GENCY FOR INTERNATIONAL DEVELOPMENT FOR AID USE ONLY WASHINGTON, 0. C. 201$23 BIBLIOGRAPHIC INPUT SHEET

A. PRIMAR e I. SUBJECT Public Health CL A51­ . FICATIOW 13 SECONDARY I Nutrition 2. TITLE AND SUBTITLE Child nutrition in developing countries; a handbook for fieldworkers

3. AUTHOR(S) Jelliffe, D.B.

4. DOCUMENT DATE I5. NUMBER OF PAGES 6. ARC NUMBER 1969I gO5 P.I ARC 7. REFERENCE ORGANIZATION NAME AND ADDRESS Agency for International Development, Office of the War on Hunger, Washington, D.C. 20523

8. SUPPLEMENTARY NOTES (Sponaoring Organlzatlon, Pubtfahera, Avalfability) Free copies available from: Office of Nutrition, Technical Assistance Bureau, Agency for International Development, Room 116 SA-2, Washington, D.C. 20523

9. ABSTRACT

A handbook to help non-technical workers recognize malnutrition in young children and to offer locally appropriate preventive and curative measures. The first chapter discusses the human diet generally: basic nutrients, vitamins, minerals, types of malnutrition and preparation and evaluation of local foods. This is followed by a chapter on the problems of food production in developing countries, theo a chapter on local customs and foods, including child-rearing proactives, attitudes toward sickness, and an evaluation of these customs. Chapter Five deals with childhood malnutrition, types, causes, diagnoses, treatment, and prevention. Nutrition is treated in Chapter Six, and combating malnutrition in Chapter Seven. The eleven appendices cover dietary allowance, weight, and nutrition tables, and suggestions for proper" nutrition.

10. CONTROL NUMBER 11. PRICE OF DOCUMENT PN-AAC-680

12. DESCRIPTORS 13. r"'OJEC'rNUMBER Developing countries Children 14. CONTRACT NUMBER Manuals USAID/Waron Huncer Infants Is. TYPE OF DOCUMENT ~ 2rrF~i , .,11.

.. ,%.2.'.j4'r4~9..4,,i.Ki*CRIESi~. A4

P.'..'6 4 o wn* ' ' ~W-,'.11 D.C.W20523 Kwashiorkor in two.year old East African child CHILD NUTRITION IN DEVELOPING COUNTRIES

A Handbookfor Fieldworkers

DERRICK B. JELLIFFE, M.D., F.R.C.P., F.A.P.H.A., F.A.A.P.

Director, Caribbean Food & Nutrition In,itute University of the West Indies, Jamaica

Visiting Professor of Tropical Medicine Tulane Medical School, New Orleans

Formerly Professor of Pediatrics and Child Yealth Makerere Medical School, Kampala, Uganda.

The writing and publication of this handbook has l;een hfianI'd by the

Office of War on Ihunger Agency for Internatioinal )cvhelopiieint U.S. I)epartivnt of State Washington. I).C.

For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 - Price $1.00 ACKNOWLEDGMENTS

The author is most grateful to the following colleagues for advice ani guidance: DR.M. BEHAR DR.D. M. BLANKHART DR. ANNE BURGESS DR. R. COOK Miss LILA ENGBEP.G MRS. FRANCES ENGEL DR.C. LEAKEY DR. J. MAY DR. M. KING DR. D. MORLEY DR. H. A. P. C. OOMEN DR. D. MCLAREN Miss E. SIMDLIN DR. G. J. A. TERRA MRS. MARJORYE VAN VEEN DR.G. SAXTON DR. M. MILNER

Acknowledgment is made to: Mr. William Seruniaga of the Department of Medical Illustrations, Makerere Medical School, Kampala, for drawing the illustrations and to the following for the kind use of photographs.

The Food and Agriculture Organization for Figs. 2 and 3 The World Health Organization for Figs. 6 and 7 To UNICEF for Figs. 10 and 11 To the Kenya Information Service for Fig. 4 To Dr. I. Schneideman for Figs. 13 and 14 To Miss P. Pollard

First Printing 1968-Financed by the Agency for International De. velopment, U.S. Department of State, and issued as Public Health Service Publication No. 1822 Revised 1969-As a publication of the Office of War on Hunger, Agency for International l)evelopment. U.S. Department of State French Editiorn 1969-Translated and published by the Regional Technical Aids Center, Paris, Agency for International Develop. ment. U.S. Department of State i CONTENTS

Page Introduction ...... i Chapter I The Human Scene ...... 5 ChapterII The Human Diet ...... 13 Chapter III Improving Food Supplies ...... 43 ChapterIV Custom and Food ...... 61 Chapter V Malnutrition in Childhood ...... 71 Chapter VI Nutrition Education ...... 95 Chapter VII Combating Malnutrition ...... 115

APPENDICES I Recommended Daily Dietary Allowances . . .. 171 II Information Required Concerning Feeding Young Children ...... 172 III Weight for Age Table ...... 173 IV A Planned Demonstration for Use in East Africa 174 V Specimen Recipes for Weaning Foods ...... 176 VI Approximate Quantities for School Meals . . . 182 VII Packed Meals for School Children ...... 184 VIII Nutrition Rehabilitation Unit ...... 186 IX Howe Feeding Kit ...... 188 X Preparation of Artificial Bottle Feeds in the Village Home ...... 189 XI The Mulanda Project ...... 191

Index ...... 195

iii List oF Tables ["age "T,bie No. 85 1 Average Eruption riie of First Teeth ...... Years of Life . .. 86 2 Inadequate Weight Gains During the First Two of Main Approximate Protein Content and Amino Acid Deficiency 3 129 Categories of Vegetable Foods Used in Minltimixes ...... 130 4 Villiage-Level M ultim ixes ...... in the Feeding Simplified Use of (Cow's Milk and Its Preparations 5 136 of Babies Up to Three Months of Age ...... Use of Cow's Milk and Its Preparations in the Feeding 6 Simplified 136 of Infants (ver Three Months of Age ...... Young Children in Re­ 7 Summnarv of Immunization Procedures for Important to, Ntritional Condlitioning Infections and Oiher lation 146 Infections ...... Cases of Some IRccognition awl Simlle Management of Early 8 148 Comimon Childhood Illnesses ...... 149 9 Basic Drug Dosage for Tropical Village Children

List of Figures Figure rntorisrii'c|.:-Kwasli-iorkor in two-year old East African child. and 1 High infant and 1-4 year mortality rates in Peru, Guatemala 8 Mexico compared with the U.S.A ...... 46 2 Traditional raised rice granary (Madagascar) ...... 47 3 Traditional granaries (Togo, West Africa) ..... 48 4 Sun-dried strips of beef (North Kenya) ...... 49 5 Sun-dried, smoked fish on sticks (Uganda) ...... beans in 6 Traditional market (Mali, West Africa), showing mixed 50 foreground ......

. 51 7 Traditional floating market on canals (Bangkok, Thailand)

iv Figure Page 8 Food and nonfood. Blood being drained from jugular vein of cow (Karamoja, Uganda) ...... 63 9 Kwashiorkor in two-year old Ugandan child, showing edema, misery, wasted muscles (with fat present) and growth failure, to­ gether with slight hair changes and a marked "flaky paint" rash ...... 77 10 Kwashiorkor in Guatemalan child, showing edema, misery, wasted muscles (with fat present) and growth failure ...... 78 11 Late nutritional mnarasmus in two-year old child, showing very wasted muscles and fat, and severe underweight (Guatemala) . 82 12 Clinical features of two main severe forms of PCM-Kwashiorkor and marasmus-contrasted diagrammatically ...... 83 13 Nutritional conviction. Two-year old child with marasmus on admission to the Nutrition Rehabilitation Unit, Kampala, Uganda ...... 100 14 Nutritional conviction. Same child after six weeks of high protein diet based on local foods ...... 101 15 Straight forward understandable oister, with few wor'ds and one obvious message. ("Breast-feed don't bottle feed") ...... 109 16 Plastic feeding cup, easier to keep clean than feeding bottle . 137

V

INTRODUCTION

those This book is intended for the many different groups including Peace Corps with no technical training in the health field, including Volunteers, who are working in a variety of programs in developing at first sight tropical countries. The aims of their projects are often that their remote from child nutrition, but experience has shown the prob­ work has often involved them, directly or indirectly, with lems of malnutrition in children. Western In addition, even health workers being trained in the feeding world may find themselves confused by differences in infant above practices, by the types and severity of malnutrition seen, and, of ap­ all, by the apparent lack of relevance, or, at best, difficulty obvious, plication, of methods that have seemed so straightforward, and common-place back home. The confused worker need not, however, feel so badly. The plight the world of the child population in tropical developing parts of of has only recently been widely recognized and made a matter health. serious inquiry by modern scientific medicine and public to Apart from a few pioneers crying in the wilderness, attention problems of nutrition in young children in developing regions started in the at the end of World War II, and bas only gained momentum last decade. It is now abundantly clear that, while such classical tropical health diseases as yellow fever and cholera are very important much less problems and blocks to progress, in reality they are of significance than childhood malnutrition. Numerically, econoilically, and socially, malnutrition not only causes a higher rate of immediate to a population that sickness, misery, and death, but also leads may be irreversibly damaged physically, mentally, and psychologically. in­ Understandably, initial medical emphasis was given to the forms vestigation of the clinical appearance of children with various changes in of malnutrition, as well as to laboratory research into knowledge biochemistry, and into methods of treatment. Certainly, required. At is still inadequate in these fields and more research is 1 the same time, it has become increasingly recognized that, even with present imperfect scientific knowledge, it ought to be possible to deal decisively with the problem of prevention. Mounting concern with the need to develop effective, economical, and acceptable action programs to deal with the problem of malnu­ trition in early childhood is indicated by the titles of recent Inter­ national Nutrition Conferences-"Meeting Protein Requirements" in Washington 1960, "How to Reach the Preschool Child" in Coino, Italy 1963, "Preschool Child Malnutrition; Major Deterrent to Progress" in Washington 1964, and "Administrative Problems in Programs to Protect Preschool Children," Hamburg 1966. At the last of these, the present situation was described as follows: "The need to find rapidly, more effective means of improving the nutrition of these children has become even more acute. Evidence of permanent physical impairment due to early malnutrition is already well established, but more recent research points to retardation of the mental development of the young child and the possibility of irreversible damage of vital brain tissue due to malnutrition in early childhood has obvious implications for the future manpower and economic development of the countries in which it occurs, and adds a fearful urgency to the whole problem." The huge size of the problem and its deleterious effects do, then, appear to be increasingly realized and, more important, the need for greater action in the development of imaginative preventive programs in the field is beginning to receive the priority emphasis and financial backing that it warrants. The urgency of the situation has been recognized at the highest planning levels in the United States, as exemplified by the call to action by President Lyndon B. Johnson on the occasion of the transmittal to Congress of the Food for Peace Annual Report dated March 31, 1965, and by the statement of Mr. Frank Ellis, Director, Food for Peace, in a memorandum dated March 24, 1965: "It has been firmly established that preschool aged children are most vulnerable to the effects of malnutrition (in some cases suffering irreversible physical and mental retardation); therefore, agencies are urged to give priority attention to the establishment of meaning. ful programs aimed at attacking malnutrition in this group." In the most recent directives outlining major activities of both the Agency for International Development (AID) and the Peace Corps, tie need to give attention to the nutrition of infants and pre. school children has been given high priority. It is hoped, then, that this handbook will help nontechnical workers to recognize the significance of the problem of malnutrition in young children, and to be able to gear their efforts toward locally appropriate preventive and curative measures.

2 It is obviots that it is not possible in this book to go into detail concerning scientific aspects of human nutrition. It is the aim rather to outlin, certain general principles and to suggest guidelines. While problems of childhood malnutrition exist in Papua and Patagonia, and while the basic needs for foods and nutrients are much the same in both places, successful preventive programs could be widely dissimilar, depending, as they do, on the economic, geographic, and social "reality" within which they will have to be applied and developed. General principles of approach are often valid; universal blanket solutions are a mirage. Each situation requires particularized knowl­ edge, ingenuity, sympathy, and imaginative understanding to envisage a course of action that is relevant to local priorities, within the frame­ work of available resources and, above all, with the community's understanding, support, and participation. Another variable will plainly be the particular project on which the worker is engaged. This may be directly in the health field, and, in the futu're, may be specifically concerned with trying to assist in the development of a Preschool Protection Program (P.P.P.), in which the prevention of malnutrition is the dominant theme. Equally, it should be possible to integrate some practical emphasis on methods of combating malnutrition into almost all types of projects in developing countries. The scene then is set. The past twenty years have delineated the clinical picture, the biochemistry, the causes and the treatment of malnutrition in early childhood. More recently, international recog­ nition has accumulated to emphasize the magnitude of the problem and its gravity as "a prime deterrent to progress." Methods of pre­ vention are theoretically known; their application is desperately needed. There is no doubt that the next ten years could be envisaged most usefully as the "decade of field application," in which seemingly simple programs, so difficult to carry out in fact, are launched collaboratively by governments and international and voluntary agen­ cies, evaluated, suitably modified, and carried to successful conclu­ sions at the grassroots level of the rural tropical villages and slums, where the majority of the world's children live. In this decade of field application, there is no doubt that non­ technical field workers, including Peace Corps volunteers, can play a most important role. This book is intended to guide them in the struggle against malnutrition. It does not, and cannot, suggest uni­ versal panaceas; but, hopefully, may indicate general tactics, leaving the detailed strategy to the planners of the specific programs, and finally to the ingenuity and adaptability of the worker on the spot.

DERRICK B. JELUrFE.

3

chapte i

THE HUMAN SCENE

TO APPRECIATE the always complex and some of these have roots in civilizations multiple factors responsible for mal- which antedate those of the Western nutrition in an individual child, or in world by thousands of years. Neverthe­ a community, it is first necessary to less, the human scene in technically have some understanding of the general developing regions of the world, which human scene in what are often called include two-thirds of the world's popu­ the "developing countries" of the lation, usually has certain general fea­ world. This term is, of course, impre- tures in common, and these need to be cise and plainly applies in varying de- recognized and understood, as they not gree to different countries of the world, only play a part in the causation of or, even to regions within a single childhood malnutrition, but they also country. In the present book, it refers help to determine and Emit possible in general to those countries which methods of prevention and improve­ have lagged behind in the technological, ment. industrial, agrarian, and economic revolutions that have occurred in the Rural Populations and Increasing Western world in the last 150 years, and Urbanization. In most developing whose populations have not been di- countries, the majority of the popula­ rectly involved in the development of tion-usually between 60 to 90 per­ the system of thought and logic known cent-are scattered in rural areas, as "scientific rationalim." These coun- dependent for the i'iost part on subsist­ tries are mostly located in the sub- ence "garden-to-mouth" agriculture, tropics and tropics, and they are now often in villages or homesteads to somc making herculean efforts to modernize degree isolated by poor road communi­ and to raise their standard of living, cations. At the same time, partly as a so that they are best termed "techni- response to planned industrialization cally or economically developing." and partly spontaneously, in all coun­ It is also apparent that all preindus- tries there is an increasing move to­ trial societies have t,,eir own well es- ward urban areas by men, sometimes tablished ways of life, and, indeed, with their families and sometimes 5 alone, seeking employment and the sibilities of investing in supplies and excitement of the big city, but only too equipment which are needed to increase often finding instead the disappoint- food production or to improve food ment and frustration of unemployment storage. and the demoralized life of the slum At the same time, the relative ex­ dweller, with all the consequent nutri- pense of a poor man's life deserves tional and social problems (p. 57). emphasis. For example, he can only afford to buy small uneconomical quan.. Antiquated Agriculture and Inade- tities of any commodity at a time, in­ quate Food Production. Old-fash- cluding purchased foods and, in some ioned methods of agriculture are usual, tropical towns, water. and although the tools and methods may The national income of highly be tin.e-liallowed popu­ by tradition and are lated developing countries is often only sometimes adapted to local circum- one twentieth of that of industrialized stances, agricultural productivity is countries, which means that there will low, under-mechanized, and usually be an understandable competition be­ based on small uneconomic landhold- tween the various Ministries or De­ ings (p. 44). Food production is, there- partments of Government concerned fore, inefficient and highly dependent with trying to develop the country for on the weather; while the harvest is the limited finance available, and espe­ exposed to much wastage by rodents, cially for restricted foreign exchange. insect pests, and molds during storage. This plainly means that all projects, Likewise, tlhe preservation, distribu- whether for more hospitals, or for bet­ tion and marketing of food is also likely ter communications, or for an i'ncreased to be poorly organized and without number of boreholes for water, have benefit of modern technology, thus to be judged, if possible, impartially. limiting the range of food distribution Emphasis has to be given to those con­ from its nrea of production. sidered to be priorities for the coun­ try's Poverty. The national development. Of such, those re­ earning capac- lated to improving the nutrition of ity of developing countries is usually young children are extremely impor­ )ow and dependent on agricultural, tant in the long run. rather than industrial, production. it Specifically, a low national income is very frequently based on one or more means that little finance will be avail­ cash crops, such as coffee: rubber, cot- able for health or other social services. ton, or cocoa, and subject to the price Thus, in developing countries the per fluctuations for these commodities on caput annual health budget may be be­ world markets; or, as in the case of tween U.S. $0.50-1.00, as compared rubber, for example, to the develop- with $30-40 per head per annum in nment of modern synthetic substitutes. Western industrialized countries. Low per caput incomes plainly limit the range of foods which families can Lack of Education. Educational prob­ afford to produce, or to buy. Thus, ani- lems will also loom large. There is neal I "otein foods which are, relatively usually a high rate of illiteracy, espe­ speaking, expensive to produce are little cially among women. The number of used. They also limit severely the pos. schools is insufficient and a shortage 6. of school teachers is often a major ob- country. All too often hospital facilities, stacle to the expansion of the educa- including beds, are even scarcer for tional system. The availability of all children than for adults, and little at­ types of technically trained personnel, tention can be paid to the sheer numeri. including those needed to man the cal size of pediatric problems, espe­ health or agricultural services, varies cially malnutrition. Shortage of beds, in different parts of the world, but, in drugs, and equipment often mean that general, will also be quite inadequate health services can of necessity only in both number and quality, supply a rough and ready "first-aid" There is no doubt that from the long- type of treatment. term viewpoint, education is a major key to the improvement of the health Nonwestern Culture Patterns. The and nutrition of a country. Educated mass of the population has usually a parents are likely to have an increasing prescientific philosophy, with motives awareness of modern ideas of nutrition, and drives very different from those of child rearing, and food production, and !he Western world, and with unfamiliar, to realize the economic limitations of but deep-rooted, classifications of dis­ trying to rear and educate an over- ease, food, and all other aspects of life, large family. often much related to magic and ultra­ human forces. Women may often be Defective Environmental Sanita- considered to have a low or subservient tion. Standards of environmental status-a point of great importance in sanitation, including ark easily available, relation to successful nutrition educa­ clean water supply and the disposal of tion. excreta and rubbish, are usually defec- The local pattern of customs, atti­ tive, with an increased incidence of in- tudes, and practices greatly influences, fections and parasites that are water- both for better and for worse, the nutri­ borne, spread by flies, or due to fecal tion, diet, and food production of a contamination of the compound. These community, and also modifies the way will include diarrheal diseases and in- in which preventive programs can best testinal worms, both of ich signifi- be developed (p. 68). The scientific cance nutritionally (p. 72). mode of thought and logic usually has neither influence nor long-standing his­ Inadequate Medical Facilities. torical roots among the majoriti of the Doctors are few-between 1 per 10,000 population. to 1 per 100,000 population-compared with Western countries in which there Young Populations. The population may be about 1 per 1,000 population. structure of most develoling countries In addition, there is usually a geo- differs greatly from, that seen in the graphic maldistribution, with a high U.S.A. and in Western Europe. In gen­ proportion of the total in cities, and a eral, there are more children and young relatively small number in rural areas. adults, aii fewer people reaching old There is a similar scarcity of nursing age. Thus, about 50 percent of the popu­ and other paramedical personnel, who lation will be below 15 years, while 20 usually do most of the preventive and percent will be young children below the curative health work in this type of age of 5 years, compared with about

7 30 percent and 10 percent for corre- children occurring in the first year of sponding age-groups in Western coun- their life. Rates in developing countries tries, of the world may be as high as ten times those found in industrialized Western Population Pressure and Food countries. Less obvious, and usually Production. At the same time, and of unappreciated, is the fact that the death great consequence nutritionally, despite rate of children in the 1-4 year age high mortality in early childhood and group--a relatively healthy period in a low life expectancy at birth of 30 to Western countries-may be 40 times as 40 years, there is usually a population high as those in the U.S.A., largely increase of about 2-3 percent each year. due to malnutrition and to associated This is due to sustained high fertility infictions and parasites (Figure 1). and the decreases in mortality that have In general terms, this will mean that taken place in recent years, as a result approximately half the children born in part of the introduction and accept- die before they reach their fifth ance of some aspects of modern pre- birthday. ventive and curative medicine, and in some measure to a decrease in warfare I year infant mortality at the local level. The consequent popu- 100 1- years lation pressure plainly has nutritional significance (i. 55-56). In particular, 80 the high rate of population growth leads to the continual outstripping of food production by the number of mouths to 60 be fed. The disproportion between numbers 40 of people and land available for food production is notable in India, where 20 2.2 percent of the world's land area is 20 occupied by 14 percent of the world population. 0 PERU GUATEMALA MEXICO U.S.A. High Burden of Childhood Dis. FIGURE .- High inf-nt and 1-4 year ease. The child population is not only mortality rates in Peru, Guatemala, a very large one, but also has a high and Mexico compared with the U.S.A. incidence of illness. A visit at any out­ patient clinic in a tropical country will Pattern of Childhood Disease. De­ show at once that about half of those spite some differences from one part attending are young children, and this of the world to another, the general impression is confirmed by the fact that pattern of disease and ill.health in early more than 50 percent of the total mor. childhood is broadly similar from re­ tality at all ages occurs in earl) child- gion to region in developing countries. hood. The "Big Three" childhood ailments The high death rate in early are usually malnutrition, diarrheal di. childhood is also shown by the infant sease, and pneumonia. Following mortality rate-that is, the deaths of behind these come the remainder of

8 the "Top-Ten"---tuberculosis, malaria, Chile, and among some groups of Eski. certain infectious fevers of childhood moe; by the usual good health of the (notably measles and whooping children of the well-to-do, both indige. cough), intestinal worms, accidents, nous and foreign, living in tropical re­ and infections of the newborn. Char- gions; and by the recurrence of similar acteristically, young children in tropi- child health problems, when environ. cal regions are rarcly found to be mental factors, especially nutrition suffering from one disease alone, but deteriorate as was the case in Holland from several at one time, each adding in the last months of World War II. to the total cumulative burden of mis- Wars, famines and other natural and ery and ill-health. man-made disasters always have their None of the diseases mentioned is main nutritional ill-consequences "tropical" in the old-fashioned sense-- among the vulnerable groups--the that is, found exclusively in hot tropi- young children and pregliant and lac­ cal regions. Kwashiorkor, one of the tating women. severe forms ot protein-calorie malnu­ trition (p. 75), was common in Europe Preventability oj Problems. The at one time, as was well documented common illnesses mentioned are all in the Irish Potato Famine of the early potentially preventable, including the 19th century. Malaria can be a scourge various forms of childhood malnutri. in Arctic regions in the summer, and tion. Cure alone is economically un. deaths from intestinal roundworm in- sound and illogical, and will in no way fections were once well known in prevent the child or others in his family Britain. from contracting similar diseases on re­ What seems a difference in place is turn to the home environment. It is this rather a difference in time and devel- preventive approach which has to domi­ opment. Urbanizing areas of nine- nate all realistic child nutrition pro. teenth century Europe during the In- grams in developing countries. dustrial Revolution had a very high infant mortality rate due to summer Holding Factors. Four groups of diarrhea, malnutrition (including factors appear to mold the pattern of "flour-feeding illness," actually a form childhood disease in different parts of of kwashiorkor) (p. 76), and many the world. These are: the economic, infectious diseases, all occurring among hygienic, and educational levels of de­ grim social and hygienic circumstances. velopment in the community; genetic The so-called "tropical" pediatrics of characteristics; the cultural pattern; 20th century city slums found in some and geographic and climatic factors. developing countries present a strik- That certain important diseases are ex­ ingly similar picture. clusively "tropical" in distribution is Moreover, that the tropics, in a cli- not to be denied-for example, some matic sense, are not primarily impli- parasitic infections, such as African cated is shown by the fact that corn- Sleeping Sickness. Also, all human parable nutritional and health problems groups are subject to different inherited are seen in less well-developed com- diseases. However, there is no doubt munities in cold or temperate regions, that most disease in present-day "tropi. including, for example, parts of rural cal pediatrics," including malnutrition,

9 is principally the result of poverty, tech- ground realities in developing regions nical backwardness, inadequate sup- and the general pattern of childhood plies of nutritious foods, lack of disease. Many bacterial and parasitic education, and defective hygiene, asso- infections are more easily acquired and ciated in varying degree with the effect have more serious effects in malnour­ of certain local customs and practices. ished children. At the same time, much malnutrition results not only from lack Size ol Problems. Some of the dis- of the correct foods, but also the addi­ ease problems mentioned above may be tional burden placed on the child by very large, and this is especially the intercurrent (conditioning) infections case with childhood malnutrition. Thus, (p. 72). in Kampala, Uganda, 10 percent of all It is in these difficult circumstances children admitted to the main hospital that all those working to improve the are suffering from the severe form of nutrition of tropical children find them. protein-calorie malnutrition known as selves enmeshed. Much plainly depends "kwasliiorkor" (p. 76) ; while surveys on relatively long-term measures to im­ in thc surrounding countryside show at prove, modify, or expand the economy, least half of the children under school the educational system, food produc­ age are suffering from lesser degrees tion, and the social structure of the of this form of malnutrition. In 1958, a particular country. countrywide survey in Haiti showed 7 Important as these long-term objec­ percent of 1-3 year olds to have tives obviously are, they cannot be kwashiorkor. considered here, and the present book Only too often the full dimensions is concerned with discussing the causes and the late consequences of the prob- and recognition of malnutrition in lem of childhood malnutrition are not childhood, and with possibl'e measures appreciated by the administrators and to improve the nutrition of children leaders in some parts of the world. The available to those working in the field. size of the problem, its direct and in­ direct influence on child mortality, and The Challenge. The challenge is how its late effects on physical and mental to make the benefits of modern scien­ development have only recently been tific knowledge avvilable simply, eco­ appreciated by the medical world. They nomically, effectively, acceptably, and are particularly unpalatable and difli- persuasively to enable tropical villagers cult for hard pressed politicians in de- to improve theii own standard of health veloping countries to accept and face, and living, and, in particular, to advise confronted as they are with a wide and motivate parents to improve the range of formidable social and eco- nutrition of their young children. This nomic problems to be dealt with with accomplishment plainly requires prac­ limited resources. tical and tactful adaptation, with the ultimate aim being always to secure Need to Appreciate Background. the maximum return in human welfare It is vital for all those working in the from minimum expenditure in money field of nutrition to appreciate the back- and trained personnel.

10 FURTHER READING 1

R. E. BRoWN, Medical Problems of the M. KINr (Editor), Medical Care in De. Developing Countries, Science, 153, 271 veloping Countries, Oxford University Press, (1966) (G&T). Nairobi (1966) (G&T). D. B. JELLIFFE, Paediatric Practice in ' G=Recommended for the general reader. Tropical Regions, Lancet, ii, 229 (1965) T=Recommended for the technically trained (G&T). health worker.

