lechtig A, Habicht J-P, Delgado H. Klein RE, Yarbrough C, Martorell R. 1975. "Effect of food supplementation during pregnancy on birthweight." Pediatrics 56:508-520.
Lele U.1975. The Design of Rural Development: Lessons from Africa. Baltimore and London: Johns Hopkins University Press.
Martorell R.1992. "Overview of long-term nutrition intervention studies in Guatemala, 1968-1989." Food Nutr Bull 14(3):270-277
Martorell R. Klein RE. 1980. "Food supplementation and growth rates in preschool children." Nutr Rep Int 1980:221 :447-454.
Martorell R. Rivera J.1992. "History, design and objectives of the follow-up study." Food Nutr Bull 14(30):254-257.
Martorell R. Habicht J-P, Klein RE. 1982. "Anthropometric indicators of changes in nutritional status in malnourished populations. Joint US-Japan Malnutrition Panels, US-Japan Cooperative Medical Science Program, Bethesda, MD." In: Underwood BA, ed. Methodologies for Human Population Studies in Nutrition Related to Health. NIH Publication No.82-2462. Washington, DC: US Government Printing Office, September 1982, pp 99-110.
Martorell R. Rivera J. Kaplowitz H. 1990a. "Consequences of stunting in early childhood for adult body size in rural Guatemala." Annales Nestlé 48:85-92.
Martorell R. Rivera J. Lutter CK. 1990b. "Interaction of diet and disease in child growth." In: Atkinson SA, Hanson LA, Chandra RK, eds. Breastfeeding, Nutrition, Infection and Infant Growth in Developed and Emerging Countries. St. John's, Newfoundland, Canada: ARTS Biomedical Publishers and Distributors, pp 307-321.
Martorell R. Schroeder DG, Rivera JA, Kaplowitz HJ. "Patterns of linear growth in rural Guatemalan adolescents and children." J Nutr 1995;125(4S):1060S-1067S.
Pollitt E, Gorman K, Engle P. Martorell R. Rivera J. 1993. Early Supplementary Feeding and Cognition. Monograph of the Society of Research in Child Development. Serial No. 235. Vol. 58, No.7.
Read MS, Habicht J-P.1992. "History of the INCAP longitudinal study on the effects of early nutrition supplementation in child growth and development." Food Nutr Bull 14(3) : 169-175.
Rivera J, Habicht J-P, Robson D.1991. "Effect of supplementary feeding upon recovery of mild-to-moderate wasting in preschool children. " Am J Clin Nutr 54:62-68.
Rivera J. Martorell R. Castro H. 1992. "Data collection of the follow-up study (1988-1989): organization, coverage, and sample sizes." Food Nutr Bull 14(3):258-269.
Rivera JA, Martorell R. Ruel MT, Habicht J-P, Haas JD. "Nutritional supplementation during preschool years influences body size and composition of Guatemalan adolescents." J Nutr 1995; 125(4S): 1068S-1077S.
Rose D, Martorell R.1992. "The impact of protein-energy supplementation interventions on child morbidity and mortality." In: Hill K, ed. Child Health Priorities for the 1990s. Baltimore: Johns Hopkins University Press, pp 191-214.
Rose D, Martorell R. Rivera J.1992. "Infant mortality rates before, during, and after a nutrition and health intervention in rural Guatemalan villages." Food Nutr Bull 14(3):215-220.
Ruel MT, Rivera J. Castro H. Habicht J-P, Martorell R. 1992. "Secular trends in adult and child anthropometry in four villages of Guatemala. " Food Nutr Bull 14(3):246-253.
Schroeder DG, Martorell R. Rivera JA, Ruel MT, Habicht J-P. "Age differences in the impact of nutritional supplementation on growth. "J Nutr 1995; 124(4S): 1051 S-1059S.
Schroeder DG, Kaplowitz H. Martorell R.1992. "Patterns and predictors of attendance and consumption of supplement in an intervention study in rural Guatemala." Food Nutr Bull 14(3):191-200.
Spurr GB. 1983. "Nutritional status and physical work capacity." Yearbook of Physical Anthropology 26: 1-35.
World Bank. 1991. "Assistance
strategies to reduce poverty." Washington, DC: World Bank Policy Paper.
1 At the time of the original study Dr. Martorell
was affiliated with the Institute of Nutrition of Central America and Panama (INCAP) in
Guatemala City, Guatemala.