806-112 o-48----2 1

chapter ii

THE HUMAN DIET

ALL OVER THE WORLD different human BASIC NUTRIENTS groups have evolved their own diets, based on an immense variety of dishes Diets are made up of six basic groups made out of innumerable mixtures of of nutrients--carbohydrates, fats, pro­ different foodstuffs. While not appreci- teins, minerals, vitamins, and water, ated by tile people concerned, a satis- together with substances added for factory diet in any part of the world has flavoring. The body has different needs to contain adequa~a quantities of spe- for these nutrients in health depending cific nutrients to supply energy, to upon size, sex, age, degree of activity, maintain body repair, and to keep the and climate. brady working normally. In addition, in childhood and pregnancy the diet must uiet ll- e a alysso f be sufficient to cover the extra needs diets of well-fed, healthy people, and of rapid growth. laboratory investigations on experi. The foods making up a diet, after mental animals and human volunteers having been eaten, are digested and have led to the suggestion of certair absorbed from the alimentary canal. recommended daily nutrient allow Within the body, the nutrients are used ances (Appendix I). for one or more of the activities already These figures are only approximate mentioned. If excessive quantities of as there is variation even between nutrients are taken, they may in some healthy individuals, and it is quite pos­ cases be passed out of the body in the sible that communities in various parts urine, as with vitamin C, or may be of the world may have adapted them. stored in the body, as with vitamin A in selves over long years to higher or the liver, and with too great an intake lower levels of intake of certain nu­ of calories, as subcutaneous fat. trients. The figures given are also aimed

13 at a safe level and may, therefore, some- are related to one another. For example, times be too high. the requirement for the vitamin thia. In any case, it will not be possible mine, increases with the intake of car­ for the nonnutritionist to calculate die. bohydrates. It is this inter-relationship tary intakes, and, for practical pur- which has led to the concept of the poses, it is more useful to plan diets to "balanced diet." In other words, not insure intakes of certain groups of foods only are certain quantities of the differ­ known to be rich in different nutrients. ent nutrients required, but for best usage they should be taken together in Needs for Growth. The nutritional certain approximate relative propor. needs of young healthy children are tions. particularly great, as would be expected from their rapid rate of growth. In par­ ticular, the requirements for protein, TYPES OF NUTRIENTS calories, and iron are much greater pro­ portionally in young children than in Full details of the functions of vari­ adults. Thus, a 150-pound man needs ous nutrients, and their sources in vari­ about 70 grams of protein per day, ous foods can be found in standard while a child of one tenth of this weight textbooks on nutrition--some of which (e.g. 15 pounds) needs 21 grams of are listed at the end of the chapter. The protein, which is almost one third of the present section, therefore, only sum. adult's requirements. marizes certain points, especially those Pregnant and lactating women also that are felt to be relevant to problems have a very high dietary need for the of childhood malnutrition in develop. growth of the fetus and uterus, and ing tropical countries. because of the nutritional drain of the human milk produced. Carbohydrates. The group of nu­ trients known as carbohydrates consists Needs During Injections. As well principally of starches, sugars, and as physiological variations in normal various indigestible substances, such as healthy individuals, many bacterial and cellulose. Carbohydrates are the body's parasitic infections can affect the body's main source of energy and heat, and nutrient requirements. For example, in every gram of carbohydrate absorbed diarrhea in young children the rapid into the body provides four imits of passage of food through the intestines energy (Calories). prevents its full absorption. The pres. Digestible carbohydrates are broken ence of numbers of roundwoims in the down by enzymes in the intestinal canal small bowel may lead to food being into simple sugars, which are then ab. taken up by these large parasites rather sorbed into the bloodstream and are than by the child. Likewise, any fever used directly as a source of energy; or leads to an increase in the body's needs are stored in the muscles and liver for protein, as well as resulting in poor as so-called animal starch (glycogen), appetite and sometimes in vomiting, which is subsequently reconverted into sugar to deal with the body's require. Inter-Relationship of Nutrients. ments for energy. An excessive intake of The body's needs for different nutrients carbohydrates means that the body is

14 receiving a surplus of Calories, and nantly carbohydrate staples also contain thse are stored as subcutaneous fat, protein and other nutrients, although leading ultimately to overweight and in small quantities. Most tropical peo­ obesity. ples also derive the bulk of their pro­ Most foods, including meat, fish, and tein from their staple food. mnilk, contain some carbohydrates. In staple foods, the carbohydrate However, carbohydrates are mostly starches are enclosed in granules inter­ found in certain classes of vegetable spersed between indigestible cellulose. foods, especially cereals (grains), such Preparation is sometimes by means of as wheat, rice, corn (maize), and the milling to form a flour, and always by millets; root crops, such as potatoes, thorough cooking to break down the yams, cassava, and members of the cellulose framework and to cause banana-plantainfamily. swelling and bursting of starch gran­ Carbohydrates may also be taken in ules. In this way the foods are made the diet in the form of naturally oc- digesiible and the full Calories become curring sugars, such as those found in available. This is particularly import­ milk (lactose), or in fruits and honey ant when preparing foods for young (fructose). children. Cane sugar (sucrose), extracted from a variety of vegetable sources, Fats. These may he derived from especially the sugar cane, beet, and sap either plant or animal sources. Th.ey of certain palm trees (jaggery), plays a are concentrated sources of energy, hay­ part in certain traditional dietaries, irng more than twice the Calorie content and, of course, a large, and often exces- of carbohydrate- (9 Calories per sive, role in the diet of modern urban gram). Animal fats are present in the communities. Sugar is one form of livers and fatty parts of mnimals and "naked Calories," that is, Calories with fish, the yolks of eggs, and in milk fat no other nutrients. A high consumption and its by-products, such as butter, of sugar seems to be one factor respon- cream, and ghee (clarified butter). Cer­ sible for dental caries. tain animal fats, including egg yolk, In developing c.auntries in the trop- liver, and butter, also contain the fat. ics, predominantly carbohydrate foods soluble vitamins A and D. are usually the main source of Calo- Vegetable fats are found in the ries in the diet, with the exception of groundnut, the soybean, the olive, the such unusual groups as some hunting oil palm fruit, all nuts, and the seeds or pastoralist communities. By con- of various pllants, including sesame, trast, in industrialized countries, Cal- mustard, and cotton. These oils are of­ ories are less exclusively derived from ten extracted by traditional mueans and carbohydrate foods, as the fat intake used for cooking. Commercially, some is higher. are grown in extensive plantations and In many tropical regions, the diet the oil used for a variety of purposes, may consist to a very large extent of including the manufacture of marga­ one or more mainly carbohydrate rine and soap. foods, the staples. However, it is im- In most developing regions, fats are portant to realize that these predomi- costly and not widely available, and

15 so form a very minor ingredient in the and the peanut (groundnut). Of these, diet. Thus, in India only 13 percent of the best protein source is the soybean the total Calories of the aduit diet are (up to 40 percent), although caution derived from fat, as opposed to 43 per- has to be exercised in preparing this cent in the U.S.A. food owing to its indigestibility (p. 31). The next best plant sources of pro. Proteins. The complex substances tein are the cereal .grains. While there known as proteins are essential consti- is great variation between different tuents of all plant and animal cells, types of cereals and many different Protein molecules are made up of var- strains exists, as a group they contain ied combinations of components called about 10 percent protein. amino acids. Over twenty of these Plant sources of protein that are often amino acids are required by the body, overlooked are dark green leafy vegeta­ but only eight are "essential" that is, bles, including tropical equivalents of they cannot be manufactured by the hu- spinach. These leaves contain about man body from other ingredients, s) 2-10 percent protein. They are also that they have to be present in the good sources of other nutrients, includ­ food eaten. ing iron, vitamin C, and riboflavin, The value of a particular food pro- especially the young leaves. Unfortu­ tein in the diet is determined by its nately, in many communities of the amino acid composition (compared world, they are often not used as much with the proteins of egg or breast milk as they might be, and, indeed, often may as standards), its known biologic effects be regarded as "poor man's food," with in experimental animals, the digestibil- little prestige. ity of the particular food, and the asso- The staple foods poorest in protein ciated calorie content of the diet, which are the various root crops, tubers, and may have a "protein-sparing" effect plantains, which have a protein con­ (p. 17). Animal Protein.Proteins may be de- tent of only 1-2 percent. As important as the total protein con­ rived from animal or vegetable sourineis tent of vegetable foods is the fact that Animal proteins are found in meat, fish terpoen ontcnantefl (including shellfish), eggs, milk( and their proteins do not contain the full some of its products, especially cheese, Forrange example,of the eight the essential protein amino of cerealacids. yogurt, and buttermilk), and to a minor grains , h c or eis dfcent extent fromextet otheroherfrm sources,oures, includingncldingin-grains, in in the essential such as aminocorn (maize) acid, lysine; is deficient while sects, snails, and so forth. Foods of ani- theprotis found i legume shias mal origin not only are rich, concen­ trated sources of protein, but also all the soybean and chick-pea are relatively low in another (methionine). The value contain the complete range of the eight of each of these 1xds is, therefore, en­ essential amino acids. Vegetable Protein. While almost all hanced if eaten as cereal-legume mix­ vegetable foods contain some quantity tures, thereby providing the whole of protein, the content varies considera- range of essential amino acids. bly. The richest in protein, usually con- Expense and Scarcity of Protein taining about 20 percent, are the leg- Foods. Diets in tropical countries are umes-the various beans, peas, lentils, almost universally dcficient in protein,

16 especially in those of animal origin, a sufficient carbohydrate foods are pres­ fact which is illustrated by a compari. ent in the diet, protein may be waste­ son of the average milk, other animal fully burned by the body for the pro­ and vegetable protein intake in Latin duction of energy at the rate of four American countries with figures from Calories per gram. This becomes of Canada and the U.S.A. The rapidly special practical significance in the rising populations in developing ceun- treatment of kwashiorkor (p. 80), when tries and the slow increase in agricul- sufficient Calories in the form of sugar tural production is tending to widen and vegetable oil should be given at the this "protein gap" still further, same time as protein. In addition, all over the world, whether in New York or equatorial Vitamins. The group of nutrients Africa, protein foods, especially those known collectively as vitamins are un­ of animal origin, are more expensive related chemically, but are all essential than largely carbohydrate staples. In insmall quantities for the maintenance Severe deficiency, lead­ proteinview of this, the need to use vegetable of good health. mixtures, if possible with sma ing to depletion of body stores, results additional quantities of animal protein, in various forms of clinical malnutri­ is an important principle of village tion, which can sometimes be recog­ level infant feeding (p. 130). Indeed, nized by the appearance of certain signs many traditional diets in different parts or y the use of appropriate laboratory of the world appear to have evolved tests. toward largely vegetable protein mix- However, vitamins are required only tures. These are often of a cereal-leg- in small quantities, so that the mixed o . dif­ ume combination, in which the amino diets, made up of a wide range acid deficiency of one food iscomple- ferent foods consumed iimost of the Europe, usually mented by that of the other ingredient. U.S.A. and Western Examples include the rice and dhal supply more than adequate quantities evidence (lentil) of India, the beans and corn in the diet itself. There is no vita­ iortillas of Mexico, and various fer- to suggest that extra amounts of the mented food preparations, such as Jap- mins are beneficial. Undoubtedly, taking of vita­ anese miso (soybean and rice) and In- result of much routine only dian idli (black gram and rice). mi tablets by well-fed people Functions and Needs o1 Proteins, leads to the production of an "expen- Protein is required for repair of the sire" urine, as the unnecessary intake body, the cells of which are constantly is promptly excreted. formationbeing broken of downbody andenzymes, rebuilt, and for alsothe variousNevertheless, types occurvitamin in manydeficiencies parts of formagroh. I or te, atr reaso the world, especially if a diet is taken for growth. Itisfor the latter reason that is limited to a restricted number of that there is a particularly high protein foods. In Britain, the elderly person, need in infancy and early childhood living alone an with a poor appetite (Appendix 1), when growth is espe- may subsist on tea and toast, and de­ cially rapid. velop various vitamin deficiencies, Carbohydrates as Protein Sparers. especially those of the B complex. His- It is important to realize that if in- torically, the diet of hardtack and salt

17 pork which was sometimes eaten for VitaminA. This vitamin can be taken months on end by seamen during the in directly. as vitamin A, which is con­ age of sail was almost always guaran- tained only in animal foods, particu­ teed to lead to a substantial death rate larly in liver, egg yolk, milk and its from scurvy (vitamin C deficiency), products, and liver oil from the cod, In some communities of the world, halibut, shark and other fish. Alterna­ the basic diet may consist of a very tively, vitamin A may be synthesized limited range of foods. This limitation within the body from orange pigment may be for economic reasons, or be- foods, containing the pro-vitamin beta­ cause of local customs, or because the carotene (vitamin A precursor). Rich terrain only permits the growing of source of carotene include such or­ limited crops, or for a combination of ange-colored fruits and vegetables as all of these reasons. Difficulties may be the pawpaw, oil palm fruit, carrots, aggravated by seasonal variations in pumpkins, mangoes, yellow sweet po­ food supply, in particular by a "hungry tatoes, and so forth, as well as dark season," which often occurs at the green leafy vegetables, including vari­ beginning of the rains when crops have ous tropical equivalents of spinach and been planted, but are not yet ready for cassava leaves. harvesting. Foods containing actual vitamin A As with other forms of malnutrition, can be obtained only rarely by the av­ vitamin deficiency disease is much more erage population of most developing likely to oe -ur in the two nutritionally tropical countries, so that the avoid­ "vulnerable" groups--young children ance of deficiency depends in large and pregnant or lactating women, measure upon ensuring an adequate in­ Their need for nutrients is high and take of carotene-containing foods. their intake is often restricted by vari- Also, tropical infants are much de­ ous harmful food customs (p. 65). pendent on their mother's diet in this Another factor to be taken into ac- respect, both as regards the stores laid count in relation to the onset of malnu- down in the liver in the fetus during trition due to vitamin deficiency is the pregnancy, and the vitamin A in their variable degree of storage of different mother's breast milk. Both of these may vitamins in the body. In a well-fed in- be deficient if the mother's diet has dividual, vitamin A stores in the liver itself been lacking in carotene-contain­ may suffice for montha, even if the diet ing foods. is lacking in this nutrient, so that clini- Problems may also occur because cal deficiency will only be detected after carotene is not well absorbed from the this time has elapsed. By contrast, intestine, especially in children who stores of thiamine last for only a few have diarrhea as is very commonly the weeks, case. Storage of vitamin A in the liver The effects, actions, and interactions may be hampered in young tropical of vitamins is a most extensive subject children by various diseases of this and it will only be possible to touch on organ, which are by no means a few important points here concern- uncommon. ing the relevance of vitamins to the nu- Vitamin A is principally required trition of tropical children, for the normal functioning of epi­

18 thelium (surface cells) of the skin and mother's milk varies greatly with her eye, including the retina. In some parts diet. of the world, vitamin A deficiency is a The daily need for thiamine is re­ most common and serious form of mal- lated to the amount of carbohydrate nutrition, which is both preventable Calories in the diet, so that feeding and tragic in its consequences, as it with overmilled white rice from the may easily lead to permanent blindness early weeks of life is another factor (p. 87). tending to lead to infantile beriberi Vitamin B Complex. The three main (p. 88). members of the vitamin B complex or 2. Riboflavin. This yellow-colored group are thiamine, riboflavin, and vitamin is also widely distributed, but niacin. is in especially high concentration in 1. Thiamine. Thiamine, which is milk, green vegetables, meat (especially required for the metabolism of carbo- liver), fish, and eggs. In tropical diets, hydrate in the body, is widely available its main sources are usually dark green in a variety of tropical foods, including leafy vegetables, cereal grains, and cereal grains (mainly in the germ), legumes. Starchy root crops contain legumes, green leafy vegetables, fish, only very little. milk, and meat. Thiamine is water Lack of riboflavin produces ulcer- at soluble and easily absorbed. It breaks the corners of the lips, and a gener ly down at high temperatures. red, sore mouth. Severe deficiency of thiamine in 3. Niacin. This vitamin is found dis­ young children results in a clinical con- tributed in numerous foods. Rich ani­ dition known as infantile beriberi (p. ral sources include meat, particularly 88). Beriberi is a public health prob- liver, while the best available sources in lem of importance mainly in those tropical countries are legumes, includ­ areas of Asia where over-milled rice ing groundnuts, and cereal grains, es­ forms the mainstay of the diet, with a pecially if they are undermined and consequent high intake of carbohydrate still contain the germ. and low levels of dietary thiamine. It Corn (maize) is a particularly poor has been termed "white rice disease." source of niacin, especially if the germ Thiamine in rice can be reduced not has been removed by overmilling. Clin­ only by overmilling, which removes ical malnutrition due to niacin defi. the germ, but also by over-soaking or ciency-pellagra-is thus principally a cooking with too much water which is disease of corn-eating communities. subsequently discarded. Parboiling (p. Vitamin C.--Ascorbic acid (vitamin 27) is a method of preparation which C) is found in vegetables, especially preserves the thiamine content, green leaves, and various fruits, par­ An insufficient intake of thiamine in ticularly those of the citrus group. There are often especially rich local the mother's diet is also of great poten- sources of ascorbic acid such as acerola tial harm to the suckling baby, in part (the Barbados cherry) in the West because the stores that he will acquire Indies, the fruit of the baobab tree in during fetal life will be low, but mainly Central Africa, and the pawpaw and because the level of thiamine in the the guava in mrmy parts of the tropics.

19 Other sources of ascorbic acid include It is difficult to give a realistic rec­ germinating cereal grains or legumes, ommended daily allowance for vitamin whether eaten raw, or cooked, or pre- D, because in tropical regions little pared as local beer. of this nutrient is obtained from the Human milk is a good source of expensive animal foods just mentioned, vitamin C, provided the mother's diet and is mostly synthesized by the skin. is adequate in this respect. A breast- The occurrence of rickets will, there­ fed baby therefore needs no other sup- fore, depend on various factors likely ply of ascorbic acid for the first six to prevent a child from being exposed months of life. to sunshine, including over-clot'ing, Ascorbic acid is both water soluble the degree of clouedness, and the avoid. and destroyed by heat. It will, there- ance of exposure by parents according fore, be lost if vegetables are left soak- to various local customs (p. 90). It is ing for too long or (!specially if they possible that vitamin D is synthesi.'d are overooked. somewhat less easily by children with Vitamin C plays various oles in the darker pigmented skins. body's metabolism, but is especially required for the formation of the small Mineral Salts. A variety of different blood vessels. Severe and prolonged de- minerals is required in the diet for ficiency of ascorbic acid produces the healthy functioning of the human scurvy. Because of the walls of the body, including some known as trace small blood vessels become fragile, elements, which are needed only in ex­ hemorrhages occur into the skin and tremely minute quantities. The present into the gums, which become large, account will deal only briefly with sev­ red, and swollen, and bleed easily when eral more important minerals--iron, touched, calcium, iodine, fluorine, and sodium Vitarmn D. This vitamin is unique chloride. in human nutrition in that it can either Iron.This is principally required for be eaten, or synthesized in the skin the formation of the red blood pigment, when the la, ter is exposed to the ultra- hemoglobin, which is responsible for violet light of sunshine, carrying of oxygen through the body. Dietary vitamin D is found only in The newborn infant relies for his iron certain animal foods, especially fish needs, in the early months of life, on liver oil, egg yolks, and milk, and its the stores laid down in his liver during products. Human skin contains a sub- fetal life, again emphasizing the re­ stance which, when irradiated by the lationship between maternal diet in utraviolet rays of sunlight, becomes pregnancy and the infant's subsequent converted to vitamin D, which is then nutrition. This is especially important available to the body. since both human and cow's milk, the Vitamin D is required for the ab- principal foods most likely to be taken sorption of calcium from the bowel and during the first months of life, are poor for the formation of strong, well cal- sources of iron. cified bones. Deficiency leads to rickets From at least six months onward, it (p. 90) in children, which is charac- is important to include iron-containing terized by deformed, soft bones, foods in the child's diet, because his

20 blood volume is growing as rapidly as lease and excretion of calcium from the his body. skeleton. In later childhood, iron needs are The best sources of calcium are much less, but in many tropical coun- human and animal milks and their prod. tries, requirements may be increased by ucts, and the bones of small fish. Vege­ the continuous loss of small quantities table foods, especially cereals and par. of blood through certain parasites, espe- ticularly millet, provide some calcium. cially the hookworm, which imbeds it- The calcium content of water varies self in the wall of the small intestine and considerably but, in some circum. feeds on blood sucked from its host. stances, may supply a significant por­ This continuous loss of blood is thus tion of the daily requirements. a cumulative drain not only of iron, but The recommended daily allowance of also protein, calcium for young children and for Dietary iron comes from both animal school children is given elsewhere (Ap­ and vegetable foods. Meat is a good pendix 1). However, this is not always source, as is such offal as liver, kidneys, valid. The absorption and utilization of and pancreas, but these sources are calcium is much bound up with the most unlikely to play a significant part availability of other nutrients, includ­ in the diet of tropical children. Another ing vitamin D and phosphorus, and source of potential significance to in- may be impaired by other constituents fants is egg yolk, which is, as a whole, of the diet. It seems also that some corn­ much under-used in infant feeding in munities may have become adapted to developing countries, higher or lower intakes. Of more practical consequence are Iodine. This mineral is required for dark green leafy vegetables, which are the normal function oi the thyroid rich in iron; although, as with other gland and, in particular, for the produc­ vegetables, the content varies with the tion of its hormone, thyroxine. Defi­ amount of iron in the soil. Grain cereals ciency leads to a visible swelling of the are also useful sources. Other factors thyroid gland (goiter). If large, this which affect the amount of iron taken can be disfiguring or even cause pres­ in include the concentration in drinking sure on the trachea (windpipe). water and the use of iron cooking pots. Iodine is widely distributed in the The latter can raise the iron content of soil, but is less concentrated inland, foods very considerably. especially in high mountainous areas, Different iron compounds, however, from which it has been washed out over are absorbed with different degrees of the centuries by the rain. ease. Various intestinal infections and TheoeThe iodinegr contentte a of omvegetables is is, diarrheal diseases, such as are common tainous areas. Fish and in children other seafood in the tropics, may also fur- are rich sources. ther interfere with absorption. Fluorine.This mineral is mostly pres. Calcium. This mineral is principally ent in the skeleton and in the teeth. It required for the formation of bones and now seems well established that rela­ teeth. In addition, a regular intake is tively small quantities protect the teeth required because there is a continual re- from caries.

21 In some parts of the world the water dration by extra loss in the form of di. supply may naturally contain an ex- arrhea or vomiting. cessively high content of fluorine, lead. Water in the diet may be drunk as ing to a deposit of this mineral in such, or it can be taken in various bey­ bones and teeth ("fluorosis"). This can erages (including milk, tea, and alco. be recognized in school children by the holic drinks). In addition, it is also scattered patches of dark brownish taken "in disguise" as a part of fruits mottling on the teeth and, in severe and and in cooked dishes, as in porridges, long lasting cases in adults, by the de- gruels, and stews. The amount of wa­ velopment of calcification of ligaments, ter required will, therefore, depend on especially those of the back. This le, ds various factors-the local climate, the to a rigidity of the spine and other degree of activity, and on the intake of joints with inability to bend and move. other water-cortaining items. VariousMinerals. The body requires For young children, the risks of wa­ various other minerals in small quanti- ter must be appreciated. Most sources ties to carry out its function in a nor- of drinking water in tropical regions mal way. In particular, in tropical coun- are likely to be contaminated sources of tries where perspiration oan often be bacterial infection, and so lead to diar­ excessive, sodium and chlorine are re- rhea from intestinal infection. It is for quired to replace the salt (sodium chlo- this reason that, unless indicated by an ride) lost in the sweat, exceedingly hot, dry climate, it is often In addition, many communities have best for young babies in tropical com­ developed a preference for food which munities not to be given extra drinking is flavored with salt, either during cook- water in the first four to six months of ing, added later, or both. So strong is life. It is probable that they can usually this drive for salt that in ancient times obtain adequate water, as well as other it was actually used as currency in nutrients, from their mother's milk. some parts of the world, as witnessed The risk of producing dangerous diar­ by the present-day word ".sniauy." rhea by giving dirty, contaminated In inland aieas of Africa and else. water from an unclean utensil is ex. where, salt caravans were an important tremely great. part of the local commerce, while var- If water is given to babies and young ious salt-contaii.ing earths,'or prepara- children, attempts should be made to tions of ashes of plants were used as persuade mothers to keep clean water salt alternatives, available, to boil it and to feed the Water. Water is a vital part of all infant from a clean utensil. However, diets. The human body is composed of for various practical and cultural rea­ over 60 percent water, and an adequate sons, mothers are often reluctant to do daily intake is required to make good this. They often do not understand its the losses in the urine, in the feces, in purpose and perceive very clearly the the moist expired air and in perspira- extra difficulties it will entail, including tion, both visible and invisible. The use of fuel. turn-over of water is especially great in In some communities, it is custom. early childhood, and the infant can ary to give young children weak tea or easily be precipitated into fatal dehy. various indigenous herbal brews, in. 22 eluding those called in the West Indies, regions, extremes can be seen between "bush teas." Some of these have been the bland, saltless steamed plantain of shown to be harmful to young children the Baganda of East Africa, taken with and should be avoided. IIowever, some unspiced groundnut (peanut) sauce, are undoubtedly harmless and may and the highly flavored masala of In­ even contain valuable nutrients, includ- dian curries or the chili beans of ing vitamin C. Under these circum- Mexico. stances, it may be possible to suggest Extreme flavoring, especially with using a diluted infusion of a harmless chili, presents problems in the feeding herb, such as the leaves of the orange of young children, because it is neces­ or soursop trees, as this will ensure sary to prepare the foods for infants that the water given will be boiled in prior to the addition of these irritant the process of making time infusion, substances. On the whole, most flavoring agents Flavorings. Various foodstuffs or have little direct nutritional value, with other substances are used principally the exception of the ascorbic acid in for the flavor, coloring or texture that chilies, and the increased digestibility they give to foods. Thus, saffron can be and vitamin 13 content of fermented used to give a yellow color to rice. Okra products. ("ladies' fingers") is widely used be- Substances used as flavoring agents cause of its viscous thickening pi'op- cover a very wide range and include the erties. Flavoring agents are mostly following: derived from plant products, which 1. Flowersand buds: capers, cloves, impart distincive tastes and odors, saffron; increase the appetite and stimulate 2. Fruits:tamarind, chili; gastric secretion. They thus enliven the 3. Seeds: caraway, cardamom, pep­ bland carbohydrate staples, which com- per, mustard, coriander, prise the bulk of most tropical diets. cuminin, nutmeg; In many countries fermentation is 4. Barks: cinnamon; employed in the preparation of foods. 5. Roots: garlic, radish, ginger; Thus, in Japan, miso is prepared by the 6. Leaves: basil. fermentation of a cereal-legume mixture of soybeans and rice. In parts of India, idli is made from rice and black gram, TYPES OF MALNUTRITION and khanam from rice and Bengal grain. In other parts of Asia, fermented Three general forms of malnutrition pastes of fish or shrimp are used. All of may be recognized: (a) dietary defi­ these examples not only produce the ciency, (b) dietary excess, and (c) di­ desired strong flavor, but the fermenta. etary imbalance. tion process also digests the protein of Dietary Deficiency. Va ious dietary the ingredients and increases the inadequacies may lead to malnutrition. amount of B complex present. There may be a definite lack of one or Great variations exist in the use of more nutrients. The classical example flavoring agents, depending on cul- was scurvy, which was so widespread turally defined preferences. In tropical and lethal among the crews of the 18th

23 Century sailing ships, whose diets were Preliminary Preparation. While usually almost devoid of vitamin C. some foods, such as fruits, are eaten Dietary Excess. Excessive intake of raw and others with only little prelimni. certain nutrients can also lead to forms nary preparation, many foodstuffs un­ of malnutrition. In the well-fed indus- dergo preliminary physical or chemical trialized countries, the most widespread preparation prior to cooking. At its example is obesity, which results from simplest, this may be considered to in­ a Calorie intake that is in excess of the dude the peeling and cutting up of body's energy expenditure. vegetables into nuitably sized pieces. With many nutrients, an excessive Similarly, the removal of the indigesti­ intake may be stored, and, when the ble husk of cereals and the grinding stores are full, the surplus is excreted of grain into flour are parts of the in the urine. However, a few nutrients same process, whether carried out by are harmful if taken in very large hand in the village or industrially by quantities, in particular vitamins A the large modern mill. and D. Nevertheless, this is very un- Various communities have developed usual with actual diets eaten by most complex preliminary treatment of food­ human groups, but poisoning by these stuffs designed to improve their flavor, two vitamins does occur occasionally digestibility or to remove harmful sub­ in children in industrialized countries stances. The Indonesian food, tempeh as a result of the accidental swallowing consists of soybean on which a special of large quantities of vitamin concen- fungus has been implanted and allowed trate, to grow, in order to predigest this food. DietaryImbalance.Malnutrition may In many countries, the protein-digesting result from an incorrect balance be- properties of the leaves of the pawpaw tween various nutrients in the diet. The tree have been recognize], and meat is most important example is one of the sometimes wrapped in them for some severe forms of protein-Calorie malnu- hours prior to cooking. Similarly, green trition of early childhood, kwashiorkor unripe pawpaw, which also contains (p. 75). In this condition the diet is this enzyme, can be added to protein­ unbalanced with a low intake of pro, containing stews. A dried extract of the tein, but with a relatively high con- unripe fruit of the pawpaw is com­ sumption of carbohydrate Calories. mercially available in Western coun­ tries as a meat tenderizer. of cassava, espe­ THE PREPARATION OF In the preparation it is neces­ FOODS cially certain bitter varieties, sary to remove the poisonous hydrocy­ Foodstuffs not only have to be pro- anic acid, which is particularly present duced but also stored, preserved, and beneath the peel of the roots. Various ultimately prepared for human con- methods have been devised by peo­ world, sumption. Problems of food storage and pies in different parts of the preservation are considered elsewhere often consisting of cutting the root into (p. 45). The present account will deal small pieces, washing, and eventually with certain general aspects of food sun-drying. preparation in relation to nutrition. Much of this preliminary preparation

24 of foods is to try to ensure their thor- tain leaf packets in which food is ough cooking and subsequent digesti- steamed in some parts of East Africa. bility. This is the ultimate rationale of A detailed knowledge of local meth. the de-husking of cereal grains, and of ods of food preparationis essential in cutting vegetables into small pieces. any program designed to improve in­ However, at the same time, wastage fant feeding. It can only be learned by may occur, through discarding edible direct observation of foods available in parts of the food, or by loss of water- the fields, storage places and markets, soluble vitamins as a result of over- and by observing their preparation in soaking, or through cooking for too the village kitchen itself. Improvements long in excess water which is then must be based on indigenous foods, and discarded. must be planned within the particular culture patern, especially bearing in Nutritional Aspects of Cooking. mind the limitations and restrictions of The cooking of foods produces chemi- real life kitchens and traditional cook­ cal and physical changes which improve ing practices. their digestibility, palatibility, flavor, appearance, and in some cases, their keeping quality also. Thus, cooking TROPICAL FOODS causes the swelling of starch granules, The Westerner working in a tropical tr ne wrng n atoia which thenenveope,ad burst wih out mat of theirause cellulose cogu- countryThu will find many unfamiliar foods envelopes, and with meat causes ioagu-and therefore all nutritional workers lation of muscle protein and conversion must have a working acquaintance with of collagen fibres to gelatin. In both the more important of these, and must instances, digestibility is improved. nutritional qualities and However,Howanees, over-cookingdiecooingity may deftdefeati itstd uhrpoeterecognize the flclfos this should not only be actually destroy nutrients, Once again, purpose and C, or heat.sensitive vitamin such as the be make certain amino acids unavailable, a theoreticalknowledge, but should reinforced by first-hand observationof There are many ways of cooking local foods growing, in the market, be­ foods, but, in most tropical countries, ing preserved, prepared, and cooked. they are usually restricted for such eco- It is difficult to classify foodstuffs nomic reasons as the cost of fuel and rationally and the following account is kitchen apparatus, such as pans and based, in part at least, on practical ovens, by the range of foods locally considerations: (1) Roots, plantains, and so forth, (2) Cereals, (3) Legumes, available, and by the indigenous culture (4) Vegetables, (5) Fruits, (6) Ani­ pattern. The cooking procedures em- mals protein foods, (7) Oils and fats, ployed will, therefore, be simple in type likely to and (8) Miscellaneous. and limited in scope, and are steaming, or rely especially on boiling, barbecuing on the open embers. Some Roots, Plantains, and so forth. communities use other less common These foods are considered together be­ methods, such as the umu (stone.filled cause they are largely sources of carbo­ cooking pit) of Polynesia, or the plan. hydrate Calories, with a low protein

25 content (1-2 percent), while also con- duced into various parts of the world, taining much water and fiber. For these incudirg regions of tropical Africa, reasons regions which use these low as a reserve or "famine food." How­ protein staples are very likely to show ever, because of the high yield and protein-Calorie malnutrition of early ease of cultivation, its use has spread. childhood. This is a matter of considerable con­ These foods are particularlydillicult cern, because cassava is essentially for children to eat in nutritionallyade. only a stomach-filling source of carbo­ quate quantities, because they are both hydrate Calories, with a protein con­ low in protein andalso extremely bulky. tent of less than 1 percent. It is often difficult for a young child As mentioned earlier, hydrocyanic even to be able to satisfy his Calorie acid is present beneath the outer coats requirements, of the roots and is removed by different Yams. These tubers are used in many traditional methods in various parts of parts of the world, especially in the rel- the world. Cassava can be boiled as a atively rainy tropical areas, such as vegetable but is often made into a parts of Africa and the New Guinea flour, which can be used to produce coast. The protein content of yams is forms of porridge, unleavened bread, about 2 percent. They are not easy or various fernented preparations. to cultivate and need careful attention. Often neglected is the fact that cas­ For storage, they need specially pre- sava leaves, especially the young ones, pared "pits" or dry, ventilated yam can be eaten and are an extremely val­ houses. uable foodstuff, which, if taken together Sweet Potato. This root crop has a with the cassava root, help to improve protein content of between 1-2 per- the plant's nutritional value. cent. Yellow varieties have a relatively "Vegetable Fruits." In some parts of high level of the provitamin A, caro- the world, notably in areas of East tene, but the white varieties are used Africa, the plantain, a term often ap­ more commonly in tropical regions. plied to varieties of the banana family Cultivation requires some degree of that are cooked when green and unripe, continuous attention. is the staple food. Again, this is ex­ Taro (Cocoyans). In parts of Poly- tremely low in protein (1 percent). nesia, some areas in Africa and parts Many different varieties exist. The of the Caribbean, taro forms the staple plantain can be cooked by boiling, food of the community. In Hawaii, a steaming, roasting, or using a flour slightly fermented paste is the ancient prepared from dried fruits. staple (poi), which is still popular. Another "vegetable fruit" is the Cassava (Manioc). Cassava, is easy breadfruit, which is a secondary staple to grow, requires little attention and is in Polynesia and in certain islands in able to withstand climatic adversity. It the West Indies. It is usually roasted or has a high yield (7 to 10 tons per acre) boiled. and a high Calorie yield per man-hour Miscellaneous. Various other foods of work. It can remain "stored" for are included here not because they are some years in the ground before har- botanically similar, but because they, vesting. It has, therefore, been intro- too, have a very low protein content and

26 are made up almost entirely of carbo- bread, or fermented to produce var­ hydrate Calories. These include arrow- ious products, including gruel beers or, root, which is a flour made from the if subsequently distilled, alcoholic starch obtained from the roots of a liquor. West Indian tuber and sago which is Tho preparation of cereals for use by prepared from the p1 th of a variety of young children is comparatively simple. palm tree. Tile)' are both almost devoid Boiling with water, especially if the of protein, are almost entirely starch flour is employed, will give a smooth, and are disastrous if used for infants easily digestible paste. without other items of food. Rice. Rice is the staple food for two, thirds of the world's population, in­ Cereals. The group of foodstuffs cluding most of Asia. It is becoming known as cereal grains are not only more popular. especially for celebra­ excellent sources of carbohydrate Cal- tions. in man) different areas of the ories, but also contain significant quan- world including parts of Latin Amer­ tities of protein (about 10 percent), ica, Africa, and the West Indies. especially as they are consumed in large Many varieties are grown in differ. quantities. They are also good sources ent parts of the world, including the of iron and the vitamin 13 complex. glutinous rice of northern Thailand, Their protein has a low content of the Malaysia, and Viet Nain which, as tihe essential amino acid, lysine. ,,ame suggests. does not boil to form Cereals are lrepared by de-husking individual grains but rather forms an and sometimes thereafter by milling. adherent, glutinous mass. The degree of de-husking and milling is Thiamine is contained in some related to the desired characteristics of quantities in rice germ. However, it the end product. The more severe the can be very largely remol,'ed by over. process of milling the whiter the end milling, ,or by over.soaking or by cook­ product and the greater thme loss of ing in too large a volume of water, nutrients which go with the germ, in- since thiamine is water soluble. In cluding especially thiamine. Overmilled some communities in India, the rice white rice, with its low content of paddy is soaked and briefly boiled be­ thiamine, is sought after in parts of fore drying alndi storing. This process, Asia with unfortunate consequences as larboiling, is nutritionally valuable as it tends to lead to the development of it causes thiamine to diffuse into the thiamine deficienlcy, beriberi. Similarly, substance of the grain. so-called high extraction wheat flour Rice is most usually cooked by boil­ used in the U.S.A. and Western Europe ing, so as to leave imdividual grains. is also depleted of its protein and vita- It is important not to use more water mins by this process. In both Japan than is necessary. Rice is easily digesti­ and the U.S.A., the thiamine removed ble by young children, and especially from rice and wheat by excessive mill- soft and suitable preparations can be ing to produce a white end product is prepared in the form of pastes or gruels later replaced by synthetic thiamine, from soft boiled rice or from rice flour. After de-husking, cereals may be Corn (Maize). This crop, which cooked as such or made into flour and came originally from South America then prepared as pastes, gruels, or has been taken by man to many parts

806-112 o-68--3 27 of the world. It has a high yield per sistant to drought and can be stored acre, but nutritionally corn has the dis- for years after harvesting. However, advantage of being not only low in the they require considerable care in culti­ amino acid, lysine, as are all other cer- vation, especially with regard to scar­ eal grains, but also being deficient in ing off animals and birds when the the B vitamin, niacin, and another grain is ripening. In addition, the amino acid, tryptophan, from which small, rather tough grains of these the body is capable of synthesizing ni- crops require much time-consuming acin. It is for this reason that niacin pounding or milling in their prepara. deficiency, pellagra, occurs almost ex- tion. This is often carried out in the clusively in areas of the world where village and is a considerable burden corn is the major food. for the housewife; .)ccasionally, millet Corn may be eaten on the cob after flour is avaliable commercially. Be­ boiling or barbecuing. It may be milled cause of difficulties in cultivation and at home or commercially to varying de- preparation, the millets are tending to grees of extraction, producing corn be grown less, and to be replaced by flour, the staple food of many African nutritionally inferior crops, such as communitias. Unfortunately, the prepa- cassava and maize. ration of preferred white flour includes The grain itself is usually too indi­ overmilling and often repeated washing gestible to be eaten boiled. Dishes are with water which remnoves protein. commonly prepared from the flour, in In the Mayan cultures of Central the form of gruels or so-called "bread," America, a particuiarly valuable meth- looking like thick mashed potatoes. In od of preparing corn has been em- Africa various fermented millet prod­ ployed for centuries. In this method, ucts are eaten or drunk in the form of corn is initially treated for some time alcoholic gruel-beer. with lime before being cooked as tor- Wheat. Wheat is a major staple in t/Uas. This has the advantage of parts of the Eastern Mediterranean, in enriching the grain with calcium and West Pakistan and Northern India, improving the amino acid value and and in regions of China. It is usually available niacin, used as a flour, as in the preparation All over the world attempts to pro- of unleavened bread pancakes (chapa. duce higher yielding and better quality tis)or Chinese noodles. In Lebanon an foods are under way and it may be interesting wheat preparation of great mentioned that outstanding success ap- nutritional value is prepared in the pears to have been achieved with form of burghul. In this nroduct, the corn-the so-called "opaque 2" vari- wheat is parboiled so that tae thiamine ety-which has been shown to have 150 is diffused throughout the grain, the percent more lysine, the limiting amino same as with parboiled rice. acid, than the usual varieties. The flour prepared after milling is Millets. Numerous species and vari- often mixed with locally produced eties, particularly finger millet, bulrush dried sour milk. The resulting wheat­ millet, and sorghum, can be included sour milk powder is known as kishkeh, under this general heading. All have and is a valuable food for young the advantage of being relatively re- children.

28 Wheat bread is spreading as a pres. otherwise a high percentage of tile tigc, convenience food in tropical urban yield can he Iost as a result "f iests areas. It is often superior to tile local including rodents and insects, particu. staple, as in parts of West Africa %here larly weevils. cassav'a is the Inaill local food. In some Witi protein shortage a major diflil. parlts of the world, protein vnrichment cilty' and with protein-Calorie inalnu­ of bread has beca rteimpted with soy trition of early clildhood PCM ) (p. flour. )east, lysine o1 fish flour. 751 thv principal public health problem it, w,rldwide nutrition, leIgumes can be Legumes, Nuis. awal Oilseeds. In ~l',tid to play an increasing alt il gener-iI this groump i.. lnt only a good the, dietary iprevelitiol. al even the source of Calories, but is also the 1,i1- tre-vatment of PCM. cipal plant surce of protein. I'lie use. of gtillnes for iil'antl feed­ Le2gunes. legumes a a lol -ilig1rouu is limited by their relative indigest. tain ablout 20t penr'et protein. excvpI ibility. Only small quantities should for the particularly proteili-riel so- e i. en initallv. altnlonh the amount lean whi;AuI contains ill) lo 0 Iercent. Howev'cr. the protein in lehgilles is ,al be gradually increased. It is im1­ SiiOrlant to ensure that legumnes are S0 ne IIat defIcli ienit ill Ile f.$5 lt ial IC inid as llethiolille. %lich is the lilitincg amino thio ,igily ci ,k d as ;iossille. ilv ski'll acid. Legulites are also sources of the Iians as i'.',nigrinih,the skils 1 comliex alI il. Their \itarlill through soaking prior to boiling or by content, including vitamin C can lie Valiafter cooking. Often it i use­ sulstantialh) in reased by fuilpatsolsaoe(treeaiyngera to start with a basic mixture of four them to geriniiate and sprout before Parts of stapl" (ircferalily Ceitlkillg, glainl to ,,iC hart of legulie allia cerealtheti Legumes are of especial importance to gradually ilncrea-e tle pioportion of when eaten ht.Lliher with tile staple tlie latter. food. This was also the case in ,nedi- Possiblv because of tile knlomi as­ eval Europe wheni pea tlour was used s,,eation of large quantities of ill­ with wheat in tile preparation of bread c Ikeihegunes with lack of digesti­ for the poor. lility and loose stools, there are many There are at least 70 varieties of ta!',Os and restrictions ill different legumes. The )roblem of their identi- parts of the world onl their use for you, g fication is often difficult, since many ,'hildren. sub-varieties often look different. Also. Most legunes are usually boiled common names i,, diffierent languagcs, whole. althrugh varionsyie flours may including English. often fu rtlier con. prepared from them which lla le fuse the issue. cooked with water to prodnce a soup Legume crops are extremely impor- or gruel or made into a varit.ty of thin tant not only nutritionally but also agri- dry pancakes. fi India. the terni dhal culturally since tlley have the property is applied to a variet% of diffe-rent I­ of taking nitrogen from the atlosphere gunies which are dried, passed tlriugl and fixing it in the soil. a wiide sieve, and then given several Legumes are compact and take up treatments with a stone grinding ap. little space but require careful storing, paratus which removes the skin and

29 splits the legume in two. The dried, has the advantage of not only posses. split end product is ultimately boiled sing a high protein content but also, to form a thin paste. because of its 40 percent fat, being rich It is not possible to consider all in Calories. The groundnut is also a varities of legumes here. Wherever good source of the vitamin B complex. work is being carriedout, it is neces. In villages, the groundnut may be sary to discover the most easily avail- eaten raw or after roasting. For culi­ able and economical varieties of nary purposes, it is often pounded into legume to buy, their protein composi- a powder and then used in pastes, tion, their alleged digestibility, their sauces, stews, soups, or milky drinks. cultivation characteristics as regards If roasted and passed through a mincer, yield and resistance to disease and cli- a thick peanut butter.like preparation mate, and local attitudes toward their will be produced, which is often rel­ use for leeding young children. ished by infants. Brief notes follow on certain legunies Groundnuts are grown commercially because of their particular significance: mainly for Iheir oil. After this has been 1. Kidney bean (French bean, Hari- extracted, the groundnut presseake is cot bean, Navy bean), (Phaseolus usually sold for animal feeding, hut it vulgaris). This is one of the most wide. represents a largely untapped potential spread of all legumes, although its phy'- source of groundnut flour which, after sical appearance varies from one vari- furlher refininrg. may then he used for ety to another. It has a high protein child feeding either by itself or incor­ content and, because it is frequently porated into a variety of commnercially easily aailable, it deserves to be in- prepared high-protein infant foods eluded more than it is at present in (p. 140). viilage-level infant food recipes. h is Unfort.nmatelv. the situation has becn usually prepared by boiling and ex. complicated h the discovery that pericce has shown that it is inipor. groundnuts harvested in hot, moist cli­ tant that the skin be removed before mates grow a fungus (Aspergillus giving the bean it) the child to cat. This flarus) which produces a highly toxic, can be carried out before boiling (when water-soluble substance, aflatoxin. This it can ie accomplished by soaking material is poisonous to various animal overnight or scalding), or after cook- species, especially their young. When, ing has been completed, for example, contaminated groundnuts 2. Chick.pea (Cicer arietinum). were used as the main source of the This legume deserves special mention diet of young turkey chicks, there was because after cooking it can be mashed an appreciable mortality from liver easily to produce a very smooth and damage. digestible paste. Wherever it is avail- Although no clear case of aflatoxin able, it should be seriously considered poisoning has ever been described in as a possible high.protein vegetable human beings, it is necessary to exer­ food for incorporation into infant mix. cise more caution before urging the tures, both in the village kitchen and increased use of groundnut flour in the when prepared comnmercially, preparation of infant foods. Current 3. Groundnuts (Peanuts). This crop information shows that if groundnuts

30 are dried to a low moisture content The soybean may also be eaten in after harvesting, aflatoxin is not many other ways. A defatted flour can formed. Many countries are consider- be added to cassava meal or wheat ing legislation to ensure that ground- bread as a protein reinforcement. A nuts must be free from aflatoxin. soybean milk was used in ancient China 4. Soybean. This legume is particu- and has now been prepared commer­ larly high in protein (up to 40 percent), cially in some parts of the world, al­ and has a better amino acid conmposi- though its value is limited by the fact tion than other legumes. It also has a that it usually costs as much as animal high fat content (up to 20 percent). milk. Also, soybean sauce is a familiar It grows widely in different parts item in Chinese cooking, where of the world and is cultivated on a large sprouted soybeans are also used. scale commercially for its oil. Current- Nuts. Although not widespread, and ly, the presscake is used variously for not likely to figure to any great extent animal foodstuff, although its potential in methods of improving time diet of for infant feeding afte suitable prepa- young children, nuts are important ration is considerable, sources of protein and are also high in The importance of the soybean in Calories because of their fat content. the diets of some communities is so Thus, in parts of tropical South Amer­ considerable that it has been termed ica the Brazil nut is used. the "Chinese cow." The soybean has Also, in various coastal parts of the the disadvantage of being diffi -ilt to tropics the coconut is extremely valu­ introduce to a community not expe- able, not only for the copra (dried rienced in its preparation and value, flesh), which is sold commercially for This is because it ias a characteristic its oil content but also because the and to some persons an unpleasant fla- fresh coconut flesh can be used for in­ vor and smell as well as a protein-digest- fant feeding. In its immature, soft, gel­ ing enzyme inhibitor which interferes atinous form, this can be eaten as such with digestion. Soaking for 24. hours or mixed into porridges. The use of helps to remove the taste, coconut presscake after the oil has been In communities where the soybean extracted is receiving attention as a po­ has been employed traditionally for tential source of high-protein infant hundreds or thousands of years, special food, although it has the disadvantage technics have been developed to de- of a high fiber content. stroy this enzyme inhibitor and make In some tropical regions, the cashew the bean fully digestible. Thus, in In- nut is commonly grown. This may be donesia taiu (a soft, white cottage used as a high-protein, high-fat addition cheese-like soybean curd) and tenipeh to children's diets. This nut is unique in (thin slices of fungus-digested soybean) that it grows attached to an apple-like are widely used and are easily digesti- fruit, which not only is edible when ble, even by young children. Similarly, cooked, but also is a good source of in Japan miso (a fermented rice and vitamin C. soybean preparation) and ketiap (a Oilseeds. In addition to the ground­ fermented preparation of rice and nut, the soybean, and the coconut, a wheat) are important items of food. variety of seeds of different plants are

31 cultivated largely, if not exclusively, for Some vegetables are used fresh, al­ the oil which may be extracted from though some can be stored or even them, either in the village or commer- dried. Some are eaten raw, although cially on a large scale. These include more often they are cooked, frequently the seeds of sesame, sunflower, cotton, bv boiling or steaming. and mustard. It is convenient to consider vegeta­ Some of these seeds are already used bles not with botanical precision, but in some localities as traditional foods, in approximate relation to the parts as with tie whole sesame seed in the of the plant eaten, that is, roots, stalks, eastern, Mediterranein. Also, the seeds fruits, flowers, and leaves. of the melon and the sunflower are eaten 1. Roots. These comprise certain in some parts of the world as a snack, root crops which cannot be considered much as peanuts are used in the U.S.A. as staples. They usually contain loss Both of the seeds are high in protein, than 10 percent carbohydrate and in­ Cotton is principally grown for its elude carrots and turnips. fiber. After tile removal of the fiber, the 2. Stalks. In tropical regions, these oil is extracted from the seeds, leaving will include such items as bamboo cottonseed prcsscake, which at present shoots, young ferns, and the pahn cab. is largely used for animai feed or fer- bage (the heart or growing center of tilizer. Much work is going on all the palm tree). around the world in attempts to devise 3. Fruits. A wide variety of different economical methods of processing high- items may be classified as "vegetable protein cottonseed flour for human feed- fruits." Two of these, namely the plan­ ing from the presseake. A major prob. fain and the breadfruit, can better be lem is that most varieties of cottonseed regarded as staple foods. Other vege­ contain a poisonous substance (gos- table fruits include the large family of sypol), which has to be removed before pumpkins and gourds, tile tomato and the flour becomes safe to eat. allied species, and tile avocado pear. The gouyd family is important as a Vegetables. It is difficult to define source of carotene. The avocado pear, exactly what is meant by the word which grows widely in many tropical "vegetable," as this useful expression countries, possesses a soft, easily is employed by different people to coy- mashed, digestible, and high-oil flesh er a variety of foodstuffs. As a whole, which can be incorporated very easily however, vegetablez are usually eaten into the food of young children without to give flavor, variety, and sometimes cooking. necessary roughage to a diet. Nutrition- 4. Flowers. While it is not custom­ ally, they are usually rather high in ary to think in terms of consuming water and. conversely, low in both pro- flowers, the cauliflower is eaten in the tein and carbohydrate Calories. How- temperate zone, and in the tropics, ever they often contain substantial various flowers, including those of the amounts of carotene, vitamin C, and banana, may form a minor part of the minerals; while their limited proteins diet. may supplement those of the staple 5. Leaves. Green leafy vegetables are foods. eaten, both raw and cooked, in very

32 many parts of the world. Thus, in the plucked, although old leaves can be Western world lettuce, cress, cabbage, used if they are cooked rather longer. and mustard and turnip greens are If need be, they can be dried, pow­ widely consumed. In the ecent past, dered, and stored for subsequent a wide variety of "wayside herbs" were use. eaten, especially by the less well-to-do. Increased attention has recently been In tropical regions, it is the dark given to the possible use of cassava green leafy vegetables that are particu- leaves, as the -altivation of this nutri­ larly valuable and, at the same time, tionally poor staple is spreading. The very often much underused, partly be- nutritional value of the plant may be cause they may be regarded as low considerably increased if the leaves are prestige food of the poor. Many of these also eaten, either by the occasional dark green leafy vegetables are to be plucking of some of the newer ones or found in a semiwild state and grow by using all the leaves when the root very easily with minimum attention in is finally dug out for c':nisumption. household or school vegetable gardens, Dark green leafy vegetables may be or in the compound. shredded, chopped, or pounded in a Dark green leafy vegetables, espe- mortar and subsequently mixed with cially young leaves, are valuable nutri- other foods intended for young chil­ tionally. They not only contain impor. dren. Alternatively, preserved pow­ tant quantities of carotene (provitamin dered leaves may be used. A), vitamin C and the B complex, cal­ cium and iron, but also have a signifi- Fruits. Once again this is a general cant protein content, the composition word that is very difficult to define with of which complements that of cereal precision. Possibly the best definition grains and tubers. Thus, young cas- is "a cultivated or wild product with a pleasantly edible when sava leaves contain 7 percent pro- sweet soft flesh, the raw state." tein and so-called tropical spinach ripe in are important (species of amaranthus) contains 4 Nutritionally, fruits of vitamin C and, percent. In addition, green bean pods, principally as sources iii some cases, of the orangc-pigmented which may be eaten as vegetables, con- C carotene. Other­ tain 2 percent protein, vitamin A precursor, are composed principally of There is a wide variety of these edi- wise they and some fruit sugars. ble dark green leafy vegetables available water, cellulose, the advantage of not re­ in most tropical countries, including They have cooking, if eaten ripe. the leaves of the sweelpotato, various quiring beans, and peas, okra, cocoyams, thereIt isare important many tropicalto appreciatefruits whichthat baobab. It is hibiscus, pumpkins, and are extremely good moresources easily of accessi-vitamin important that these should be used, C and often much Ce locally and more conomiical than especially as there are in some parts of the world indications that they may be the citrus fruits which are usually superseded by vegetables such as the thought of in the Western worl. Thus, cabbage, which has nore status but is in various tropical regions of the world, nutritionally inferior, the following may be considered­ If possible, young leaves should be guava, Indian gooseberry, fruit of the 33 baobab tree, fruit of the cashew nut, particular region, both cultivated and and, as a very rich source, the Barbados collected wild. These may include pine. cherry (acerola). apple, Cape gooseberry, cactus fruits, The following fruits may be men- a variety of citrus fruits, various types tioned particularly: of soursops, and so forth. Local sources Papaya (Pawpaw). This fruit is very should be sought f'or in any region. widely distributed in tie tropics and frequently is not used nearly enough Animal Protein. Animal protein aspecially for young children. Various foods are everywhere the most expen. food attitudes and taboos may be partly sive and difficult to obtain, and they responsible. The dark yellow, orange, are often used only for celebrations or red sweet edible pulp of the fruit and as prestige items. All over the world is rich in vitamin C and carotene. It large numbers of food attitudes, ta­ is soft, pleasant flavored, easily mashed, boos, and prejudices, often of a re­ and can be fed to young children with- stricted nature, are associated with the out cooking. use of animal protein foods. These often Mangoes. The dark yellow or orange are directed at women and young chil­ flesh of the mango is particularly rich dren and tend to limit their intake of in carotene and vitamin C. Also, espe- animal protein. cially in the larger varieties, it can be Animal proteins contain all of the a source of CaL.'. s for school children, eight essential amino acids in abund­ Bananas. Although mainly of value ance. If available, even in small quan­ for its Calories, the sweet banana also tities, they are best used together with contains small quantities of carotene vegetable foods, preferably with a com­ and vitamin C. The advantage of the bination of a legume and a cereal staple. sweet banana is that when fully ripe, as In this way, the nutritional value of judged by the appearance of brown the plant protein foods can be enriched spots on the skin, the fruit pulp will as the amino acids in which they are have become soft, easily mashed, di. deficient can be made good from the gestible and sweet, as the starch gran- rich surplus iii the animal protein. ules will have been converted into The question of the absolute need sugar. It can, therefore, be used imme. for animal protein in the human diet, diately for young infants without cook. especially for young children, has not ing and can be mashed and mixed with yet been conclusively determined. Most other foods with a higher protein so-called vegetarians usually take some content, form of animal protein food, particu­ Dates. The fruits of the date palm larly milk or its products. It has been are moie often used when dried and, shown, however, that young children as in the desert regions of North Africa, grow adequately on vegetable protein may be an important, easily transport- mixtures and that even severe types of able, and a preserved source not only protein-Calorie malutrition, maras­ of Calories but also, to some extent, of mus and kwashiorkor, can be cured protein (2-4 percent). by vegetable protein mixtures alone, A wide variety of other familiar and although recovery is slower than when more exotic fruits may be used in a animal proteins are given.

34 The present view is that vegetable in Africa, blood is used and is obtained protein mixtures will form the main- from cattle by puncturing a vein in the stay of infant feeding in most develop, neck and "bleeding" off a quantity, ing tropical countries, but that the which can then be drunk as such, or addition of at least small quantities of allowed to clot and mixed with other animal protein to these diets should be foods, or which can be dried to form a the aim, wherever possible. powder. Meat. With the exception of certain Milk. Man being a mammal, he rears hunter and pastoralist groups, animal his offspring with milk. Howeve- , man meat plays an extremely limited part in alone among other mammals, has in­ the diet of tropical peoples. It is usually troduced the milk of other animals in reserved for celebrations or special the diet of his young. The composition occasions, when most of it will go to of the milk of different mammals varies adults, especially to male elders. Young considerably. Some, like the seal's, the children will rarely receive meat and camel's and the rein leer's are rich in even when it is available it is usually fat; others contain raore protein than tough and often ill-cooked, so that its some. However, ll contain protein, preparation for infants poses problems. milk sugar, fat, caicium, and vitamins, Simple, locally appropriate methods of both of the fat- and water-soluble kinds. chopping, shredding, or grating meat, All milks are poor in iron. The concen­ either before or preferably after cook- tration of these major ingredients also ing, have to be devised to make meat varies considerab!y from one species to palatable for infants, another. As a result of the selective Meat is a source not only of protein processes of evolution, each species pro­ but also of the Bvitamins and of iron. A duces the milk whose composition is variety of different meats may be eaten optimal for its young. In other words, by, or prohibited to, different communi- cow's milk is the specific food for grow­ ties in the world (p. 62). These include ing calves and human milk is the best such items unfamiliar to the Westerner food for human infants. Cow's milk can as dog, newborn rat, kangaroo, monkey, only be regarded as second best and snake, and hyena. Although unfamiliar artificial in the nutrition of human and culturally difficult to appreciate, the infants. meat of these creatures is not much 1. Human BreastMilk. This valuable different nutritionally from that of do- and traditional source of clean, digesti­ mesticated animals. In addition, in ble, specially adapted, high quality pro. many communities insects form a part tein baby food is very frequently over­ of the local dietary, often seasonally. In looked, possibly because it is not com­ various parts of the world these include monly sold on the market! Its amino snails, locusts, grasshoppers, lake flies, acid composition is such that it has various caterpillars, and flying ants. been used as a reference standard of While insect eating is strange to the protein excellence. However, like all Westerner, it must be remembered that other milks, it is low in iron. While its the secretion of one insect, the bee is protein content is relatively unaffected widely relished as honey. by inadequate maternal nutrition, its Blood. In a few communities, notably content of water soluble vitamins (thi­

35 amine and vitamin C) can become de- lation to the prevention of protein- ficient if the lactating mother's diet is Calorie malnutrition, cow's milk, in low in these nutrients. Also, if the whatever form, should not be regarded mother's diet is deficient, the output of as a competitor with breast milk in the breast milk may be diminished, espe- early months of life but as an im­ cially in late lactation. Eventually the portant, although not irreplaceable, nutritional drain will be felt by the protein-weaning food. mother herself in the form of maternal In the foreseeable future, adequate depletion. sources of animal milk cannot conceiv­ While breast feeding is desirable in ably be available for the majority of any part of the world, it is of particular young children living in tropical devel. importance in developing tropical re- oping regions; therefore, alternative gions in terms of nutrition, economy, protein-rich foods of animal and vege­ and sanitation. table origin will have to be employed, 2. Animal Milks. Animal milks used especially legumes. These should be in various parts of the world, both in chosen in conformity with local re­ the general diet and as foods for young sources and the local cultural pattern. children, include the milk of the bu- 3. Commercial Milk Products. Very falo, ass, sheep, goat, llama, reindeer, large numbers of different brands of and yak, but cow's milk is by far the processed milk are prepared by com­ most commonly employed. Its composi- mercial companies, although only four tion is different from human milk: it types are commonly available: full contains two to three times as much pro- cream and skimmed, dried powdered tein, the same quantity of fat, and half milks, evaporated milk, and condensed as much milk sugar. The protein of milk. Their use in infant feeding is cow's milk is relatively indigestible; discussed later (p. 133-134). however, it can be modified to suit the 4. Village Milk Products. Various needs of human babies in the first three peoples in different parts of the world months of life by diluting it with water have developed techniques for preserv­ to decrease its relative protein content, ing milk, especially in times of rela­ by boiling it to make the protein more tive surpluses. Most of these processes digestible, and by adding sugar to it to are based on planned microbial souring increase the caloric content, of milk. Various preparations may be Two points concerning cow's milk used, including acid milk, yogurt-like require special emphasis, as they are products, and cheeses. In Lebanon, for often not adequately understood by instance, there is a flour which is com­ Westerners. First, cow's milk is ex- posed of a mixture of milled, parboiled pensive when bought on the market in wheat, and dried sour milk (kishkeh). developing countries. Because of its In many areas of the eastern Mediter­ price, it will be given in highly diluted ranean and elsewhere, various forms form. Second, because of environ- of cottage cheese are available and mental conditions described in Chap- can be incorporated in infant food ter 1, and because of the addition of mixtures. unclean water, it is most likely to lead There is evidence that some of these to infective diarrheas. In brief, in re- Preparations are not only valuable be­

36 cause of their keeping qualities but also Eggs may be cooked in a variety of because they are more digestible and ways, some of which, including boiling perhaps less susceptible to infection and scrambling, are especially suitable with harmful baceria. Thus, amasi, the for young children. Alternatively, if sour milk of South Africa, has been culturally acceptable, raw chicken's shown to be somewhat resistant to the egg may be beaten into tileinfant's growth of tuberculosis bacilli. Wher- food. ever these preparations exist, their use Fish. Fish and other sea products in infant feeding should be considered. remain a major unexploited natural re. Eggs. Although these are widely dis- servoir of animal proteini food in the tributed throughout the world, they world. They are valuable nutritionally, are not generally used for young chil- not only for their high protein con­ dren. Often they may be considered tent, but also because they contain rather as a form of "cash crop"; while vitamin 3 complex, vitamins A and D, in many cultures strong food preju- calcium, and iodine. Fish also have the dices concerning the use of eggs for advantage of being sniall compared, for infants are to be found. In parts of In- example, with the large carcasses (if dia they are considered to be too "hot," animals. such as cattle or swine. and in parts of eastern Nigeria, they In addition to fish as such, a wide are believed to cause baldness in in- variety of other sea products, such as fants. This is a pity, because not only shellfish, crustaceans, and seaweeds, are eggs a rich source of protein with are eaten in some parts of the world such a full and well-balanced range of and could be consumed more widely. essential amino acids that they are used The principal problems limiting the as a protein reference standard, but wider use of fish include difficulties of also the yolk contains iron, vitamins preservation and transportation, cost in A and D, the B complex, and fat. They relation to local purchasing power and, are also easily digestible and can be in some parts of the world, cultural mixed with other foods in many ways. food prejudices. Eggs are also compact units which Canning and refrigeration of fish can be easily used in infant feeding. In usually put the price well beyond the addition, like milk, they provide ani- reach of the average family in tropical mal protein without the necessity of regions. However, traditional methods slaughter thus avoiding the economic of drying, salting, or smoking may loss involved in killing an animal or exist and deserve further investigation the religious taboo against killing liv- to see how their effectiveness and the ing creatures which obtains in some quality of the end product can be im­ parts of the world. proved. Commercially, the possible use Chicken's eggs are most commonly of fish to produce fish flour which used and those of free ranging tropical -could be used, either alone or as a com­ village birds may be half the size of ponent of a manufactured infant food, those from well-fed fowls. In addition, is receiving much attention. the eggs of other birds may be widely The increased production of fish at eaten in some communitids, especially the village level is of great practical duck's eggs in some parts of Asia. importance. Better use should be made

37 of nylon nets and motorized canoes, ter), lard, and some forms of marga. and encouragement should be given to rine. Fats derived from milk are sources the development of fish ponds or fish of vitamins A and D. culture in wet rice fields. By contrast, vegetable fats contain Fish ponds have been in traditional no vitamin A or D. These include oils tse for many hundreds of years in vari- obtained from the groundnut, sesame, ous parts of the world, including China mustard seed, and cottonseed, coconut, and medieval Europe. Recent emphasis and oil palm fruit. The last is of par­ has been given to the development of ticular interest because of its extremely fish ponds by governments and the high content of carotene, the precursor Food and Agriculture Organization of of vitainin A. Other fats derived from the United Nations (FAO). Their use plants, include vegetable ghee and is by no mineans withou; problems. Sev- vegetable margarine. cral species of fish need to be intro­ (uced at one time, as otherwise very Miscellaneoius. Many foods are large numnber, of small fish of one eaten in various parts of the world species may result. The pond has to be which do not easily fall into the cate. cared for and organic vegetable mate- gorics already out]ined. rial, such as cut grass, has to be added Sugar. Most conmmunities cat sugar at appropriate intervals. The risk of in some forni or another, whether as breeding malarial mosquitoes and the naturally occurring honey or sugar. spread of hilharzia has to be borne in taut, or as prepared in the village as mind. Ncvrthcle s, %sithdue care fish pigger'y, tr as commercial crystalline ponds ,can represent a valuable con- cane sugar. Sugar, especially in its re­ tribution to village protein resources, fined form, represents only naked Calo. espe ciallv since they uring fish near to ries since it contains no other nutrients. rural homes. In sonic communities In industrialized countries, the sugar these ponds can also be used for rear- intake is undoubtedly too high and, in ing ducks and growing various water part, is responsible for the high inci­ vegetables. dence of dental caries and obesity. The same trend is also beginning to occur Oils and Fats. Many animal and vege. in some developing countries. table food,; contain fat or oil. In addi- in sonie communities, diluted sugar. tion, various so-called "naked fats" water is given alone for prolonged may be taken in the dietary as oils. reritds to sick infants, with resulting Fats are relatively expensive every- miaraslfus. where but owing to their high caloric Alcoholic Drinks. Most, but by no value they represent "compact Calo, means all, communities prepare their ries" which may be important for chil- own alcoholic drinks. In some places, drem whose diet otherwise consists of these are prepartd from fermented bulk% carbohN drate foods of 1,,% calorie grains, and take the form of thick al­ densit,. coholic gruel-like lreparations. In parts Aninal fat is piesent in. meat, egg of Africa, these are still widely drunk yolk, milk and its products, and the anti apart from a source of Calories, flesh oj certain fish. Extracted aninal also contain vitamin C and vitamins fots include butter ghee (clarified but. of the B complex. 38 Similarly, alcoholic drinks may be consumed. They are especially impor­ prepared by the fermentation of milk, tant for their iodine content. or honey, or the sap of various palm Likewise, a wide range of different trees (palm toddy), including the types of fungi are eaten in various parts coconut, date, andi palmira. of the world. Although not making a In addition, many groups of people major contribution to an), dietary, it prepare high-alcohol liquors by distil- may be noted that fungi contain a small lation. These include rice wine, quantity of protein and of the vitamin waragi in East Africa and white rum B complex. in the West Indies. Nutritionally, these products, in common with similar ir- TROPICAL DIETS ported alcoholic spirits, are sources of energy alone (7 Calories per gram). Although many different dietary pat. As anywhere in the world, the nutritional consequence of alcohol,main as world,ters a etincertain diferangeneral similaritypart oth can nutitinalconequnceof lcoolas be found in many regions, especially far as young children are concerned, bfond in many eion e cl is social in that if the parents spend among the less well-to-do. excessively on alcohol, then the chil- For economic, geographic, dren are likely to be neglected and in- tral reasons, diets tend to he basedor cul­ on suient eliely m be letd adpu- a limited number of foodstuffs, cooked sufficient money may be left to pur- in what to the outsider is a monoto. chase adequate food. - nously limited range of different dishes. Cafleine Drinks. Beverages contain- The main bulk of the diet will be com­ ing the mild cerebral stimulant caffeine, posed of one or more carbohydrate are used in many parts of the world, poe ofnermrecbhyat inclusdin anteacoffee, thandorad staples which will including, tea, coffee, and ratM, with sm',ller quantitiesbe eaten, of mixtures very often of Nutritionally, these may be of little wih sm allerqunities omtueso - various vegetables, relishes, or sauces. consequence but supply needed variety Nutritionally, the diet of many peoples in taste and refreshment. However, in in developing tropical countries is some parts there is a tendency for a much bound up with the major staple high percentage of limited budgets to which is the main source not only of be sent on tea or coffee or for mothers Calories, but also of protein and other to try to feed their young children on nutrients. This dominance is often em­ tea with little or no milk with disastrous phaized hy the use of the same word and ith e us of the sae results as the child is thus starved the staple likely to developlikey nmrasnius.t deelopinaasnus.in and the for vernacular"food" in general.both for Agriculturally and economically, the Not infrequently, only a limited edible local production of these caffeine crops is range of the potentially extremely important since in many re- foodstuffs will, in fact, be eaten. In par­ gions they may be a significant na- ticular, there is often underuse of vari­ tional and family source of cash in- ous sexniwild dark green leafy vege­ come. tables and certain fruits, such as the Seaweeds and Fungi. In some na- pawpaw and various berries. tions with a marine coastline, notably Because they are based on one or Japan, seaweeds of various sorts are more staples, tropical diets tend not only

39 to be principally composed of carbohy- It is useful to obtain approximate drate Calories, but also to be relatively qualitative information concerning bulky. feeding practices in the earl), years of life. This can be carried out by means VALUE OF DIETS of a questionnaire, particularly related to the preparation, or otheiwise, of spe. Methods of Assessment. There are cial protein-rich di,.hes for young chil­ various rmiethods of trying to assess the iren. Local houschl utensils of known value of humlan diets. In more sophisti- ;izt cal ieused il tie questionnaire cated lilrate communities. question. when mothers are interviewed, in order naires may ieissuzed to householders. to assess appiroxinmate quantities. In developing countries, however, ifde- For young childr'n, the question­ fol­ tailed accurate information is required, nairt should cverin partiular te it is usually necessary to carry out lowing aspects related to tle usual lim­ dietary surv'cys by means of home visits, iting factor. pirItein intake: during whiil the an ioint of food used I.Brea.st./,('ding: still carried on or ind cooked for Illfamily can he re- not; colnlllete or pallial, i.e., night corded. Prolllenms with this method are onIy; illi nerlim is. bIth at tie social level-in 2. Carboh)dratt food.,: types e.g., gaining aeceptalilitl and in knowing part of adult fhoo ds, or specially lre. whfther the diet rn the days chosen lorld giiels or pastes) ; quantities adequately irctilsc the nlornial range tiiies If f d taken lI lh, fanmilv--.and at 3. P'roteinlodls---aimalmilk: tylpe the tec'hnic'al levl in estimatimig the re.g.,fresh or boiled liquid 110111 nutricnt loss o'curriig dluring prepara- goat.gaw. and so foilrh, sour milk tilln aIIl cooking. initaking inlto account llrluI'ti tinned lIw(lrcd, coIl­ foods eatl'i olllt(If the hollse,. and ill dtnsl'd. or eaIlmaell-i; quantities (daily allbowiig fl seasonal variation in the M! miitllhly) : 'o.-1;iulillr. approxi­ foIod pallerli. mate tinilng anl11vIliniw. dilutlili. and l)ietary al--essmlent is tiarticularl lii.iIinllreliclilts ic.-., sluiar) ii feeds; dflvult with yotIng cliildren. This n.thold If fecill (e., hottle, cup, and shoull he a jI(riiod jf itgradlial transi- llloon. illiligeli llis feediig \i.s,, and lion. wheln ilew foolls are inrioldiced so forth): gi'adiiall v ii variable. but increasing. 4. Other animal proteins: types ,llanlitiis. At the saite tilie, the yonIIg ( .g... epgg. fish. lialt, etc. .quiitity; cilhd will il,, often be rm'eivihg breast fiquelue.N Milk in lmiltjvs which are difficult to 5. Vegetable protein foods: types miawasure. (e.g., legllnes, ee lil e afy vegeltables) Ihlaih'd dictar\V assessillent will only quantity: frequency; iiethod of lie lossiile for the non-niutritionist with cooking. siupcrisioli. IIevci. approxiimate The questionnaire shoubh lie tried chlc mayIV ltaililed b obselr'lng oult firstand thenicall lie used oila food iaratillins and tneals, espe-cially sample group of mothers. It should aim iiniig %wIihicl ittins aie gi\vi Itoyonllg at ascertaining oily thlie foods taken ']ihdell. currently. that is. in tIe past 1-7 days.

40 Its construction will be guided by back- Calculation of Food Values. Once ground knowledge of available local (tuantities of foods used by tilechild foods, have been determined, it is possible to In this simplified, rapid technic, the calculate the total intake of Calories, mother is first asked to say spontane. protein, and other nutrients by refer­ ously what the child has eaten in the ence to appropriate tables which give past 1-7 (lays. Following th' she is the detailed compositiou of various questioned as to how many tih,,.s a (lay foodstuffs. Difficulties may occur with each item is being eaten and in what variations in the composition of foods approximate quantities, using house. from one region to another. hold measures (e.g., cups, spoons, FURTHER READING' gourds, and so forth). The information obtained is recorded as given by the A.M. ALTSCIIUI., Proteins, Their Cheris. mother, e.g., rice, two tablespoonfuls, try and Politics, Basic Books, Inc., New twice a (lay. York (1965) (T). W. R.AYKnoyD, Food for Man, Perganmon When the mother has given her spoin. Press, London (1964) (G&T). taneous answers, questions are put sys- W. R.AYKIROYD and J. DorGrY. Leg. tematically on the use of other foods, nines in Ihunan Nutrition, l":O. ttoia. (1965) (T). and, in the event of an affirmative an- D.B..IEL.IFFE, Infant Nutrition in the swer, on the number of times daily and Subtropics and Tropics, WHO Monograph, approximate quantitie Geneva ies. (G&T). (1955) (Second Edition 1968) This questioning should be done M.I,ATHiAM. ltuman Nutrition in Tropical quickly because too much interroga- Africa, FAO, Rome (1965) IG&T). an( cross-¢checking leave both the D. H. K. LEE, Climate and Economic De. tion velopment in the Tropics, Harper Bros., New mother and tlb.interviewer confused. York (1957) (T). The information may be entered in G. B. MASrFI-LLt, Famine: Its Prevention columns ruled for each of the local and Relief, Oxford University Press, London (1963) (G&T). foods likely to be used for young chil- E. R:HE,Manual on lousehold Food Con- dren. The frequency of use of different smnption Studies, FAO Nutritional Studies foods can he calculated fer each three- No. 18, Rome (1962) (T) G. J. A. TrmuwA, Tropical Veretables, Royal month group for the first two years of Tropical Institute, Coniuncation No. 54, life and for six-month age groups there- Amnsterdamn (G&T). after, and expressed as the average STANDARD TEXTBOOKS number of times eaten per week in eachaken group.can also Approximate quanlities L. S. DAVIDsoN and 1. PAssM 'its;,1human be calculated for each Nutriti and Dietetics, Second Edition, Livingstone, Edinburgh (1963). group. lesults of such a simple question- G=Recommnendcd for the general reader. naire can give rough qualitative infor- T=Reconinunded for the technically trained ti health worker. maion o)I giv'cn the foods Sat io,to oN.young" JoLLIFFF (Editor), Clinical Nutrition, children and those that are not suffiei- Second Edition, Harpers, New York (1962). ently used. It can form te basis for H. SINCLAIR and D.B.JELLIFFE (Editors), relevant advi'e on improvement of in- Nicholl's Tropical Nutrition and Dietetics, Fourth Edition, Balliere, Tindall and Cox, fant feeding using locally available London (1961) (T). foods.

41

chapter iii

IMPROVING FOOD SUPPLIES AND POPULATION PRESSURE

Food production, distribution, and pests and diseases of plants and marketing within a country are directly animals. related to the feasibility of achieving While modern methods of food pro­ adequate nutrition. Therefore, any pro- duction are being iotroduced increas­ gram aimed at improving the nutrition iqgly into limnited areas, for the most of children must be made not oniy part agriculture, rearing of livestock, within the framework of the present and fisheries arc dependent on methods range and availability of foods in the that are in a sense traditional and time­ particular region but must take into tested, but which, at the same time, account changes that may occur at the are by modern standards inefficient present and in the future. It must also, and unproductivc. To understand this, as far as possible, consider methods of it is necessary to consider briefly the improving food production and utili- methods employed, including problems zation, both at the national and local of available labor, land ownership, an( levels, soil characteristics, as well as custom­ ary methods of storage, preservation, and marketing of food. PROBLEMS OF FOOD PRO. DUCTION IN DEVELOPING Labor Force and Equipment. In REGIONS most tropical countries, methods of food production will he essentially "la­ The effectiveness of iethods of food bor-intensive"-that is, relying on hu­ prouction depends on many inter- mail labor rather than on machines. acting factors, including the soil, the Traditionally, the labor force is made climate and rainfall, the level of health up of the family, the clan, or the peo­ and vigor of the community, the cus- pie of the same village. Much of the toms and social organization of the hard work is often the duty of women, people, local crops, and indigenous especially in Africa. Methods are usu­

806-112 o-08----4 43 ally based on the use of limited crude permit women to spend more time on equipment, such as the hoe and entail other things, including the care and a large expenditure of erergy and ef- feeding of their children. fort for a small return. The daily A further problem with regard to the round of digging, grinding, pounding, production of food is that in some and carrying heavy loads involves a countries the labor force is itself being tremendous expenditure of time and reduced by the movement of men to energy. towns in search of more lucrative and Additionally, the physical energy of supposedly exciting employment. Not a chronically malnourished, diseased, only may this migration deplete the and parasite-ridden community is re- rural labor force, but also, at the same duced, leading in turn to the vicious time, it adds to the numbers of town circle of defective food production and dwellers needing to be fed by the rural continuing malnutrition, population. Often only simple methods of In many parts of the world, much ploughing and irrigation will be avail- greater use could be made of village able. There may be an inadequate ireal- gardens, which with very little change ization of the need to rest the soil or could often produce much more food rotate crops, except perhaps by means which would be immediately available of clearing new cultivation areas each to the family. year by so-called "slash and burn" methods. In fact, "farming may be rgn Ow esi.n ost tro mired in Babylonian technology." regions, the question of land owner­ the problem canLarge-scale undoubtedly mechanized play a major agriculture role in ofship modifying greatly complicatesmethods of food produc­ cang oubted playdactiorrein tion. In some regions, ancient feudal increasing food production in some systems may still persist. In other parts parts of the world, perhaps using of the world, various complex systems machines, such as tractors, hired from of land ownership and inheritance are cooperatives. Often, a more realistic based on family ties and clan rights. approach than the use of expensive, Ofen ln ily te sall r. difficult to repair, elaborate machines Often land is split into very small por­ maytions, and a family may own several improvements ("intermediate technol- small areas situated far apart. Farming ogy"), such as an ox plough, or rela- under such conditions is inconvenient, tively simple mechanization, as, for difficult, and uneconomical. For large-scale food production us- example, the introduction of a man- For ecaed peton s. thresher, a mechanical ing modern mechanized methods, some walkerateoterorually operated groundnutdige.a form of land consolidation is desirable walker tractor, or a groundnut digger- as a part of a sound agricultural policy This type of approach also has the ad- based on the rational and economic use vantage of mintainingemployment, of land. However, with the worldwide An advantage of mechanized farm- deep eimotional attachment of peasant ing in parts of Africa is that it is a peop!e to the land and with current man's job, as opposed to traditional complicated systems of ownership, nec­ cultivation which is usually a woman's essary reforms cannot be brought about task. The new allocation of duties may easily or speedily.

44 In addition to consolidation of land breeding have already W, to great im­ into large and econoinicall sound provements in yields and quality. It is holdings, in some tropical countries it increasingly possible to develop strains may be possible to reclaim new land that are adapted to special needs, such by settlement, 1)y clearing bush or for. as being resistant to particular climates est, y)vdraining swanip lands, by in- and diseases, bringing a higher over-all troducing irrigation systems, or, in ,ield, possessing improved nutrient parts of Africa, by tie eradication of content, or being unattractive to in­ the tsetse fly, the carrier of sleeping sects, rodents, or bird pests. sickness. IHowever, experience has clearly shown that careful testing of community Soil and Cliiate. In tropical coun- acceptability of these new varieties is tries, the soil is often shallow and as important as their scientifically leached of the minerals contained in proved values. They must possess the the organic humus that are needed to apparance, taste, and cooking prp­ make it fertile and productive, partly erties that are acceptable to the people. because of the heavy rainfall and soil Considerable attention has also been erosion. In some 1laces, ian(d is over- giw(n by stock breeders in recent years used agrcltrally, or by vergrazlng. to trying to develop strains of cattle Livestock may be kept in too large and other aninmals which have a high numbers for their prestige valuc rather yield. are adaptcd to a tropical climate than for their food potential. Likewise, and available idher, and resistant to available animal manure may not be local diseases, such as trypanosonmass used as fertilizer, as in India where cat- in Africa. tie dung is employed principally for fulel. Other fertilizers, inciuding con" Food Protection and Storage. post and chemicals. are also underused. (figs. 2 oid :1 .',uch loss of food ('all Agriculture everywhere depends on occur while it is still growing. as a the climate but in developing Iropical result of the ravages of rats and birds countries this dependcncy for survival and, in some places, monkeys, porcu. is often nearly absolute. In India, wide- pines, and other creatures. spread food shortage or even famine In most places it is necessary to stor. is at then mercy of the annual monsoon, food harvested to last until after tIt In some tropical countries, rainfall may next cultivation season. With present be too abundant, leading to soil ero- methods, there is frequently a very sion, or too scarce, leading to aridity, considerable wastage, so that in India wich may he further increased by it has been estimated that about one overgrazing. third of the food harvested and stored

Seeds and Stock. Variation in in traditional granaries is destroyed by quality, including nutritional value, al- insect pests, rodents, and molds. This ready exists between different strains worsens the seasonal shortage likely to of a particular crop, arid the popular- occur prior to the next harvest-the ization of the Lest variety can be of "hungry season"--when both fresh great value. In addition, modern de- foods and stored staples are likely to velopments in seed genetics and stock be in short supply and less nutritionally

45 granaries that -areraised off the ground and protected by inexpensive insecti­ cides that are not toxic to man.

V- Food Preservation, Distribution, and Marketing. The distribution of foods is frequently restricted by poor communications, difficulties in trans­ porting crops and other foods, defec­ tive means of preservation, and inade­ quate and economically unattractive marketing opporkunitis. For example, for all these reasons, fish is available for only a very limited distance around the great lakes of Africa. 'Village-level methods of food pres­

,e. ervation are based on making the par­ ticular material less liable to bacterial invasion and decomposition. Canning and bottling are too expensive and sophisticated for most families in de­ veloping countries. com­ FIGURE 2.-Tratlitional raised rice Drying is the method most granary (Madagascar). monly employed, using either the sun or fire. Drying can be used for certain and pep­ desirable famine crops are used, espe- vegetables, including okras such as dates, cially cassava. pers, for some fruits, meat cut into thin In some places, farmers recognize apricots, and figs, for jerkey) (Fig. that this loss is likely to occur and, un- strips (biltong, charqui, fortunately, sell most of their harvest 4), for small fish (Fig. 5) and shrimp, and other fungi, at once. This means that they need to for some mushrooms grasshoppers buy the same foods for their own con- for edible insects, such as for various green sumption from shops later in the sea- and termites, or then sometimes son at much higher prices, leaves (which are The provision of insct-, rodent-, pounded and stored as a powder). and old.proof granaries would in- Smoking, salting (or brining) or crease the availability of foodstuffs im- spicing (e.g., with red pepper) may also mensely. These granaries can some- be employed, and several processes may reinforce one be cheaply made concrete com- be used together to munaltimes stores; while, a~tvillage level, another, as when fish is salted and then munidestoes ileeat ille eel, dried in the fire-smoke for prolonged considerable improvement is frequently periods. In addition to salt, various possible by means of such relatively un- other substances and spices may be complicated methods as trying to en- used as preservatives, especially vine­ sure that grain and legumes are stored gar, as in Korean pickled vegetables dry in sealed rat-proofed, mud-brick (kim chee). 46 FIGURE 3.-Traditional granaries (Togo, West Africa).

Controlled bacteriological change "cash crops." These may include such may be induced and can lead to short valuable foodstuffs as eggs, salad vege­ or long-term preservation, as with tables, an(d milk which may be sold and fermented dishes, such as Japanese the cash obtained used to buy carbo. miso (soybeans and rice) or Indian hydrate foods or household goods. idli (black grain and rice), or with However, this may le helpful if farm­ sour milk products, such as curd or ers can be encouraged to grow enough dried cheese. of these foods to enable them to sell There is a great need for practical some while retaining some for family research into ways of applying modern consumption. Rural prosperity and im­ scientific knowledge for the improve, proved nutrition can both be related to ment of these ancient village practices. marketable food surpluses. Another nutritional aspect of market- While many rural communities con­ ing is that certain foods which could tinue to be subsistence farmers growing best be eaten by the family are sold as their own foods, in most areas some

47 'gions, including such commodities as kerosene. antimalarials, and agricul­ tural implements. At the same time, the foods they sell very frequently tend to be what are in many tropical circum­ stances nutritionally undesirable or even luxuries, such as tea, sugar, and expensive, inappropriate tinned foods. It is to be hoped that in the future vil. lage shops may act increasingly as out­ lets for the low-cost, high-protein foods that are being developed in various countries of the world.

Cash Crops and Food Crops. A key problem in many present day communi­ ties in the tropics is to try to develop a balance in their cultivation between a locally-grown, nutritious diet intended for the family or village itself and cash crops, such as coffee, cotton, and cocoa, FIGURE 4.-Sun-dried strips of beef which are the main or sole source of (Norlh Kenya). cash income for the family for taxes, school fees, and household goods, and form of traditional market continues, the chief source of foreign exchange This marketplace often acts as a focal for the nation. point for the community where produce However, it is increasingly apparent can be brought for sale or barter and that nutritious food "crops," such as wh~re information and news can be ex- beans and eggs, can also be important changed. Traditional markets are also as cash earners if grown in larger extremely important as sites for nutri- quantities. tion education activities (Figures 6 and 7). Finance and Incentive to Change. linor improvements ;n transport Many peasant farmers in developing can be most valuable to the farmer eco. tropical regions are unremittingly nomically and to the community nutri- bound down by chronic poverty and tionally. Simple miodificaions and indebtedness. The development of gov­ strengthening of bicycles can permit ernment assisted cooperatives, crop in­ greater loads to be carried increased surance schemes, and bank and credit distances to market, systems may enable the cultivator to More recently, omall village shops obtain loans of money and credit in selling a simple range of goods have the form of insecticides, improved become a feature of many tropical com- strains of seeds, and equipment which munities. Undoubtedly they are playing can enable him to start on the road to a part in spreading gcods to remote re- modest prosperity.

48 FIGURE 5.-Sun-dried, smoked fish on sticks (Uganda).

Incentives to increase production tries is usually dominated by one or. and to change to new crops are also more local starchy staples, such as rice. needed. These may be supplied by gov- corn, or yams, upor. which the popula­ ernmental assurance of a market with tion relies for the majority of its Calo­ a guaranteed remuneration per acre ries and, indeed, for much of the rest cultivated, or by import restrictions on of the nutrients of its diet, including foods that are producible within a protein. A top priority must therefore country. always be the increased production of improved quality staple. SELECTED FOODS The production of protein foods, Vegetable Protein Foods. The pro. both of vegetable and of animal origin, duction of foods in most tropical coun- is usually deficient, sometimes because 49 FIGURE 6-Traditional market (Mali, West Africa), showing mixed beans in foreground.

50 fl4 iI,

FIGURE 7.-Tradiional floating nmrket on canals (Bangkok, T[ailand). of difficulty of producing these foods, In some countries, it would be most but more usually because their nutri- desirable if sonic inducement to their tional value is not appreciated. In par- increased cultivation could be devel­ ticular, pulses or legumes very fre- oped, possibly by governmental assur­ quently are not produced in nearly the ance of a local market for a certain quantities that are desirable or feasible, percentage of the yield. Many different varieties exist and ef- Legumes may be eaten fresh at the forts are obviously needed, both on a time of harvest or, more usually, died national and on an individual cultiva- and stored, when special care has to be tion basis, to increase their production. taken to prevent their infestation with Legumes are, and in the future will be. weevils and other insects. come increasingly,the world's mainstay Particular emphasis needs to be as regardsproteinnutrition, given to solving problems of increased

51 production of aflatoxin-free ground- expensive bottling, and economical nuts (p. 30) and of using the presscake distribution and sale. Preferably, there obtained after the extraction of oil from should be some system for ensuring soybeans (p. 31) and cottonseed (p. that at least a part of the end product 32) to prepare high-protein flours reaches the young children who need it suitable for infant feeding. most. Most indigenous tropical cattle yield AnimnaZ Protein Foods. There is a very little milk, and to increase produc­ great need to increase the production tion to an economic level it is necessary of animal protein foods in tropical either to introduce such high yield countries, except for certain favored exotic breeds as Channel Island types groups, such as fishermen, pastoralists, or Fresians, or to develop hybrids be. and, in rare places, hunters. At the tween exotic and local species. In both same time, the production of animal cases, it is usually necessary to take protein foods is often not the most special care with disease protection by biologically efficient or economical way means of immunization and tick con­ of using available land. Problems re- trol, and to ensure the animals an ade. lated to local geography and climate, quate diet and water supply. Plainly, such as scarcity of water and fodder, this is difficult for an uneducated and the disease pattern may make ani- farmer to icilize or, indeed, to put mal husbandry difficult, into practice, without some form of Milk. Increased dairying is rightly subsidy or inducement from the gov­ regarded as an important aspect of ani- ernment. However, in some parts of the mal protein production which has world, as in Uganda, a small but in­ special relevance to young children, creasing percentage of "Progressive However, as has been noted elsewhere, Farmers" are rearing cattle with all animal milk, although an extremely these precautions and finding it most valuable food, especially for young profitable to do so, thus providing the children, is by no means necessary as financial motive for others to follow evidenced by the fact that many com- their example. munities have reared their children In some places, it may be possible to successfully without this food-for produce a relatively inexpensive example, the Chinese and the Polyne- "toned" milk, made up of locally pro­ sians. duced fresh milk mixed with inex­ Often with international assistance, pensive imported dried skimmed milk. various tropical countries have been In particular, this has been tried with making great efforts to increase their milk production, both from cows and successI nriu in Bombay,a h, iaIndia, whereere high­ith filpro ualos. Wth sroml from psant fat buffalo milk (7-9 percent) has been buffaloes. With small peasant m x d wt m o t d l wf t d i stock raisers, it is necessary to intro- d duce some system of rural milk collee- milk, with a resultant mixture rather tion, using robust, simple equipment, similar to cow's milk. and to devise some method of trans- Meat. Increased meat production may porting the pooled mixture to a process- be possible in some regions, by means ing center. This should, in turn, be of improved breeds and by better pro­ followed by factory pasteurization, in- tection against disease. Equally im­

52 portant in some places is the need to animal prodators and from accidents is make use of animals, especially cattle, great. which at present are not eaten for vari- Chicken is eaten in most parts of the ous cultural reasons and which in fact world, although in some parts of Africa, act as competitors with human beings both chicken and eggs are still taboo to for the limited food available, or over- traditionally brought-up women, as stock and overgraze the available land. they are believed to produce infertility. Thus, in India it is forbidden, for reli- Despite the existence of a variety of gious reasons, for the Hindu popula- worldwide and tropical fowl diseases, tion to cat beef or, indeed, to kill these chicken rearing on both a medium and sacred beasts, which are permitted to large scale is being carried out increas wander the streets uncared for and ingly in some tropical regions. How­ often diseased, ever, even with the use of the cheapest Likewise, in many traditional Afri- local materials and labor for building can communities, small stunted cattle deep-litter pens, a considerable amount are kcpt as symbols of wealth and pres- of care, expense for feeding material tige and for use as the bride price, and large numbers of birds are re­ Usually the health and general condi- quired before it can become reasonably tion of the animals is of less importance profitable on a conunercial basis. than their number, although some cat- Alternatively, a compromise can be tle-keeping people pay great attention employed for the small fanner, for ex­ to certain nutritionally irrelevant ample, by devising an inexpensive aspects of their appearance, such as the chicken run and a protected raised curve of the horns and the color pattern roost, by feeding the birds with left. of the skin. When cattle are kept, they over peelings and food waste and by in­ are usually milked, but give a low yield troducing a better breed of cock. which is most often reserved for the The rearing of a variety of other elders of the community. Animals are small animals as food can be attempted often slaughtered only on special occa- in the right circumstances, provided sions, such as feast days. they are acceptable to the local cultural in certain favored tropical regions, pattern. In various parts of the world, ranching schemes may be practicable, these may include pigs, goats, rabbits, while, in some parts of Africa, attempts guinea pigs, and agoutis. have been made to obtain meat on a Eggs. In niny parts of the world, continuing commercial basis by game- eggs are particularly underused as cropping, either in extensive fenced-in food, espe-ially for infants. Frequently areas, or in natural circumstances as this is because they are considered as with hippos in East African rivers, a "cash crop" to be sold at the local In most tropical villages, chickens market. In addition, however, many are to be found, although usually living cultures have traditional beliefs that a "free-run" existence on the rubbish prevent their being eaten by young and insects to be found in the com- children (p. 64). pound. These birds are small, with lit- Fish. Basic and applied research is tie meat and with a low yield of under- being carried out on improved methods sized eggs. Their mortality from small of fishing approuriate to particular

53 tropical communities. For example, addec' to livestock rations as a high strong nylon nets can be made avail- protein source. able at relatively low cost and loans Microbial Protein. Recent research can be supplied to purchase outboard has shown that microbial protein may motors. Often, a major problem is be grown on petroleum. The end result preservation and distribution; and if appears to have promise at least as ani­ this could be improved, the incentive mal feed. to obtain larger catches would ob- Food Yeast. Highly nutritious food viously increase greatly. yeast can be easily grown in molasses. In some parts of the world special Its use as a protein additive for various fish preparations are much prized as commercially prepared infant foods is foods, as with the fermented, predi- being explored. gested fish and shrimp pastes of parts Leal Protein. Methods have been of Asia. Investigations aimed at im- devised to extract protein from various proving the nutritional value and in- types of leaves and the iresulting dark creased yield are plainly of importance. green powder has been employed ex­ perimentally in the feeding of young Vegetables and Fruits.As a general- children. ization, it may be said that vegetables However, it must be stressed that, and fruits are not grown or eaten as with the exception of oil seed residues much as they might be, especially dark which are not at present much used for green leafy vegetables. The production human food, the solution to the world of these foods could very often be in- food problem lies principally in the di­ creased easily by the development of rection of augmented production and improved home gardens or school impoved quality of traditional, gardens. orthodox food sources.

New Sources of Food. Intensive re- PROBLEMS OF MODERN search into new sources may be ex­ pected to play a role in the world food scene in the future. Two problems of extreme impor­ Synthetic Amino Acids and Vita- tance to food production and to the rains. The economical synthesis of cer- nutrition of populations as a whole, tain essential amino acids, notably and especially to young children, have lysine, has suggested the possibility of merged in the past few decades, par­ reinforcing cereal flour with this lim- ticularly since World War II. These are iting amino acid (p. 2). Cost and (a) a rapid population increase, and practicability make this approach un- (b) urbanization. Almost all countries likely for most tropical communities, have been affected, althou h cu very The use of synthetic vitamins, es- different degrees. pecially thiamine, to reinforce over­ milled rice and wheat flour has been in Population Increase. Tradition­ effect for decades in limited areas of oriented people all over the world the world. desire to have large families, as an ex­ Plankton.These small sea organisms pression of virility for the men, of can be harvested, concentrated, and fertility for the women, as a source (J

54 strength to the clan, group, or tribe, as the import of foodstuffs from elsewhere a work force, as a source of insurance and extremely vulnerable to natural in old age, and, in some places, as a hazards, such as droughts or floods or source of wealth, either from bride man-made disasters, such as wars and price or doweries. In addition, politi- civil strife. cians tend to equate numbers with In many other regions, food in­ power. adequacy is particularly related to pro­ Over the centuries, communities tein, resulting in a poorly balanced have become accustomed to a high national diet. child wastage, often with over half the Population Pressure and Arable children born dying before adolescence. Land. Administrators in many coun­ A high birth rate was required to corn- tries do not seem to appreciate that pensate for child wastage. However, with the present geometrical progres­ with the introduction and acceptance sion in their population increase, they of at least some aspects of modern too may meet the extreme problems of methods of medicine and public health, the more over-crowded Asian countries and with the establishment in most in the coming decades, unless appro­ places of some degree of law and order priate action is taken now. Thus, even the death rate in childhood, although in the apparently underpopulated areas still extremely high, has decreased of East Africa, it has been shown that, greatly. In fact, death control has oc- by the year 2000 A.D., the population curred without parallel fertility con- density in Kenya in relation to useable trol. As a result, the population has land, will approximate that of India increased ever more steeply, sc that the today. present world population of about three Population Pressure and Social billion is expected to reach seven bil- Services. Another nutritional and lion by 2000 A.D. health consequence of an over-rapid in­ Population Pressure and Food crease in population is that the hard­ Needs. There is a widening gap between won advances in "development," both the growing world population and economic and social, constantly lag be­ available food supplies. Of especial hind the extra numbers of people ex­ seriousness is the fear that the most pecting to share in these advances. rapid increase in population has oc- General and health education through curred in the parts of the world where schools are important methods of nu­ food production has lagged, that is, in tritional improvement; with a too developing tropical regions. This is rapid increase in child population, the especially striking in some Latin Ameri- building of adequate numbers of can and Asian countries who were food schools will never catch up with the exporters some years ago, but who number of children. The result is a now have to supplement their own growing number of uneducated young production with imports and whose people unable to find jobs. food production is increasingly inade- Child-Spacing and Malnutrition. An quate even as regards Calories. The often ill-appreciated, but highly im­ situation is plainly precarious with food portant, aspect of over-large families is supply dependent to a great extent on related to child-spacing. If children are

55 born at too close an interval, severe type of approach a practical possibility nutritional consequences occur, both although it is still fraught with many for the mother and for her offspring, cultural, religious, and political mis. Many tropical women marry young understandings and difficulties. In par­ and commence child bearing before ticular, the use of the plastic intrauterine they have completed their own growth. device (I.U.D.) has revolutionized the Thereafter, their life may be one of approach to family planning, as it is continuous reproductive nutritional a method which is inexpensive, often drain, as one pregnancy and prolonged culturally acceptable, practical, simple lactation is followed by another. In and, once inserted, does not entail any mothers, this cumulative "maternal de- alteration in customary sexual behavior. pletion" may sometimes manifest itself The move toward family planning as a definite deficiency of a certain nu- has increasingly involved greater areas trient (as for example iron-deficiency of the world, although there are still anemia), or alternatively may lead to many countries or regions where this general malnutrition, with weight loss, approach is unacceptable and the dan­ thin muscles, and subcutaneous fat, gers of over-population are either not and with premature aging and death. appreciated, or are thought to be amena­ If children are born with too short ble to increased food production, to an interval between them, this may lead technological advance, and to raised to the newborn baby himself being un- standards of living leading to reduc­ derweight and with less than adequate tions of family size. The inescapable stores acquired from an already nu- conclusion is that increased food tritionally depleted mother. Also in production and family planning are tropical village circumstances, both complementary and that both are prolonged breast feeding and close and urgently needed. careful attention by the mother are de- Many countries now have family sirable for the child's nutrition and planning projects, often on a vast scale health, as part of official government policy, The ideal gap between children is e.g., India, Pakistan, Egypt, Tunisia, probably between two to three years and so forth. Still more have small­ because, if children are born in rapid scale family planning associations or sequence, the period of breast feeding activities which are increasingly sup­ and of close maternal care is too short plying the demand of the well-to-do and the possibility of the infant devel- and middle classes (the trend-setters of oping protein-Calorie malnutrition the future), although they have no di­ (p. 75) is greatly increased. Many corn- rect, open support from governmental munities had traditional customs which authorities, largely for political reasons ensured child spacing. since they may be misconstrued as sin­ Family Planning and Nutritional ister tey at enocideor at re­ Needs. Family planning is required striattempts a genoc i lar nutritionally both to achieve child- stricting the "power" of a particular spacing and to control the "population group, community, or nation. explosion." Recent changes in opinion in many parts of the world and new Urbanization. Many tropical coun­ technological advances have made this tries are in the relatively early stages of 56 industrialization and, indeed the newer ing, some infections of nutritional con­ lproblems of the present and the domi- sequence, particularly tuberculosis, nant problems of the future are in many whooping Cough, and diarrhea, can cases bound up with the partly planned, often occur more commonly than they but mostly haphazard urbanization that do in rural areas. is occurring in the same way as hap. ChangingFoodHabits.Most directly ptned in the Industrial Revolution in relevant to the nutrition of children will Europe in the early 19th century. be the change in food habits that can People, and especially men, come to occur as a result of moving from a the towns to seek work. where it seems rural traditional way of life to an urban to them that more mnodern, prestigious situation, where the family concerned and lucrative opportunities exist than will depend, in major part, upon a cash in the rural areas. As an.where, they economy-that is, u,,on food bought are also attracted by the bright lights, rather than the food grown through excitement, and hustle of town life. All home cultivation. This situation too often,. only a few can obtain gain. poses problems of budgeting for in­ ful employnent and reasonablh low- experienced "new townsmen," exposed cost housing, so that the majority may to many understandable temptations find themselves living the "detribal- to spend their limited resources ized" lives of discontented, under- wastefully. privileged, unemployed slum dwellers, Often the main foods that have been with immense potential for social customary in the home area, including unrest. even the staple, may not be easily trans­ Family Instabilily. Under these cir- portable and hence may not be found cumstances, the traditional customs to any large extent in shops in towns. and restrictions of the home contau- For example, nillet-eaters migrating to nity are abandoned, often with a rise towns do not usually find this cereal in temporary marital liaisons, illegiti. available to them and often have to macy, venereal disease, alcoholism, move over to less nutritionally desir­ broken families, and abandoned chil- able, cheap, easily storable staples dren. The last is particularly striking in available in the stores, including cas­ certain African cities, since in tradi- sava or maize (corn) flours. In general, tional society children born out of wed- there is also often a tendency to use lock are usually absorbed into the clan convenient, refined, less nutritious or tribal structure, whereas in towns the foods, including white overmilled flour, neglected or abandoned undernour- sugar, tea, arid carbonated beverages. ished young child is nowadays becom- However, the people do have an op. ing an increasingly serious problem. portunity for wider exposure to nutri­ Nutritionally Relevant Infections. tion education, which should be made As regards nutritionally important in- available to then, and are often closer fections (p. 72), in some ways the town to limited health services. child is at an advantage. For example, Another point of considerable im­ malaria and certain types of parasites portance is that many rural people will usually be much less of a problem, make use to a very considerable extent However, as a result of the overcrowd- of a variety of different foods of vege­

57 table, and occasionally of animal, skimmed milk has helped increase at­ origin which occur wild or semiwild in tendance at child hcalth services, has the countryside. These may include drawn attention to the problem of various green vegetables, fruits, ber- childhood malnutrition and has, in ries, eggs, and, in some communities, some places. stimulated the local pro. hoitey antid insects. These are no longer ductionl of low-cost, high-protein foods available in towns. suitable for you ng chilren. Of parlicular importance as far as Tile disadvantages of this approach the feeding of younglchildren is con- are Ihat it was geared to the use of cerned. is the fact that urbanization surphises that were ilot ci'iesarilvy tlie seems to be paralleled by a harmful most suitable foods for the area and trend away from breast feeding toward that it coulhl discourage local produc­ artific.ial feeding with cow's milk, often tion. using a feeding bottle. The situation has chaiiged radically In additiotn, rural mothers exposed in Ihe last few years and the previously to the advertisiig of the towns are ex- huge food reserves in the U.S.A. have tren iely likely fo Ibuv not only i1)pos- decreased greatly, inainly because of sibly expliisive lk prel)rations but nassive ftod aid to avert fa mieli in also a variety ,of costly largely carbo- India hut also bvcause new markets hydrate tiined foods, which are eco- hae (lcloped. noinically beond their reach, nu­ tritioally tf low valtie, vnd a misuse War on Hunger Program. In view of their limited Inidget. of recent developments, the policy of the U.S. War on lunger Program is to FOOD AID try to deplo m,ore specifically needed food aid to deal with de*fiinedt nutri­ In the past decades, very large quan- tional problems, especialy thosei of tities of food from agriculturally highly young children arid, at the same time, productive countries have been used as to assist in the development of indig­ "food aid" for developing regions. The enous food production. vast majority of this has come from With this in mind, farmers in the surplus foods produced in the U.S.A., U.S.A. will be induced to grow specific as, for example, the low fat foods that are required for the prob. (dried skimmed) liilk distributed by lems of particular regions, expanding UNICEF, CARE, and the Catholic Re. cultivation to use previously idle land. lief Service, and the foods distributed These foods will be related to actual by the Food for Peace Program. nutritional problems and will, there­ These have been used on a very large fore, frequently be the animal or vege­ scale and have been of much value in table protein foods, such as dried trying to deal with actual malnutrition skimmed milk or legumes, especially through supplementary feeding pro- the soybean, produced to combat pro­ grams, as with dried skimmed milk for tein-Calorie malnutrition of early the thera!,y and rehabilitation of childhood. young children with varying degrees of Lastly, and most importantly, food protein-Calorie malnutrition, aid will, as the name suggests, be In addition, the use of dried geared to stimulating food production

58 iithin a country instead of producing ages, or even mass famines, is a real the negative effect it has often exerted possibility for large areas of the world on agriculture in the past. in which all age groups would be in. volved, although young children would World Food Program. In a similar be the principal sufferers. way, this multilateral U.N. program is principally designed to assist with food Over-all Policies. There is in many aid from a variety of participant countries an awakening awareness of countries in the support of technically this problem, especially in light of tile sound and feasible projects intended to current lack of food surpluses from the improve a country's economic develop- U.S.A. The message seems clear. A ment and especially its owni foo3 pro. sound food productionpolicy based on duction. Thus, in the building of a dam the nutritional needs of the country, designed to increase land irrigation, as coupled with some sort of locally ac. well as produce power, part of the ceptable f-idly planning program, is salaries of the labor force may be made what ;- -eq aired. available in the form of food. This These programs rank even higher enables food production to be increased in urgency than educational develop. and, at the same time, mobilizes man- ment or the extension of all but tile power and provides employment, simplest health services. Of course, they Other projects covered by the World are not as attractive politically as such Food Program include subsidizing edu. prestige items as national airlines or cational development through school grandiose public buildings, and they feeding, direct preschool child feeding require the support of technical advisers schemes, and assistance in the develop, and workers if they are to gain accept­ ment of locally produced high.protein ance. foods for young children. In the last The aim should be an increased, category, sorghum (a millet-like cereal) diversified national food production, flour has been made available in Senegal using both large scale and domestic for incorporation into a processed in- level approaches, with special relation fant food which is being manufactured to vegetable protein /oods, and with there. It is hoped that this initial reduc- the object of improving the family diet tion in cost of the product will enable with particular reference to young it to be launched more easily and children. that local sorghum flour will be used A balanced approach is needed subsequently. between rrcasures designed to im. prove a country's wealth-that is, its FUTURE DEVELOPMENTS IN economic development-by means of FOOD PRODUCTION industrialization and the cultivation of cash crops on the one hand, and those Realization of the Situation. The measures to increase food production world population is increasing twice by agriculture, animal husbandry, and as fast as the increase in food produc. fisheries on the other. However, in most tion, and the gap is especially marked countries there has, in the past, been in developing tropical regions. The an over-emphasis on industrialization threat of extensive major food short. and cash crops. In the context of the

806-112 c 59 world in the near future, it may well be related to national policy, much im­ possible to appear to be developing the provement in food production can be economy of a country favorably and achieved at village level by the use of still be short of food. high yield seeds and fertilizers (includ. That an increased national food pro- ing manure, compost, or mulching), by duction is needed for full insurance pest control (especially with insecti. against national food shortage is em- cides in stored grains and legumes), phasized in a recent speech by Presi- and by the increased cultivation of pro­ dent Ayub Khan of Pakistan when he tcin foods (as with legumes and dark said: "The time has arrived when the green leafy vegetables in home gardens, world cannot produce food for us and or with fish ponds). In these important, after some further time it will not be small-scale activities, the field worker able to supply us with food even for may be strategically situated to help in­ gold. We have to feed ourselves." troduce and popularize new or n,.di­ Blocks to Increased Food Produc- fled ideas in collaboration with the tion. It is now recognized that blocks local agricultural extension services, to vastly increased world food produc- village clubs, and other organizations. tion are neither technical nor even "natural," :,at is, related to geography

or climate, but that limitations are C. J. GAMBLE and A. F. GUTTMACHER, A rather due to economic, social, and challenge to health workers of every nation, cultural factors. Family Planning, (1966) (G&T). J. M. MAY, The Ecology of Malnutrition Improvement appears mainly to re- in Middle Africa, Hafner Publishing Co., quire education and motivation of gov- New York (1965) (G&T). ernments and ultimately of the farmers A. T. MOSHEn, Getting Agriculture Mov. ing, Agriculture Development Council, Inc., themselves. More efficient marketing New York (1966) (G&T). systems are particularly needed, thus Time Magazine, "The struggle to end hun. supplying both incentives to the food ger," Time Essay, August 12,1966. p.42 (G). producer and also lowering the price H. D. TiNDALL, Fruit and Vegetables in for consumers. West Africa, FAO, Rome, (1965) (G&T). 1 G= Recommended for the general reader. The Field Worker and Food Pro- T= Recommended for the technically trained duction. In addition to wider issues health worker.

60 ckapter iv

CUSTOM AND FOOD

Each of the many different commu- necessary to realize the existeiice of this nities of mankind has its own pattern of "cultural relativity," especially the uni. behavior, customs, and beliefs, which versality of scientifically unsound together are termed its "culture." This behavior. complex set of attitudes and ways of The conditioned responses and be­ life are by no means inherent; they are havior of . mmunity which make up learned after birth by instruction from its culture are particularly important in parents and others, but mostly by means relation to food and eating practices, of subconscious imitation of the be- and to methods of food production. An havior of the family and other mem- understanding of some of these vari­ bers of the community. By the time ables is imperative, if cross-cultural later childhood and adulthood have misunderstandings and clasbes are to been reached, the individual has been be avoided or minin'ized. conditionel to accept the ways of his particular group as the correct and CULTURAL FACTORS AND proper way to behave, and, indeed, CHILD NUTRITION often to regard other culture patterns as bizarre and absurd, if not positively All the aspects of a culture are inter­ harmful, related and interact one with another, In fact, all different cultures, whether so that an understanding of the leader­ in a tropical village or in a ligily, ship structure, kinship systems, life urbanized and technologically sophis- goals and values is helpful hi trying to ticated community, contain some prac- understand local health and nutrition tices and customs which are beneficial problems, and in carrying out a pre­ to the health and nutrition of the group, ventive program. and some which are harmful. No cul- Two "nonnutritional" cross.cultural ture has a monoply of wisdom or ab. problems often of importance in nutri­ surdity. For a worker Irom a Western, tion work may be mentioned as industrialized society, it is absolutely examples:

61 1. Specimen collection, which may the benefits of a good diet are not be misunderstood and resisted through quickly produced. fear that the blood or urine may be used Basically no human group eats all for occult purposes, or that its loss may the potentially edible material available weaken the donors; to it, but arbitrarily classifies these 2. Difficulties with names and num- items into food and nonfood (fig. 8). bers, which arise when the culture for- Thus, in the U.S.A., dog, although a bids that one's own name or that of good source of animal protein, is cate. one's husband or child, or the num- gorized as nonfood. Certain hunting ber of children in the family, should be groups in remoter Tanzania, hard mentioned before strangers, or when pressed as they are for food, do not eat names are changed for various reasons. fish, even if it is available to them. Also, Nevertheless, there are certain cus. the categorization into food and non­ toms that are more obviously and di- food may be on a ritual or religious rectly relevant to child nutrition and basis, as with the avoidance of beef by feeding. Certain of these can now be Hindus, and of pork by Muslims. considered. Cultural Super-Foods. In all com­ munities, one or more items have be­ Food Classifications.These are often come the cultural super-food. The of great complexity and usually the characteristics of cultural super-foods result of numerous interlocking his- are that they are usually, but not al­ torical, social, and rconomic factors ways. the dominant staple and main that have influence.1 the culture source of Calories. Their production pattern, and preparation occupy a major part of These subconscious classifications the community's work time, both agri. comprise one of the most deep-rooted culturally and domestically. If the cul. aspects of all culture patterns. They are tural super-food is a grain, its preferred learned by imitation in early childhood preparation is usually overmilled and and are notoriously dificult to modify as white as possible (e.g., wheat or corn or change. flour, rice). The food classifications employed Because of their importance for the usually have no relation to scientific survival of the particular community, divisions (e.g. protein, vitamins, and they often have semi-divine status, be­ so forth). They seem complicated to the ing i -- woven into local religion, outsider, but appear natural, normal, mythology, and history. They have pro­ and correct to the particular commu. found emotional value to the group nity. It is most unusual for there to be concerned and tend to dominate the of the relationship be. local diezary so much that often a any recognition vernacular word for "food" is the same tween the type or quality of diet eaten and health or disease due to malnutri. as Examplesfor the staple. of cultural super-foods in­ tion. In fact, trying to convince peo. elude rice in most cf Southeast Asia, pie of this concept is basic to much matoke (steamed plantain) in Bu­ nutrition education, and is particularly ganda, corn (maize) in Central Amer­ difficult to achieve, because evidence of ica, and wheat in Northern Europe.

62 FIGURE 8.-Food and nonfood. Blood being drained from jugular vein of cow (Karamoja, Uganda).

The nutritional importance c' the advantage with regard to infant feed­ cultural super-food is that it will usu- ing and are likely to avoid kwashior­ a pre­ ally also be the main source of protein kor, compared with those eating as and other nutrients as well as Calories, dominantly low-protein staple, such and will be the food which mothers will plantain or cassava. have over-value and will tend to feed their Prestige Foods. All cultures are young children on preferentially. Peo. prestige or status foods, which occa­ ple with a relatively high-protein cul- mainly reserved for important com­ tural super-food, such as one of the sions or for the illustrious of the in millets, are at an automatic, base-line munity. Examples include chicken

63 Africa, various special milk deserts in any extent in Britain is that, by this parts of India, camel hump in some classification, it is traditionally the traditional Arab groups, and the pig in prime seat of "melancholic humor." New Guinea. Equally, in the U.S.A., a Sympathetic Magic Foods. All *'ver nutritionally equivalent quantity of the world some foods arc eaten or steak would certainly have greater avoided, at least in part, because of prestige than a corresponding quantity subconsciously assumed "sympathetic of cheese. magic" properties. That is, it is felt that Examination suggests that, even in the appearance or original fitrction of so.called vegetarian societies, prestige the food may affect the cater. Thus, in foods are usually protein, frequently of Gujerat the convoluted walnut is re­ animal origin, often a milk product. garded as a brain-food; while under. They are usually difficult to obtain, so done steak-symbolically representing that they are expensive, vigor, energy and masculinity-was Body-Image Foods. Many cultures used for training university athletes in have their own body-image that in- Europe until recently. cludes theircept own conernngculturallyte wokins defined ofthe con- EuroloilPhysiological rntSy. Group Foods. Special cepts concerning the workings of the foods are often resei ved for, or forbid­ body and itsphysiology, which are to- den to, certain physiological groups, tally different from modern scientific including males (especially elders), views. These ideas may be systematized women (particularly when pregnant, as with the ancient Hindu classi- after delivery, or lactating), and chil­ fication of body physiology into doshas dren (iostimportantly in the early (humors), especially "heat" and (os imortanl in theaearl "cold,"~ or the similar systems found years of life). For example, in Malaysia in LatinoAricand, si the s sterun fish is the most available source of ani­ iti ran dt r mal protein locally, but is still some­ Mei r ance otimes thought to be unsuitable for chil­ The mpotancofthes clssifca- dren in the early years of life because tions is that both foods and illnesses are of it all caat o produe usually categorized in this way, so that the diet permitted may be of consider- testinal worms. able influence in both health and There may also be foods considered disease, in relation to its supposed to be particularly suitable for young influence on the body. For example, children. Sometimes they may he soft in Bengal diarrhea is classified as a and easily fed to infants, including "hot" illriss and, to the village mother, squash, sweet banana or arrowroot it is plainy dangerous to feed her child paste, but otherwise nutritionally infe­ with milk, even during recovery, as nor. Occasionally, high protein foods this is also classified in this system as are considered especially appropriate, being "h3t." as bone marrow in Northern Tanzania. Relics of ancient classifications exist General dietary restrictions for in industrialized countries. For exam. women are quite common, as with eggs, pIe, the Galenic hunoral concept of ill- chicken, mutton, and certain types of ness may influence modern food intake, fish in East Africa, and with pork in One reason that spleen is not eaten to Polynesian Hawaii.

64 In Burma and elsewhere, the mother's New Customs. At all times in history, diet may be restricted during preg- cultures are always undergoing a slow nancy, in an attempt to have a small process of change. However, in recent baby and an easy delivery. These decades the speed of modern communi­ practices mean that the fetus receives cations has increasingly brought tradi. inadequate stores of nutrients from the tional non-Western societies in contact mother. with both the science and the cultural As restrictive dietary practices often assumptions-two very different as­ apply to women, especially in preg- pects-of Western, technologically de. nancy, they may be in worse nutritional veloped communities. This has led to condition than men. In addition, the obvious and rapid changes in some tropical mother is often in a continuous customary forms of behavior usually state of productior • if she is not produc. related to convenience or status, as, for ing a baby, she is lactating. In many example, the use of Western style cultures, it is also customary for her to clothes for men, the bicycle and other continue her normal hard physical work wheeled transport, and the telephone. in the garden or in collecting wood and In the field of child nutrition, many water. traditional practices have remained un­ Nutritional Significance of Food changed. However, especially in towns, Classifications. Affluent societies with there has been an unfortunate tendency an abundant supply of foods, covering for unsophisticated, less well-to-do a wide range, can, as it were, "afford" mothers to try to follow certain types of the idiosyncrasy of scientifically absurd Western practice, in particular the use food restrictions. Ti Western Europe, of bottle feeding. the taboo on protein-rich grasshoppers Other problems of infant feeding in or dogs (prized foods in parts of towns (p. 58) include adapting to a Africa) is not important. A parallel money economy, unavailability of some avoidance of fish for young children in customary staples, and the use of nu­ Malaysia may be disastrous. tritionally valueless dilute tea or car­ Examination of the food classifica- bonated beverages (which often cost tions briefly presented here suggest more tlan milk). that they often have a significance in public health nutrition in developing Child Rearing Practices. Local regions. In general, they are often methods of bringing up children must pattern of related to protein fuclts, especially those be known, including the how the of animal origin. While they may be infant feeding (Appendix II), nutritionally beneficial, they more child is separated from the breast (i.e., often tend to restrict or limit the use whether suddenly or slowly, whether of available foods ("cultural blocks") the infant is sent away, and so forth), ofeyaaeofo d athe way children are disciplined, ceremonies at different stages of life young children. They can have, there- (rites de passage), and the commu­ fore, a direct and important relevance nity's ideas about the relative impor­ in contributing to the dietary causation tance of girls or boys. of malnutrition in these vulnerable Various rites may be significant nu­ groups. tritionally, as with the rice-feeding

65 ceremony f Hindu infancy, before a variety of other different methods. which rice may not be given to the baby. The cooking utensils may be of various Customs in relation to child spacing types, but are often very limited in are important both as regards the likeli- range and number. The type of stove or hood of a baby being breast-fed, and fire used and the availability of fuel are as regards the health and nutrition of also relevant, as are village methods of the mother. Some communities forbid measurement, as, for example, the types sexual intercourse for parents until a of spoons, bowls, bottles, gourds, or child has reached one year or more. other containers. Numerous customs may influence Ideas about Illness. Parents will practices in food preparation; for in­ usually have quite different ideas as to stance, in traditional Hawaiian society, what they believe to cause disease in the man did the cooking, but had to their babies (i.e., evil spirits, witch- cook food for himself and his wife in craft, ritually incorrect behavior, eating two entirely separate pits. forbidden food, and so forth), and it It is necessary to know whether is important to know what is in their food is cooked in pots, in leaf packets minds. or in various other types of containers. Local concepts of the causation, cure, The appearance, consistency, flavor or and prevention of disease are often lack of it, color, and temperature may complex. Illnesses, especially diarrhea, greatly influence acceptability of food. are often treated by dietary changes, To some people it is highli important mainly of a restrictive nature, as well that cooked food should be hot, whereas as with herbals and appropriate the temperature is quite immaterial to magical ritual, other groups. In the Highlands of New The advanced, and therefore more Guinea no liquid foods are used at all, obvious, forms of malnutrition are a practice which must be taken into often recognized and classified by tun- consideration in attempts at providing educated indigenous peoples. The terms protein supplements for the young used usually refer descriptively to some child. striking feature, or to the presumed Obviously the methods by which at­ causation. For example, the Luganda tempts are male to prevent malnutri­ word obwosi, synonymous with lion through nutrition education will "kwashiorkor", "disease of the dis- need to be kept within the framework placed child" indicates astute insight of local home economics and the reali­ into the social background, but reveals ties of the kitchen. no understanding of the actual dietary causation. Meal Patterns.In some communities, it is usual to have only one or two meals Food Preparation.The traditional daily, which means that the nutritional methods of food preparation are needs of young children are particn. plainly of great practical importance, larly difficult to meet, unless extra meals as far as tile feeding of young children are arranged for them. In much of the is concerned. Foods may be cooked by world there is little appreciation of the boiling, by steaming, by barbecuing, or special needs of children.

66 Also, the method of eating and the Another important point with regard intrafamilial distribution of food may to meal preparation is the realization be of relevance. If, as is often the case, that the tropical mother's day is ex­ the family eat together and use their tremely busy and full. She will have fingers rather than cutlery, then young many chores occupying her from dawn children are often at a considerable dis- to dusk, including collecting wood, car­ advantage. Not only are the more nutri- rying water, and, in some communities, tious foods given preferentially to the cultivating the fields. Under these cir­ older males, but the small child is in- cumstances, suggestions concerning the experienced and less adroit at feeding use of local foods for young children, himself and often tends to get the car- or the attempted introduction of new bohydrate staple rather than the pro- processed foods, are not likely to be tein-rich sauce or relish, which is often followed if they impose much extra somewhat liquid. In some cultures burden on an already crowded and forced hand feeding of young children over-full day. by the so-called "swallow or suffocate" method can lead to aspiration pneu- Food Production. As is understand­ monia. able in view of its importance to sur­ Many practices encountered in devel- vival, traditional agricultural practices oping countries will seem rather ridicu- are everywhere much bound up with lous unless certain patterns in Western rites and customs, so that attempts to culture are considered. In the 1955 change may be extremely difficult and edition of a standard American book likely to meet with opposition or, at on etiquette, there is a chapter titled least, with lack of enthusiasm. "Foods That are Sometimes Difficult," The planting, harvesting and storing referring to certain foods that can be of the cultural super-food is particu­ eaten by hand without offending one's larly likely to be the occasion for cere­ host or neighbors and certain foods monies and rites of fertility. Phases of which must be eaten only with the aid agriculture are also likely to be related of various utensils. The fact that these to the calendar. are classified under the heading of eti- Disasters to food crops, such as quette in no way makes them different drought or locust swarms, may be from equally absurd and arbitrary cus- equated with the influence of ultra­ toms elsewhere. human forces, often especially with The prechewing of food is practiced witchcraft. Specialists may exist for by numerous communities in various specific problems, in Africa particu­ parts of the world, including the Hadza larly rainmakers. may be much of Northern Tanzania, some Eskimos, Animal husbandry an vaious Polnean gomepsk , influenced by the particular symbolism and various Polynesian groups, of certain animals in some communities. The order in which various members In New Guinea, the pig is important for of the family eat at meal time is im- status and not eaten except rarely at portant because sometimes the adults, large-scale, nutritionally wasteful feasts. particularly the father, may eat first In much of Africa, especially among and receive the more desirable portions pastoralists, cattle represent wealth, of lood, leaving little for the children, prestige, and bride-price, In rural 67 Burma, chickens and eggs were tradi- of illness occurs. Thus, in India, tetanus tionally reserved for divination rites, of the newborn is common in some areas because dung, a product of the Pattern of Authority in the Family. sacred cow, is used as a dressing on the Of great importance to practical nu- umbilical cord. In Buganda, kwashi­ trition education is to discover which orkor is partly related to the over­ member of the family is responsible valuation of the plantain-the local for the final word on the choice of diet cultural super-food-in the diet of for the young child, and also for the young children. control of the family purse and deci­ sions as to management in illness. Very Effectiveness of Health Education. often this may be the father, although, Secondly, much improvement in the in communities with extended families, field of nutrition is sought through the grandmother or the mother-in-law health education-that is, by attempts may be at least responsible for decisions to persuade people to modify their pres­ as to what food the young child should ent dietary behavior. This is particu. be given and when. larly difficult to do in the field of food and nutrition, but can be best ap­ IMPORTANCE OF CULTURAL proached with most chance of success FACTORS by working within the frame of refer­ ence of local ideas. All those working outside their own In fact, it is a classical mistake to culture pattern, especially when in assume that the parents concerned have direct contact with communities, must no ideas on food and infant feeding have a clear understanding of cultural themselves, and that all that is required relativity, and realize that all their own is to make available to them modern practices and customs may not be factual knowledge. Methods of trying logical and ideal anywhere, and partic- to persuade parents to change feeding ularly that they may not be appropriate practices are considered elsewhere outside their own community. For (pp. 95-114). example, in the Western world, it is now realized that btrictly regulated "by the Acceptability of New Infant Foods. clock" breast feeding is incorrect, and In many parts of the world, attempts that a more permissive attitude toward are being made to introduce low-cost, timing-such as is practiced naturally high-protein infant foods. It is possible iy traditional village mothers is more to plan economical, acceptable, and nu­ likely to suit the nutritional needs of the tritionally desirable food supplements baby and lead to psychological rapport for young children only if the product, between the nursing couple. and nutrition education relating to it, An understanding of the local pattern are suited to the indigenous culture. of customs and beliefs is important from several points of view. Establishing of Rapport With People. Lastly, but importantly, a Disease Patterns. Firstly, a knowl- sympathetic understanding of local edge of cultural practices may help to ways and attitudes is helpful to the for­ explain, in part, why a certain pattern eigner in ensuring his acceptability by

68 the local community and by estab- exist because of sleeping sickness, and lishing a friendly rapport with them. no alternative sources of good quality protein are available. APPROACHES TO CULTURAL Likewise, practices which favor the VARIATION early introduction of animal protein foods for young children are also bene­ It is vital to become as familiar as ficial, such as the use of bone marrow possible with the local culture pattern, among the Hadza of Northern Tan­ This can be attempted by the reading zania. of appropriate general, anthropological, Beneficialcustoms should be actively and nutritional books or papers con- adopted into nutrition education. By cerning the particular region, and must these means it seems likely that the form an important part of the general confidence of the group may be ob­ preparation for anyone about to work tained, and subsequenr suggestions on overseas. customs regarded as harmful may more Discussion with, and questioning of, likely be heeded. apparently well-informed, modern­ educated local people and foreigners Unimportant Customs. Certain long resident in the country are often practices may appear strange and un­ helpful, although the bias of the par- necessary to an observer reared in the ticular informant has to be borne in U.S.A., as, for example, avoiding giv­ mind. ing double-bananas to pregnant women If it is realized that differences in in case twins are produced, or using practices and customs are certain to be special meat from the nose of the hyena found, a great deal can be learned by to help blind children to move around unobstrusive observation and, when better. sufficient rapport has been achieved, by If, however, they are of no signifi­ friendly inquiry. cance one way or another to the health and nutrition of the child, they should CATEGORIES OF CUSTOM be left well alone.

It is often possible to classify cus- Customs of Uncertain Effective­ toms roughly into four groups accord- ness. Sometimes customs will be found ing to their apparent effect on health which appear to have both beneficial and nutrition, and harmful effects, so that it is difficult to say how they should be classified. For Beneficial Customs. These are cus- example, in some African communities, toms which appear to benefit the various clays or earths are fed to chil­ health and nutrition of children, dren. Without analysis, it is impos­ although they may be very different sible to be certain of their value or from Western practices. For exam. otherwise. pie, prolonged breast feeding (p. 120) With customs in the uncertain group, up to two years or so is a beneficial further observation and investigation practice in most of the tropics, especi. is required before undertaking any ally in areas of Africa where no cattle action.

69 iHarmful Customs. In all cultures change (p. 96). Without motivation, there are practices which are harm- improvement is not likely. ful from the point of view of health and Occasionally, it may be possible to nutrition. In Western countries, the plan infant feeding so that it is nutri. excessive use of sugar and over-refined tionaly correct andis acceptable in the flour is undoubtedly in part responsible local culture pattern. Thus, milk, which for the high incidence of dental caries, is "hot," will not be given by a Bengali In various tropical countries, the mother to her child recovering from a following practices may be mentioned "hot" illness, such as diarrhea. How. as being harmful nutritionally-the ever, she will be very ready to give prolonged starvation of children with home-made acidified milk, which she diarrhea, the restriction of protein categorizes as "cold," thereby achiev­ foods for pregnant women, and an ing the same nutritional goal. under-usage of eggs for young chil­ dren, because they are too "hot" or lead FURTHER READING' to baldness or for other cultural D. B. JELLIFFE, infant Nutrition in the reasons. Subtropics and Tropics, WHO Monograph Health education is often largely No. 29, Geneva, (1955) (G&T). H Culture, Social Change and Infant concerned with the last category-that Feeding,Amer. J. Clin. Nutr. 10, 19, (1962) is, with harmful customs. Suggested (G&T). B. D. PAUL (Edit.) Health, Culture and methods for use in trying to deal with Community, Russell Sage Foundation, New deleterious feeding practices are given York, (1955) (G&T). elsewhere. M. READ, Culture, Health and Disease, Tavistock Publications, London, (1966) It is absolutely essential to try to con- (G&T). vince parents of the need to modify the particularpractices-thatis, to moti- G=Recommended for the general reader. T=Recommended for the technically trained vate them to want to learn how to health worker.

70 chapter v

MALNUTRITION IN CHILDHOOD

CAUSES OF MALNUTRITION causes, such as infections, are usually also present. diet may itself be due The causation of all forms of mal- An inadequate to to a darit of c auses: nutrition, from marasmus (p. 82) may put various foods obesity, is always complex, and this is 1. Poverty certainly so with malnutrition in young beyond the budget of the family, and children in developing tropical regions, this is especially the case with regard This realization is fundamental be- to expensive animal protein. cause, in different parts of the world, 2. Certain foods may not be avail­ the same type of malnutrition may able in adequate amounts in a commu­ occur with very different causative fac- nity because of poor production, some­ tors responsible. It is plainly necessary times because of an unsuitable climate to know the detailed causes of malnutri- or soil, or defective food distribution tion in a particular region, because or marketing. without this knowledge it is not pos- 3. There is usually a lack of knowl­ sible to plan and to carry out a pre- edge of the best foods for different age ventive program relevant to local groups, and especially the special die­ circumstances. tary needs of young children, such as Three main groups of causative fac- the high requirement for protein during tors will be considered here: (1) this phase of rapid growth. Without ex­ dietary inadequacy, (2) infections, posure to modern knowledg - it is im­ and (3) socio-cultural factors, possible for a,- intelligent but illiterate and uneducated individual to have Dietary Inadequacy. In tropical any awareness of modern nutritional children, malnutrition is often in large concepts. part directly due to dietary inadequacy, 4. Lastly, what may be termed whether this be a lack of nutrients or "wrong knowledge" may be nutrition. an imbalance. However, at the same ally significant. This may form part of time, "pure" dietary malnutrition is the the traditional local culture pattern exception, and other precipitating (p. 61) or may be a recent importation 71 into the community. For example, in follows the "whoop" at the end of the Bengal a study was carried out which characteristic bout of coughing. also showed that, although kwashiorkor was Infections with various parasites most usually mainly clue to poverty, may have nutritional relevance. In are there were, in fact, a range of locally some countries, young children available protein foods which were not continually exposed to malaria during '.ie being given to the child for a variety of early childhood, and apart from mil­ different cultural reasons ("cultural general effects of any fever, the blocks"), lions of malarial parasitis throughout the child's body also affect the nutrition Infections. Much work has been car- directly, as they too have needs for var­ ried out recently on the interaction be- ious nutrients which are derived from twcen nutrition and infections. It has tile host child. Also of importan:e can been shown that many infections occur be heavy infections with various intes­ more easily, persist longer, and have a tinal parasites, especially with round­ much higher mortality rate in malnour- worms and hookworms. ished children; while infectious dis­ easLs also play an important role in the Socio-cullural Factors. Various initiation of malnutrition itself. socio-cultural factors can play a part Many infections are characterized by in the causation of malnutrition. poor appetite, and sometimes by vomit- Separation from the Breast. The ing and diarrhea. Apart from this, it method of separation from the bieast has been shown that during even minor is often very relevant-particularly how infections the body's need for protein and when this is carried out. In different and other nutrients increases. Also, in communities, this may be at various some communities the diet during in- ages, with different degrees of abrupt. fections may be severely restricted, or ness or gradualness. Sometimes substi­ the child starved, as a misguided part tutes may be given in the form of food of treatment. delicacies, and sometimes there may Infections are of particular impor- be actual geographic separation from tance in the production of malnutrition, the mother when the young child is especially marasmus. kwashiorkor, and sent to stay with a relative. vitamin A deficiency, because during There is no doubt, especially in some the early years of life, they have little parts of Africa, that the sudden separa­ immunity. while infections are extreme- tion of the child, who previously had lV common. repeated. and often occur been in close contact with the mother together, both day and night, can lead to psy­ Particularly important in the causa- chologic illness. The "maternal depriva­ tion of kwashiorkor and other forms of tion" that results may be characterized malnutrition are measles, whooping in the child by poor appetite and vomit­ cough, infectious diarrhea, and tuber- ing, which are of obvious importance culosis. In some places, especially in nutritionally, as is the loss of the breast West Africa, measles is particularly milk. serious in this regard. Whooping cough Length of BreastFeeding.The length can also be of importance, especially of breast feeding is also a socio-cultural because of the vomiting, which often factor of significance as, apart from 72 anything else, breast milk often repre- represents an economical, safe, high. sents one of the few sources of good protein food requiring no kitchen quality animal protein. In most tradi- preparation and carefully adjusted to tional societies (including the Western the young child's digestion arid needs. world until very recently), breast feed- As discussed elsewhere (p. 124), breast ing is carried on for at least two years feeding alone is all that is requ;red or until the next pregnancy or the next for the first 4 to 6 months, while the child has been born. All over the world additional supplement of protein sup­ nowadays there is a tendency toward plied by prolonged breast feeding of a shorter period of breast feeding than 1 to 2 years can be of significance previously. In the tropics, this has as nutritionally. yet affected mainly town dwellers, and While this book is concerned with the majority of rural people usually the nutrition of childreni, it is obvious breast feed in the traditional way. that this is much related to the nutri­ Food Preparationand Meal Pattern. tion, health, and survival of the mother The local pattern of eating obviously herself. The mother needs a generous has significance as far as satisfactory diet based on local, usually largely infant feeding is concerned and conse- vegetable foods, containing adequate quently in the prevention of malnutri- protein, minerals, and vitamins, both tion. These patterns will include the during pregnancy and lactation. She methods of cooking, thu number and also needs a reasonable period of rest times of meals, and the priorities of and nutritional recuperation between distribution of different types of foods pregancies. within the family. Mother.Child Interdependence. In- MALNUTRITION IN digenous practices with regr rd to child PRESCHOOL CHILDREN spacing are of much nutritional rele­ vance. Children born too close together When considering malnutrition in deplete the mother nutritionally and children, it is useful to differentiate two also are more liable to malnutrition age groups-preschool children,' i.e. themselves, because they have a rela. infants and 1- to 4-year olds, and school tively short period of breast feeding children, as they have very different and the mother is not able to care for problems. The present account deals themi herself for sufficient time. with the most important forms of mal­ Tropical children are usually very n close to their mothers most of the time, f V receiving continual care, protection, so that, for example, obesity is not men­ and affection. This close contact tioned. The causation, diagnosis, sirn­ between mother and child leads to great pie treatment, and main approaches to psychological dependence of the young prevention are considered for each of child on his mother, these conditions. Also, the stores of nutrients obtained The from the mother in the last three months diffcrent "prso hiis In n of g ya rrent ways by various authorities. In the r present account it refers to all children up ing infant. After birth, breast milk to theirfifth birthday.

73 Rapid growth is a fundamental char- continued, but the quantity is no longer acteristic of a healthy, well-fed young sufficient jor the larger infant; addi­ child, and the growth curves seen so tional foods given to him will all too commonly in young children in many often consist of insufficient quantities tropical countries are revealing, as they of carbohydrate pastes and gruels with indicate the type of circumstances little in the way of protein or vitamin­ which can easily lead to the develop- rich foods. Also, at this time the infant ment of malnutrition, will be losing the immunity which was Growth curves in less well-to-do chil- passed to him across the placenta from dren in many tropical communities his mother and will begin to be suscep­ often show four stages: tible to various infections. Birth to 6 Months. Birth weights of Usually, therefore, during the second tropical babies are usually somewhat 6 months the growth curve is less good below the standards considered to be than in the early months of life; al­ "normal" in Western countries. Rea- though, if breast-fed, severe malnutri­ sons for this may vary from one region :ion is usually not seen. However, if to another but include maternal malnu- lactation fails, nutritional marasmus is trition and overwork during pregnancy, likely to develop. malarial infection of the placenta, in- I to 3 Years. The next phase of adequate prenatal care, and inherited growth is undoubtedly the most dan­ (genetic) differences in diverse human gerous, often especially the second groups. However, it is probable that year. Breast feeding may or may not genetic diffe-cnces are less important be continued during some or all of this than previously considered, as the birth time, but the amount of protein sup­ weight of the babies of well-fed, upper plied in this way is small. The diet dur­ socio-economic groups corresponds ing this period will all too frequently much more closely with Western be largely composed of rather ill­ standards, cooked, indigestible vegetable foods If the infant is breast-fed as is, fortu- often predominantly carbohydrate in nately, still the case in most rural nature. The protein content of the diet tropical communities, weight gain is will be low, while at the same time the usually very good during the first 4 to child will be involved in a continuous 6 months of life, as lie is receiving an succession of bacterial, viral, and abundant supply of protein and Calo- parasitic infections. Also, this is often ries from his mother's milk and has his a time of considerable emotional upset own stores acquired during pregnancy during adjustment from babyhood to to rely upon. During this early period, childhood proper. the weight gain may be superior to that It is during this transitional period of bottle-fed Western babies, and it is that in many areas the growth curve no exaggeration to say that in some becomes seriously abnormal. Weight communities an individual may never may continue to increase very slowly, be better nourished throughout life as or the curve may remain almost flat at the age of 4, to 6 months. during some or all of this period. In 6 to 12 Months. During the second 6 some children, the weight may actually months of life, breast feeding is usually decrease during this period so that it

74 the is by no means unusual to see a child of fecting in some degree over half 18 months who has reverted to his young child population. original weight when 6 months old. The term PCM is, in fact, a collective Failure of weight gain is the earliest term and refers to a variety of different sign of malnutrition and may herald clinical forms of malnutrition. These decline into the severe forms-maras- can be best visualized in the form of a mus and kwashiorkor. triangle, which is intended to show that Over Three Years. After tlie age of there is a gradation between the three years, the young child has fre- normal, healthy, well.fed child at the quently acquired a certain degree of apex ol the triangle and severe PCM resistance to various infections and is at its base. In between, mild and able to obtain and digest a wider range moderate degrees occur. Two types of of the family diet. Under these circum- severe PCM-nutritional marasmus stances, although he may remain below and kwashiorkor-can be easily recog­ standard weight and height for years, nized. he starts growing slowly. The term PCM is used for this group However, in the event of famine, of conditions because all ol them are war, or complete family breakdown, due to a diet low in protein but with such as may occur with refugees, mal- different levels of intake of carbo. nutrition may be seen in older children hydrate Calories. The name also draws or even in adLIts. attention to the fact that Calories are While the ultimate impact of lesser Important in the diet of the young child degrees of protein-Calorie malnutrition and also in the treatment of PCM. The on physical development in later life -ather vague label "early childhood" requires further study, there is no is deliberate, because PCM has a doubt that the short stature and under- slightly different age incidence in var­ weight physique of some communities ious parts of the world, although always is the result of childhood malnutrition having its main occurrence in the early together with continued inadequate nu- years of life. trition thereafter. Long-term effects in- PCM has recently been shown to have elude possible mental retardation and long-term consequences among survi­ narrowed pelves, which in women lead vors which are of a greater importance to difficulties in childbirth. than previously realized. Not only do the severe forms of PCM have a high Protein-C a a r i e lalnurition mortality, and the lesser degrees make (PCJII) of Early Childhood. Studies children more susceptible to infections, but also they may rsult in physical in the last decade have clearly shown stunting and permanent brain damage. that the most important form of malnu- theefrea llp e m en fr pe. trition in developing tropical countriesnil-Therefore, all possible means for pre­ is what is termediseried hatis "protein-Calorie prtei-Caori nmal-vetnthscdtiimutbbrgt venting this condition must be brought nutrition of early childhood" (PCM). into action. This can occur with several different The word "kwashi- clinical appearances, as will be de- KWASHIORKOR. to medical scribed below, and in many parts of the orkor" was introduced in the world is so prevalent as to be the pri- literature by Dr. Cicely Williams mary public health problem, often af- early 1930's. It is from the Ga language 75 806-112 o-OS--6 of West Africa and means "disease that protein-rich blood from the small in. occurs when displaced from the breast testine, it can lead not only to anemia, by another child." It is interesting that but can be an additional factor leading :her African languages have niames to kwashiorkor. By contrast, in another for the same condition which also part of the same country, the round. referred to this association. Howev,,z, worm is a very common intestinal although as noted earlier, kwashiorkor parasite, and in heavy infections, sev­ often does occur after weaning from the eral hundre, I of these large worms may breast, it can also develop months after assist in th,, development of malnutri­ separation from the breast. tion as a result of their absorbing food Causation.Kwashiorkor is one of the from the intestinal contents. severr. forms of PCM. It is due to a diet Diagnosis. (Figures 9 and 10) The which is very low in protein, especially clinical appearance of kwashiorkor animal protein, but one which contains varies in different parts of the world, Calories in the form of carbohydrates. both because oi the genetic character­ In other words, it is not starvation, but istics of different human groups and is due to an unbalanced diet. While it also because the detailed causation of can occur at a wide range of different the condition varies as regards diet, as. ages from infancy even up to adult life, sociated infections, etc. The signs found it is usually most common during the in kwashiorkor can be conveniently third growth period mentioned above-- divided into three groups: (1) always that is fr:m 1 to 3 years. present, (2) usually present, and (3) During this period, the child has high occasionally present. needs for protein for growth, and yet 1. Signs Always Present. Four signs is often receiving an indigestible, bulky, are always present in children with largely carbohydrate diet, and is still kwashiorkor: edema (swelling of the further nutritionally burdened by many feet, ankles, and elsewhere), growth common, often multiple infections, in- failure (especially a low weight for cluding measles, malaria, and infective age), psychological change (misery, diarrhea. As noted earlier, psycho. poor appetite), and weak, wasted logical factors also often play a part, muscles, with some overlying sub­ especially if the child has been abruptly cutaneous /at. separated from the mother's breast Edema is the cardinal sign of kwashi­ Kwashiorkor is, then, a disease orkor. It is usually obvious on inspec­ principally due to an unbalanced, tion and commences on the feet and largelycarbohydraediet, but is always lower legs. Other parts of the body, in part caused by injections and para- including the back and hands, may be sites, which make still worse the basic affected. dietarynutritionalinadequacy. In mild cases it can be demonstrated The detailed factors causing kwashi- by pressing firmly with one finger on orkor may vary considerably from one thc ankles or on the upper surface of part of the world to another. Thus, in the foot, for three seconds, when a one part of Uganda hookworm infec- definite pit will be produced. The edema tion is very common in young children is partly the result of the low proiein and, as these intestinal worms drain content of the det, which leads to defec­

76 FIGURE t.-Kwashiorkor in two-year old Ugandan child, showing edema, misery, wasted muscles (with fat prebent) and growth failure, together with slight hair changes and a marked "flaky paint" rash. 77 tive production of plasma by the body with subsequent leakage of fluid from the small blood vessels. The growth retardation, which is a characteristic feature of kwashiorkor, is to some extent masked by the water­ logging effect of the edema. In fact, a truer picture of the degree of under­ weight can better be judged after some days on treatment, when, as the edema disappears, the weight at first decreases before commencing to gain as the child starts to grow again. Children with kwashiorkor are no­ tably miserable, apathetic, withdrawn, '.-..* nimmobile and with little interest. They also have a poor appetite. Various factors may be responsible for this, in­ eluding the psychologic upset produced as a result of separation from the breast. Also, actual changes in the brain, both biochemical and anatomical, may be in part responsible. During recovery, the child's return of interest in his sur­ roundings is an excellent indication of progress. U;.[ Muscle is the body's principal store of protein and is used up by the child S- . developing kwashiorkor as emergency rations of this nutrient. The thin, wasted muscles can easily be seen, es­ pecially in the upper arm and in the neck, where they may be so reduced that the child is unable to hold up his head. By contrast, there will usually be a layer of subcutaneous lat present, which reflects the child's intake of carbo vdrate Calories. 2. S ns Usually Present. Although not req. red for diagnosis, various hair and skin changes, anemia, and loose FIGURE 10 Kwnshiorkor in Guate- stools are usually present in children malan child, showing edema, misery, with kwashiorkor. Characteristically, asted muscles (with fat present) and growth failure, the hair is light in color, silky in

78 texture, straight,sparse in distribution, diarrhea, caused by bacteria swallowed and only loosely attached to its roots, by the child, but may be due to a reduc­ so that it can be plucked out easily. Oh- tion in the body's enzymes, as these re­ viously, assessment of hair changes will quire protein for their production. Low depend upon the normal appearance levels of intestinal enzymes lead to in. for the particular genetic group. adequate digestion of food and the pass. Plainly, a standard for Swedish chil- ing of loose or semi.solid stools. dren will be different from that for 3. Signs Occasionally Present. A Indonesian infants. wide variety of other signs may be Hair abnormalities in kwashiorkor present in children with kwashiorkor, can vary considerably, especially with including a flaky paint rash (Fig 9), regard to color change. If kwashiorkor an enlargedliver, ulcers andopen sores develops suddenly, the hair may be on the skin, and sometimes the features completely normal. Also, abnormal of associated deficiency of various light colored hair can be seen in young vitamins, such as vitamin A. children in the "kwashiorkor age Treatment.Severe cases of kwashior. group" who are plainly not suffering kor should be admitted to a hospitalfor from this condition. However, this treatment, if at all possible, as even usually occurs in communities where there the mortality may be up to 30 per. children's diets are protein-poor and cent. They need special biochemical predominantly carbohydrate, and some investigations and other tests to exclude of these children may probably repre- less obvious infections and to guide sent lesser degrees of PCM. l e obv i led ret en n g e Especially in darker complexioned more detailed treatment. In general, children, there may be a parallel lighten, treatment should include dietary ther­ ing in color of the skin itself, which is apy and nutrition education of the often particularly noticeable on the mother. face. Both lightening in color of the 1. Dietary Therapy. The main es­ hair and skin are probably mainly due sential in the treatment of kwashiorkor to deficiency of certain amino acids, is to keep the child warm and to supply Another feature usually but not what has been lacking from his diet­ always present is anemia-that is, an that is, protein-in a form that he can inadequate production of red blood take and easily digest, together with an cells. This may be due to a variety of adequate supply of Calories. causes including the low protein con- Usually a milk formula is used, fre­ tent of the diet together with lack of quently based on dried skimmed milk other substances mation of blood, requiredespecially for iron.the for.In (low-fat milk), as this is economical many communities, there may also be and sometimes available either from man comuntie,teremayals be UNICEF or some other organization, other conditions likely to aggravate any dietary anemia present, including or commercially from shops or stores. malaria and hookworm disease. Alternatively, suitable formulas for Some degree of loose stools is usually treatment can be prepared from fresh prcsent in kwashiorkor. This may cow's milk, full cream dried milk, or sometimes be due in part to an infective evaporated milk,

79 Extra Calories should be added to The daily dosage of apy of these milk all these milk formulas to prevent the formulas can be calculated approxi­ protein being burnt as Calories by add- mately by multiplying weight in lbs. by ing cane sugar and, in the case of 21/2 which gives the 24-hour total in driedskimmed milk, preferably by add- fluid ounces. In the hospital this will ing both sugar and a digestible, edible often be best administered through an vegetable oil. The dried ingredients-- intragastricplastic polyethylene tube, that is, the milk powder and the either as a milk drip, or by giving cal­ sugar-are mixed first in a bowl or culated feeds by syringe down the tube plastic pail. The vegetable oil, which at 2-3 hourly intervals. may be sesame, cottonseed, or other I it is absolutely impossible to admit edible oil, is then stirred in slowly and a child with kwashiorkor to a hospital, thoroughly with a wooden spoon. treatment should be tried using one of Finally, the coole,' boiled water is the milk formulas suggested in the total mixed in to make up the final liquid quantity advised, but divided into eight diet. If there is a refrigerator in the small feeds given at two-hour intervals hospital, it is useful to make up the throughout the day, from 6 a.m. to 10 total quantity for the day at one time. p.m. This method requires much pa­ This will often be 40 fluid ounces tience and can be very time-consuming (1,100cc). as a result of the child's apathy and The following simple but effective lack of interest in food. It can be at­ formulas may be used: tempted with supervision in the child's a. Dried skimmed milk powder 20 home, or in a feeding center, or a nu­ level teaspoons ' (10 level dessert trition rehabilitation center. spoons), sugar 4 level teaspoons, edi- As soon as the child shows signs of ble oil 6 level teaspoons, to 20 fluid improvement as evidenced by disease in ounces (550 cc) of boiled water; edema, by a general improvement in b. Full cream milk powder 20 level alertness, and by returning appetite, teaspoons (10 level dessert spoons), other foods should be introduced into sugar 4 level teaspoons, to 20 fluid the diet in addition to the milk formula. ounces of boiled water; These additions should be based on c. Boiled liquid cow's milk 20 fluid the range ?f foodstuffs available in the ounces with sugar 4 level teaspoons; particular region. The aim should be to d. Reconstituted evaporated milk (1 give as wide, as mixed, and as econom­ part milk, 2 parts boiled water), with ical a diet as possible, with special sugar 4 level teaspoons added to 20 emphasis on digestible protein foods fluid ouncem. both of animal and vegetable origin, as These mixtures can often be pre- well as those known to be rich in pared more simply by the use of locally vitamins and minerals. If vitamin A available measures (e.g. tins) of known deficiency is common in the area, a size. vitamin concentrate or fish liver oil "The volume of teaspoons varies, hut these should be included in the early treat­ formulas refer to those of 5-6 cc volume. ment of all cases. One dessert spoon has twice this volume 2. NutritionEducation.The recovery (approximately 10-12 cc). of a child with kwashiorkor as a result

80 of correct diet is not only of therapeutic maternal diet during pregnancy and value, but also of educational value, as lactation. in many tropical hospitals mothers, 2. Prevention of Injections. Various fathers, or other relatives accompany measures can be attempted from the their children into the wards or visit public health point of view to minimize frequently. the burden of infections to which In areas where kwashiorkor is com- tropical children are continuously mon, group discussions and demon- exposed. These measures include im­ strations should be carried out in the munization against whooping cough, wards with, if possible, the mothers tuberculosis, and measles; the routine assisting in preparing and cooking the use of antimalarials; health education right dishes and in feeding them to aimed at measures to decrease the their children. The changing appear- incidence of infective diarrhea, includ­ ance of the improving child is, in fact, ing the encouragement of breast feed­ a "vislial teaching aid" for the group ing, the use of clean foods and feeding (p. 99). utensils, and the boiling of water; and It must be stressed again, however, malarial suppression in areas where this that kwashiorkor cases require hos- infection is common. pital treatment if at all possible. Medical 3. Adequate ChildSpacing. Kwashi­ supervision is needed to deal with com- orkor often follows the sudden stopping plicated cases, to diagnose correctly, of breast feeding because the mother is and to treat effectively the often multiple pregnant again. In order to prevent this infections present and associated vita- from happening, mothers should be min or mineral deficiencies which the taught how to postpone their next preg­ child often has at the same time. nancy until a nursing infant is slowly Prevention. There are four main weaned and eating independently. principles in the prevention of kwashi- Furthermore, if they do become preg­ orkor: (1) a high-protein diet in the nant, they need not stop nursing sud­ early years of childhood, (2) the pre- denly, but should be taught to do so vention of infections, (3) adequate gradually while eating more protein child spacing, and (4) the early themselves because of the extra drain recognition and management of mild on them. and moderate PCM. 4. Recognition and Management ol 1. High ProteinDiet in Early Child- Early Cases. Kwashiorkor is one ad- stances,hood. Basically a high-protein in most diettropical can circum-best be vanced,Early severeses. formor of oPCM, o neandad­ it obtained from breast feeding and by the should be the aim of any health service optimal posibeaus ofeavilab aniytto optimal possible use of available animal tionrecognize and to earliertake promptstages of preventivethe condi­ te po t reventive and vegetableprodcedocaly, protein vailblecomner- foods whether measurestion a att this time. The recognition prodcedlocalyavaiabl comer-of early PCM is considerej later (p. cially in stores, or issued in a supple- 84). mentary feeding program (p. 141). In N addition, the roots of successful infant NUTRITIONAL MARASMUS. The word feeding must be recognized as being in marasmus is derived from the Greak large measure related to an adequate language and has been used for years

81 as a medical term for the severely wasted, underweight young child. Causation. Marasmus differs from kwashiorkor in several respects. It is the other severe form of PCM, but is due to a diet which is low both in pro­ tein and in Calories. It is, in fact, the result of starvation. The condition occurs commonly in the first year of life (early marasmus) when it is most often the result of a failure of breast feeding and unsuccess­ ful attempts to rear the baby on very dilute, infected bottle feeds (p. 119). Unfortunately, marasmus is on the in- crease in many countries, especially in t towns, and in many parts of the world is much more common than kwashior­ kor. Late marasmus can occur at any age, including adulthood, from near starva­ tion. In particular, it can develop in the second year of life in children who are subsisting on breast feeding alone with­ out the necessary other foods (Figure 11). Once again, the basic dietary inade­ quacy is made worse by various asso­ ciated infections, and children with this condition may well he suffering from tuberculosis, infective diarrhea, and oral thrush (a fungus infection of the mouth shown by the presence of little white patches scattered over the inside of the cheek and gums). '.4. Diagnosis. The signs of marasmus may be considered in two groups: (1) always present, and (2) occasionally present. 1. Signs Always Present. Marasmus I.always Alayratezent.yereme FIGURE 1.-Late nutritional marasmus is always characterized by extreme in two-year old child, showing very growth failure, so that the body weight wasted muscles and fat, and severe will only be 60 percent or less of what underweight (Guatemala).

82 would be expected for a child of that to associated lack of vitamins, anemia, age. Secondly, there will be a very and diarrhea, sometimes with signs of marked wasting ol the child's muscles dehydration (drying up of the body). and also his subcutaneouslat.This con- Treatment. Cases of severe marasmus trasts with kwashiorkor, and is due to should be admitted to a hospital, and the fact that the marasmic child has even here their response to treatment is been living on his own body stores of often extremely slow, much more so both protein and Calories. than with kwashiorkor. Basically, the Again, by contrast with kwashiorkor, treatment is the same as for kwashi. marasmic infants are usually more orkor-that is, with one of the milk vigorous and tend to have a better ap- formulas already described, in order petite; their hair is relatively normal; to supply protein and Calories (p. 80). and there is no edema. In marasmus, However, in view of the extreme under. the face is thin, wizened, and has a weight of the infant, it is better to try "little old man" or skull appearance to increase the total quantity of feeds compared to the often rounded "moon. as soon as practicable and to base the face" of kwashiorkor. Also, the head calculation of the daily quantity on seems very large in contrast with the expected rather than actual weight. thin, wasted body (Figure 12). Hospital admission is particularly 2. Signs Occasionally Present. A required for investigations to exclude variety of other features may some- the possibility of tuberculosis and to times be present, including those due treat diarrhea. Thrush, if present, can

KWASHIORKOR NUTRITIONAL MARASMUS

Hair Changes Normal Msr<-- Old Man's

Misery--Moon Face Face

q.Thin Muscles -Fat Present ° Thin Muscles Thin Fat

EdmNo Edema

Underweight Very Underweight

FIGURE 12.-Clinical features of two main severe fornis of IPCM-kwashiorkor and marasmus--contrasted diagrainatically.

83 be simply and inexpensively treated by The clinical signs are variable and in. painting the inside of the mouth three constant. Biochemical tests are being timcs daily with I percent gentian developed but are still under trial and, violet, in addition, will riot be available to Prevention. Prevention is based on most workers in the field away from the same principles as have been men- major laboratory services. tioned for kwashiorkor, but with special The earliest sign of PCM of early reference to the irst year of life-that childhood is growth failure, and this is is, (a) a high-protein diet, (b) the pre- best detected by a low weight or a fail. vention of infections, and (c) the early ure to gain weight normally. recognition and management of mild The careful weighing o/ young chil. and moderate PCM. dren is the most important method oj In practice, for the majority of trop. recognizing PCM in its early stages. ical children this will mean (1) breast Useful information may sometimes feeding, (2) the avoidance of artificial be gained by a single weighing, but feeding, (3) the initroduction of other serial measurements at intervals are al­ foods only when required nutritionally ways preferable as they give a contin­ (e.g., '1-6 months of age), (4) the pre- uing picture of the individual child's vention of tuberculosis by BCC im- progress or otherwise. inunization, and (5) the avoidance of In tropical communities, two prob. infective diarrhea by breast feeding, by lems have to be faced when trying to boiling drinking water, and by using assess the significance of children's clean foods and fieding utensils, weights. Firstly, the question of locally If artificial feeding is absolutely appropriate standards of comparison necessary, particularly if the mother is has to be considered. Standards may dead, a cup and spoon or a feeding cup occasionally be available from measure. are preferable to a feeding bottle, as ments made on healthy, well-fed chil­ the latter is particularly likely to be- dren of the local elite. Usually, they are come contaminated and a major source not, and the standards given in the pres. of infection. If. however, a relative in- ent book are those collected in Boston sists on using a feeding bottle, then in the 19 3 0's (Appendix 11I). Although advice mmust be gi~ her as to how she they may not always be genetically ap­ cran atlempt to minimize the risks of propriate, they are convenient and infection. widely used. Also, present evidence sug­ Mtt.D-M IotrRArE t'CM. For every case gests that really well-fed children oi of severe I'CM, whether nmarasmus or different ethnic groups are more kwashiorkor. there are many hundreds similar in weight than previously (if thousands of young children suffer- appreciated. ing from the earlier stages of mild to Secondly, a major difficulty in many moderate PCM. Plainly, it is necessary tropical communities is that of age as­ to try to detect cases in the early stages sessinent. Precise ages are not usually and by suitable advice and management known, as they have little significance to prevent them frorn erer reaching a in most traditional societies. This poses se:eredegree. an obvious problem, as weights in Diagnosis. The detection of mild to young children have to be compared moderate PCM is by no means easy. with standards for the appropriate age.

84 Attempts must be made to see if docu. ably at least fortnightly), and the mentary evidence of birthdate is avail- mother should be given careful advice able, or if the mother in fact does not on locally practicable infant feeding. is­ know tile age but can recall the actual sued with dried skimmed milk or other day or month of birth. Alernatively, a protein food supplement, and also, if calendar of local events can be con- practicable. the child should he foI­ structed from whici the child's birth- 10 wed up1 b nbeal s of home visiting. date cani lie approxi matelv pinpointcd. If the weight is between 110 to 11)) The stage of dental eruption may Iteent of the stan da rd, te mthl~er also be helpful at least in giving a should be given advice on infant feed. lower limit. esp ially as this seem s to be little affected by malnutrition. ]low- ing, antd weighing (-ntinnel in te ever, as is well known, there is much future at monthly intervas. variation in the appearance of teeth Serial weighings shouhl alduays he even in health),, well-fed children the aiml, and results (all best le plotted (Table 1). oil weiglit graphs, if such are available. A simple approxiiation cali be used By this means, failure to grow ca iLe where tile age in months is calculated deleed early 1))' a falling or Stltion­ by adding six to the number of teeth ary weight curve for tile jiart icuilar present. child. If weilghl graphs are riot avail. If only a single weighing is possible, able, levels of "inadilate weight gain" this can be compared with standards may be used (''able 2). for age given intabular form in Ap- Both an alormal weight curve or an pendix Ill, or as a graph (p. 156). Both inadequate weight gain shold alert the representations show tile "standard" observer to deterioratin intriion and (or average for weil-nour.;shed ehil- the nieed for careful advice oii infant dren) and levels for 80 prcunt and 60 feeding, for more frequent supervision percent of this standard, and for the issue of supplenientary pro­ If the weight is below 60 percent or tein food if available. if edema is present, Iospitalization is In many tropical circu instan'es, it indicated if possible. If the weight is may be imlipossible to obtailn the (xawt between 80 percent and 60 percent, the age. althugh ill surveys dental second child should be seen frequently (prefer- year may be defined as chilren with

Table 1.-AVERAGE ERUPTION TIME OF FIRST TEETH'

Tooth Lower ,Jaw Uipperjait,

Central incisor ...... 6 months ...... 7..months. Outer incisor ...... 7 months ...... 9 months. Canine ...... 16 months ...... 18 months. First molar b...... 12 months ...... 14 months. Second molar b ...... 20 months ...... 24 months. I Reproduced by permission from Massler& Schour (1944). a Incisors range ±2 months. t,Molars range ±-4 months.

85 Tal ?;

Age' (mhi) Mirnitm dqwn ofJ Inadtquaie Wi$'dht 0a l Qbwiaswlio (moti)

7-12 1l 11 4.53 g)pcr 2 nontla 1tib 453 g)pcr -inotas.

I I-1wel- (11-MI ft),,ll tniaart h, cir- heet mentioned hSlenldtslCussng fIjlaanluaa'',. it aplth liscsiurtcnt of Uwashorkor and] uataraasms (pp. 8]­ -i I t(".I'l -ily- 111-1111frtl I~I ty- I Wt - Bl"I a 111lV01heelaborated later- (p.- ol-g*inaaa V Ily!J wraaiolaa ian. I50). * IvivalaIIMI) beii fuasilol %dieat "i taaaldc U;iP 'I'lle.u a eta of ilad Inia.we igl 'pitlit' (T'Iab le 2) ta y sitii andftOl li 01)) at' 'C is constIidered latter gustad'ttoateaaettag ataulataa11ialaa(p 11! In addlationa, I11Itolaeasuaretlunt of tile uIIIII etra'aaaIIIferaclceaa nlke i-ilhti it tntp. vitai(,f i )e/aciercais. rIe presenat olasaaitalc a16ayItweaat tIme elbow atadl braef acconat caan (:over onaly certain the poinat oftte %IaaderhIkay b~hae fail. maajor aspccts of the cot nt onter via inini Tisa ~it ItIIA a tint d ill Severe PCNI defiienacy aiseases,d especcially those ta11141Ils( 14 paa r' to behaffected it lessear i ait. are pubI lic heathl prolemtls int dvlevsN' of IaaaalaaaaItiaatn. It is especially' variouas parts of the wvorld.' naitfa intat( shtecondaa yeaar of life Mien, VII NiIN A Dt. tIIF~iNCY. Avitamainosas ial nora al cIa 11(1 it the a~ Ari- A as see Ci O naOlly it) younag chlildreat f.~eece reainis maore or less cons~tant tnatitItropical re-gions, but is'a common (16 (-1at) II'irtgliolt IIat. whtol. of this aaaaalimnportant condilioat itt certain year., TIhe reti9oaa for thisa as tht iac regions including parts of India, Indo-' compteIJ~atts of the arat tare. cagiiang nessia, anad tlac eastern Nlealtrrtmcan Wilt ilt!~afial of~ aanfantcy beang replaced counatries. * by te mauscle of [lhe toddler, but %itla Causation. rhte condiition is caused *thle overall (:ir-caaaference reciaianng 1h,atvery low ini Ike of vitamin A, both tabot the samet, ats 'the' vitamin itself and in' the form TlO detect catrIy PCM if the age is of the ortaage-pigmcented foods contain­ raot kno%%am exactly, thet iaran circum. ing carotene, the proa-,arsor. of vitamin fereaace of chlildren ill tiac second year A (p).18). It is particularly likely to' of~life, ay he compared with various *occur an children whose mothers are on peorcetntages below. stanidard (16 can) :a' diet poor in vitamin A and who have, 90 percent,, 14.4 can'; 80 per-cent, 12.8 in c"-isequence, transferred only a cut; 70 percent, 11.2 cmi;' 60 percent, 9.6 small q'uantity to the fetus during preg­ (i.Experieince sutggests that children nancy,' and whose breast milk is also withmeasremets blow80, percent poor in this nutrient. of standard (12.8 can) require supple- Severe avitamiinosis A may 'accom­ mentary fcc'ding'if practicable. ~''' pany kwashiorkor. It is also notoriously Prevention. 'The(inain aspects 'of the associated with ill-advised attemp~ts to prevention of all de-rees of PCM have rear babies on formiulas of dried or 86 condnse. sitmmed~milk which 'are~ and the tuld should ,nlulneiat%1 ib lacking in this fat-soluble vitamn., give'n I~C)O(1--20,OO Intelnational Severe vitamin ~ deficiency isjpre-, its~of vitauin Aintra llcularly or doiunantly a problemn of the'earl) years fly 'mouth as drops onl the ha 'of ilha

of life. "~A tongue, Thereafter, trcatinent~should lie Diagnosiu Vitamin A is required for continue 4with a daily dIose of 25,M() the normal functioning >of certain W. ,vitamin A byno uth for 5 days, to. epitheliaI.may Iprodu :@ celsof,:'; ight'.,e,ile . body., .nd DeficiencyeS, but getheroure...... of;with antib a ifiticshigh-protoin ?diet 1wl)niilan~d 'a this is ci reelvKdificult t ;dcect ~in lii orsulfm mnidt8 as inftm:ioiof ilia ateyoung chidren, who are Princlpallnn lik< __ _ohave______

'afected, ith'-sL~vedelgrees'of this con-K throi4,li the" weakeiiid 'cornea. ' : dition. III addition, various forms of finaras where vitain 'Aefciency dry and roughened skin may mometimesmon, 25 0 s .beass.ocated with lack ofvitamin A. given 1 mouth to all children foltaw. "Howeer, the main effects of vitamin ing nisle or diarrhea. r. ~A deficienicy are onl dhe eye- The conl Prevention, Tho preventlion of junctiva beccomes~ dry and b'rownish in- miitamninosis A of 'early Childhood stead of glisteming "iiid muoist. Some- should comnco in pregnancy when times a silver or white~superiil ~ nte' itsol oti tg.1 roughly triangular patch appears on oroiis quantity of this nutiemnt or, more tile conjunctiva of one or both eyes usually, of carotune-.COt11Ing foodsi (Bitot's spots). This znay be followed (1p.18). This 'will enstre adequaite fetal1 by'a dryness and cloudines of the storm This diet should also ) en-* cornea wh~ich in turn may lead to a coitraged (durinig brcwit f(4-ding. softenin- of the corneasand a rupture I 'areas of the world where severe *of the eyeball.' Both .eyes are usually af. cvitamin deficiency is common InIYoung fected, but 'often to different degrees. children, the fetal stores ay he raised Treatment. Young children with a by giving women a single (lose of dry conjunictiva should be referred for '300,000 I.U.' by miouth in the later medical attention or, if this is ziot avail- months of pregnancy. able easily, should be treated with vita- During' infancy thle b~aby should be min~ A (6,000 international, units daily. breast-fed, and after 4. to 6 months of by mouth for 2 'weeks). 'This' can be in age, when a mixed diet is intioduced, the form of vitamin concentrate or fis this should contain local sources of liver oil (cod liver oil contains about vitamin A, such as fish and animal 2,000 I.L. of vitamin A per teaspoon; and of carotene, shark liver oil, 1,000 '. of vitamin liver, and egg yolk, A per teaspoon)." At the" same time, including dark e l a rid a wid. fruits and' health education- ...... should be undertaken ...... range blesof orange-pigment(p.;18). Tile pa~wpaw i to persuade parents to widen the child's vetlsp.).....i diet to include localy available caro. often widely, available and a rather tene-containing foods. little-used food for youngchildren. It If cloudiness, bulging, or rupture of is a valuable source of vitamin A the cornea have occurred, this should precursor and, being soft and easily j be regarded as a medical emergency mashed, is suitable~for young children.

''7>87 n p~oin ofvtmnAdrn h eidifntl eieii u odeay

...... P" , youn chidi-ci,i ma be xefu and pnil ar,.m ti a p lI in etn

;';, bf anthars, wilbo ifllifow odwito frm iv r ormol, Ihota-of reateltishe fedng.:!lead d 4 ieredag: respctively averen to yung dilron(:iu'nbe usefuiainl prticvaitg asqa proeni nCatenies

erd gra andl ts lti lkl ta igW)sis5. llbies developing':in fan.- :::

milothls ofn (: til ruars2 lliis nflr vurcgnru and sisif hartfaiure, dp ot doicJ o 10i 0 0 i nra tinal fuon r mother's,ie breast ni k.rlhe) ... 4"cra owintm lk,~ofl rdllY~ oil (1etea- breatfing an ohrcillnesses io sponwit dain A requalrd.ir oriN yrkporn stolrenoft nruret iu theu eiw 5dto diMtnyhi. ______liillilil Of(2IlKisVihIIHiIn rcmdeA%lolly te f' eriodth an" usmnlaiaepiotre, b facit wic iakeser w of lr111it ill!4 Cthaisd foro 6l iilsiouiiin less cryin ( hploha) duron.

lips /::If bsdaily tillchildsho~uildt~il isartificiallybeeifoed .fcd4with fullit -suchtile bariber itsblueness is dianoipoiddioftile and rapid

suvision;l an he lisisedo, aile t reat'me.Inate ererin houClode : dail~fccilinig fit oifliroilyounig f infantsr0000 belowineat 6fronil12, rom;ocr difficultthaeir morsfor trained'bemrest doctors mihto diag.::ahe anunits of vitiunainject ie 'hichn 'byt iaveousul or~ itamscla intoe7iont. in, sevl vioi .y riii~tini Tho an oral (lose of 50oms of suddmiel m la ti thai tis i e onlyisfr biberbe n on te ' -' (ioliHIc'iiAINE~t (iae I)PI('NY. However,i'ise.i'hlg~ill;: Dfiievca of fotllsoudlsHowby1il-ver areas(apthiain whr infantildaily 1).r iruit avaitle; whenit wnllyhat e giv ic clojrto onlde timne (v~itmin B,) produtesthereafter. vu dysleatseuaionansis'o hrthueof efase nownl is aertbi. hisfcusiwitfl uhaet ' srqiedleeso pthhip an rapi olr childre r'ill th am orfpla na inroe ttiMamn 'ot'aissesfoodn yitand ns omofhous elby uari medila dvde.h Caloriesiat.In illillit'ialiii! oi A lf is prticula'sl ,(1.1 arid) ynondoei n ohdetn tefreNitabydiet.dTeherspch e yhelt

feetiuieofyong iifsklow 6 to 12ien diffiult foradited dtor oia

88~ ~i lfrno uaa I;1) oso nereeiihtersed't otei' fiainl form of tie condiioocurs be snt for medicaladvice andbwill

briberi." nhiamine If ti isiot isaiuite, any fCa vaiolabSevere thenia'in defi- vailablethiinie conaininamti

Ss almoithodnf'inoed wioseparthvteaiso pti. diaoy beused it any lcalrnmaion rown to be highhexil:1.k. levrwhnasit n

1) io1n y n _fra,_m l w c -i- e uird-okl

in t nuis tri reensyt 'or U foillte}l y incri ngl tile s,I [Allies< souo gegramehrfrs base oi bole, rpw tebayillbeinnte treaed ile' d<,l~eatredior, evauorstt. mile;+.,th o:Iond~itio

tiebrbr le setal nipo i bycl nlit-at a llr ith h proilingle of

latton trial) an~a ds ;linl wcvlinrg0f

Smilled rice, ii~ch-may benmuch pre so braniTiids ofilconuneircdialjii prepare

leu e.I o ecru sanei a i itr in adlt.F or examnpler ,

durinu thieriodlng p inariu]pat oile body,

ay iuio Vitpamiun Cdficiency0 u nis~ Prermion Th Wotnata, pre

Baialy, Wrareltheeenbibthe7theo problem bingstraed of: beriberepcalunrthcorig(r­ aue eto~nf or nfanil schev oisin the other' ud e usuall thpisane b) Isl bato eve in provsidd the ndeoute(20antity) r4 ekof ascorbicsu acid insattnohrsde cnalso giaien. 4 rvd s etoe efrb ien etogt to ibe paralyze(] beauise ihe ;; ..... o en ur that...... rice is".ndermille or til......

- - :o lactq:. -?ation' . . ,v :. ': , ., in te;:-- ia , nd; als v, in 2th 1 , - " >? v -,: 7 {7]' ;:,, !; 7{'::g: { :g ::; ¢{" th{:{, ;; ",I)7 :!; ::vi }.. :<;9,l:3 > };'} { q 47 * ::]:77 p: r,£ c {" s:7. ingi/.of {, i i c{ ,- .'£ -? taken to s t these conai lc ipl source of t .a trd e to..mxdfoscaes ulbe tpe ofecibn.-al apeane T-n. freatment::::: f

tiI:riberi)i;sen;i+ll min" :: by ;, a- o of C-rich foods. Again,'after 4 to 6 months, exposure of the skin to the ultraviolet when the diet is widened, it is important light of sunshine. to see that these also include sources of Causation. Vitamin D deficiency ascorbic acid, such as vegetables, fruits, (rickets) occurs most easily in cloudy, and germinating pulses. temperate zones with little sunlight and It must be stressed that for the breast- with cold weather which requires con­ led infant there isno need for any siderable clothing and keeps children vitamin C supplementation inthe first indoors. However, at the present time, 4 to 6 months of life. Infantile scurvy there is relatively little rickets in these is extremely rare in the breast-fed, and, regions because of a fairly wide aware­ what is more, the danger of introduc- ness of the problem and because many ing fruit juices from various unclean foods, including milks, are often rein­ sources very much outweighs any forced with vitamin D. By contrast and doubtful advantage, as they pose a con- paradoxically, rickets is common in siderable risk in terms of infective certain subtropical and tropical diarrhea, countries. In some towns, housing may In artificially fed infants, however, it be so close together that little sunshine is necessary to introduce a source of can penetrate into the dark courtyards. vitamin C into their diet, unless the In other places, infants may purposely particular milk preparation used has be kept covered by their mothers when been already enriched by the manu- they are outside, sometimes to avoid facturer. In these children, vitamin C "the evil eye" and sometimes to prevent skin. may be given in the form of a locally darkening the available fruit juice or as ascorbic acid Diagnosis.Vitamin D is required to tablets, and should be continued until assist the absorption of calcium and the child is having a full, mixed diet. to ensure the formation of normal It will be noted that orange juice, strong bones. In rickets, walking is while a good source of ascorbic acid, delayed, while the eruption of the first will also be later than usual. possesses no special or magic properties, Thleset of skl teeth islrer than normal, and arid the best, cheapest, most easily kull islarg available fruit juice with a high vitamin the back is bowed. The long bones may C content should be used in preference be bent or bowed, and there is a thick­ (p. 16 ). It may be moie convenient and ened prominence at the ends of the economical, and with less danger of bones, especially noticeable at the wrist. make Treatment. Unless in a part of the introducing infective diarrhea, to world where the condition is well rec­ use of ascorbic acid tablets (30 mg per oid it usal is rc day). ognized, itisusually necessary to carry out further investigations on the child viTAMin DDEFICIENCY. Most dietary by way of X-rays of the wrist and bio­ vitamin D is contained in expensive chemical tests of the blood. animal foods such as dairy products Severe cases of rickets are treated (p. 15), so that, for the majority of under medical supervision by large tropical children, the vitamin D intake doses of vitamin D. This can be given is in no way related to the diet, but orally as a concentrate or as fish liver entirely proportional to the degree of oil, in a dose of about 2,000 I.U. daily

90 for 1 to 3 months. Alternatively, a account, including margarine, vege. single intramuscular dose of 100,000- table fats, and milk, including dried 300,000 I.U. of synthetic vitamin D skimmed milk. may be given, which lasts for 3 months. IRON DEFICIENCY. Iron is needed to Mild or suspected cases can be given make hemoglobin, the oxygen carrying smaller doses of vitamin D (1,000 units pigment of the red blood cells. An in­ per day) for 1 to 3 months together adequate intake of this mineral leads with exposure to the sunshine for the to an iron deficiency anemia in which whole body for at least one hour in the there is a defective production of red morning or afternoon, blood cells owing to lack of this esser. Fish liver oils are frequently avail- tial ingredient. able and may often be used for the Causation. Poor stores of iron may treatment or prevention of rickets-1 be acquired during pregnancy from a teaspoon of cod liver oil contains about mother'who is herself deficient in-iron, 350 I.U. of vitamin D, and shark liver as can occur for various reasons, in­ oil, 100 l.U. cluding a too rapid succession of Prevention. In tropicalcountries, the pregnancies. best way of ensuring an adequate avail- This is particularly important, as all ability of vitamin D is by exposing milks, including human and cow's, con­ children to the sunshine, and this is tain negligible iron, so thai the infant cmphasized by the absence of rickets who has a high iron need during this in most ruraltropicalcommunities. time of rapid growth and increasing However, in some areas, such a. blood volume, has to rely to a very con­ Ethiopia, the practice of covering up siderable extent on the stores in his young children when they are outside own liver. the house is deeply held in the local From the age of .1 to 6 months on. culture, and health education to per- wards, the child's body stores are suade parents to allow their children largely exhausted, so that it is impor­ to be exposed to sunlight is difficult to tant to ensure that the diet the child re­ put over effectively. ceives in the second six months of life In high risk areas, it may sometimes contains local foods which are rich be desirable and sometimes feasible sources of this nutrient, including to issue vitamin D as a supplement for green vegetables and egg yolks. young children, either in the form of Anemia is extremely common in fish liver oil or of actual vitamin. This tropical children but, it must be noted, should be continued from 6 months to is often due to several causes at one 2 years at a dose of 400 LU. per day. and the same time. Thus, there may Alternatively, in areas of high risk, it often be a coincident nutritional iron may only be practicable to give children deficiency together with hookworm in­ a single intramuscular depot of 300,- fection, further draining blood from 000 units of vitamin D, which will last the child, and also with malaria infec­ them for 6 months. This will only be tion. Investigation with suitable blood done under medical supervision, tests is indicated whenever practicable. In urban communities, possible en- Diagnosis.The main sign of anemia, richment of foods must be taken into whether due to iron or from other

806-112 o-l---.7 91 causes, is a pallor of the tongue and Prevention. As iron deficiency in in­ conjunctiva because of the dilute blood fancy often begins with insufficient circulating in the child's small blood fetal stores, attention should be given vessels. If anemia is prolonged and to the mother's diet in pregnancy, es­ severe, the child will be tired, listless, pecially the use of dark green leafy and eventually breathless. vegetables. Clinical examination for routine hemo­ Iron deficiency anemia due to die- anemia and preferably made during tary causes occurs most commonly from globin checks should be 6 months and 6 to 18 months of age, and may even pregnancy, especially at ferrous sul­ occur in children who are receiving later. If anemia is found, 0.1. g three sufficient protein, Calories, and vita- phate tablets (1 tablet of for the mins, but who are on an almost exclu- times daily) should be given ideally, sively milk diet. However, iron defi- rest of pregnancy, although, thor­ ciency anenia, also associated with the anemia should be investigated be pos­ intestinal blood drain of hookworm in- oughly. lowever, this may not fection, can occur at any age in child- sible in many tropical circumstances laboratory hood or adult life. because of lack of available services. Treatm t. Medical advice is needed, regions where iron defi­ as various blood tests should be carried In some common, it may be out to pinpoint the exact cause of the ciency is extremely give ferrous sulphate tab. anemia. Hospitalization is required for advisable to daily) throughout preg­ severe cases of anemia, as blood trans- lets (1 tablet well-fed women from the fusion may be indicated. nancy to less In moderate anewla, treatment will lower socio-economic groups. In some areas where iron deficieacy in the diet be with iron gengiven byya mouth or ocea-. it evun more frequent, it may be possi­ sionally by intramuscular injeo;on. ble as a public health nutrition Oral iron, usually as either tablets or a approach to the problem to enrich the mixture of ferrous sulphate, is ex- staple food with iron. Thisis, however, tremely cheap. A dosage of 120 mg only practicable if the staple is in the three times a day can be used for young form of a flour and is prepared centrally times daily children, andforchidren 0.1choo rorg three at a limited number of mills. fortcho cire. asgiAn important minor, but not insig­ At the same time as giving iron me ificant, method of increasing iron dlicilially, health uducaticn should be fiatmehdoinrsngrn ttshoue stores in the newborn baby is to ensure carried out to persuade mothers to give that the umbilical cord is not cut at children locally available foods which once, but only after a few minutes, are good sources of this mineral, when blood from the placenta will have In manylparts of the world where had an opportun.ty of draining into the hookworm infection is an important baby. This extra volume is not required cause of iron deficiency anemia, the as blood, but, when broken down by stool will have to be examined micro- the baby's body, will increase his iron scopically for eggs of this parasite, and, stores. if present. the child will have to be The iron stores will be used up by treated. the age of 4 to 6 months, so that it

92 is important to ensure that the mixed deficiency (p. 17), the cracks and sores diet introduced from this time onwards at the corners of the mouth that can includes all available sources of iron, result from an inadequate intake of particularly dark green leafy vegeta- riboflavin (p. 17), and the dark, scaly bles and eggs. areas of skin that occur in niacin defi­ ciency (pellagra) (p. 19). MALNUTRITION IN SCHOOL- The teeth may show signs of dietary AGE CHILDREN abnormality. An excessively high in­ take of fluorine in the drinking water Unless the local availability of food leads in school children to character­ is very poor, school-age children do istic brownish mottling of the teeth not usually have the severe problems (fluorosis); while conmmunities who found in the early years of life, and have moved toward the more refined there is little mortality in this group foodstuffs of a Western-type diet, es­ from malnutrition. By this age, chil- pecially containing sugar, flour, and and dren will usually be eating most of the sweetened, carbonated beverages, adult foods and will have become, to who, at the same time, have little in some extent at least, immune to many the way of dental services, will show a important infections and parasites. high incidence of dental cavities as the Also, at least in rural areas, school result of untreated caries. children may have available to them Growth and nutritional status of a selection of wild foods from the bush, school-age children can be assessed by including berries, insects, and eggs. taking weights and heights and com­ Nevertheless, school children in paring them with standard weight-for­ tropical regions very frequently show height-for-age tables. Alternatively, es­ some degree of malnutrition. They are pecially if ages are not known, serial often underweight and below standard measurements may be made. As an ap­ height, which may, in part, be due to proximation, it may be noted that be­ failure to catch up following some de- tween 5 to 10 years of age, the weight gree of protein-Calorie malnutrition in increases by 10 percent and the height early childhood. Evidence of poor cur- by 5 cm (2 inches) annually. rent intakes of protein and Calories Although there is a low incidence of may be indicated by thin limbs with severe or killing malnutrition in this only slight subcutaneous fat and poorly age group. nutrition work aimed at developed musculature. school children is important because: Anemia may be present in some de- 1. In order to derive optimum bene­ gree, as judged by a pale tongue and fit from the school experience, children conjunctiva. This may, in part, be due must have an adequate dietary intake. to iron deficiency sometimes associated Many children walk long distances to with hookworm infection, although the .-chool with little or no breakfast and causation is often complicated by other with nothing available for lunch. Under conditions, including malaria. Various these circumstances, they are often specific signs of dietary inadequacy tired, unattentive, and apathetic. Sonic may be found-for example, the en- form of school meal, therefore, must larged thyroid (goiter) due to iodine he regarded as an important measure

93 in improving the value of a nation's ing food and health than older people. educational system. Also, they will be parents themselves 2. Although school children have and responsible for young children in passed through many of the infecLions the very near future. School children and parasitic diseases that cause such must, therefore, be regarded as a pri­ havoc in early childhood, nevertheless, ority group for nutrition education for they are still growing, although less the coming generation. fast, and the danger of certain infec­ tions is still considerable, especially FURTHER READING tuberculosis. 3. Lastly, D.B. JELLIFFE, The Assessment and very importatly, Nutritional Status ol the Community, ofWHO the school children represent a highly sig- Monograph, Geneva (1966) (T). nificant "target group" for health N.C. TROWELL, J. N. P. DAVIES, and R. F. education, even though only a percent. A DEAN, Kwashiorkor, Edward Arnold, age of children of this age are, in fact, London (.1 54) (T). attending school. Their school expe- GRecommended for the general reader. rience is one of learning, and they are T=Recommended for technically trained more amenable to new ideas concern- staff.

94 chapter vi

NUTRITION EDUCATION

Education lies at the core of all minimal beneficial modification in their attempts to improve the nutrition of traditional way of life. individuals and of communities. It is, The expression "nut:ition education" however, much easier to talk about than is used here to cover aspects of health to carry out effedtively, education concerned with trying to im­ Nutrition education is concerned prove, directly or indirectly, the nu­ with trying to persuade people to trition of an individual or a community. modify their way of life with a view The modifications in behavior that are to improving their health and nutri- often the aim of nutrition education, as, tion by the better use of available for example, with food habits, child resources, both traditional and modern, rearing, or agricultural practices, are and both man-made and natural. It is difficult to effect, as these aspects of life much more than the mere supplying tend to be particularly deeply wo en of information and basically is con- into the culture pattern of communities cerned with trying to convince people and often are resistant to change. with different cultural concepts of food Although poverty is often an impor­ and disease and to motivate them to tant causative factor in childhood mal­ want to make the changes suggested. nutrition, frequently a considerable It is a difficult process and much re- proportion of the malnutrition seen mains to be learned concerning the best could be avoided, if local food resources ways to undertake effective nutrition were used to a better purpose by educatior. It is a fact that in this "age parents. of mass persuasion," nutrition educa- Nutrition education is one of the most tion is still neither as efficient nor as important methods of combating mal. scientifically-based as desirable. nutrition. It should be carried out at Patterns of behavior are always in every opportunity by all members of the slow process of change, and modern staff and should be incorporated into nutrition education is concerned with all types of health, agricultural, and guiding people more rapidly toward community development work and into 95 other extension activities related to vii- change, rather than merely to offer lage or home improvement, them advice. In fact, persuasion, to be It is no exaggeration to say that successful, consists of imparting infor­ the most important global target for mation, of changing attitudes, and nutrition education is to persuade trop- finally of altering behavior. ical parents to feed their children in To change habits, people must ac­ the early years of life as well as is quire knowledge in such a way that possible with local foods produced in new beliefs and attitudes result. It is greater quantities in the village, important to create the desire for change. There are three criteria for THE PURPOSE OF NUTRITION successful motivation of the individual EDUCATION to change his behavior: 1. He must be aware that there is a Until recently nutrition education problem for him; was largely concerned with instruction 2. He must know that this problem of the "do this because I tell you it is has serious consequences and that these good" or "father-knows-best" type. It are important to him; was often immensely boring, full of 3. He must believe that there is a exhortations and admonitions. It was practical solution to the problem. often neither suited to local conditions, The process begins with understand­ nor carried out with any realization that ing, followed by the winning of con­ communities have their own well-de- fidence and the introduction of incen­ fined classifications of food, causes of tives. The ideas suggested must be disease, and so forth. suited to the local situ ition and aim at Sometimes this old-style didactic nu- improving traditional methods. trition education must have produced Learning is influenced not only by beneficial results, especially if ljrCfteIU'1L th- student wanting to learn, but by the by a sympathetic, respected, and pres- educator. He should have a sense of tigeful person. More usually, a main vocation, a respect for the people being result may have been the feeling of "do- taught as well as a knowledge of how ing something in a good cause" evoked to teach. He should be aware of the in the would-be health educator, but various influences, such as prestige, often, in fact, with little idea of the personal experience, and repetition of effectiveness or otherwise of the session. ideas which form the basis of habits. Problems with this type of nutrition He must know the people, their prob­ education are firstly, that the ideas lems, and what they want to know, and presented are too often unrelated to he must understand how poverty local concepts of disease causation, food and ignorance, long-established, deep. classification, or other aspects of the seated customs, inertia, and supersti­ indigenous culture; secondly, that tion can offer resistance to change of learning is less likely with an audience habits. He must appreciate that before in a passive, noninvolved state; thirdly, people change they must want to and most importantly, it is now realized change and that this desire involves be­ that for health education to be effective lieving that the new way will lead to it izi necessary to involve people in plan- desired goals and that it is physically ning and to motivate them to want to and economically possible.

96 BACKGROUND INFORMATION addition, attitudes to family size and NEEDED child spacing must be known.

Before the planning of any health Local, Home Economics. The type education, it is imperative to have as of kitchen, the cooking methods and much background information as pos- utensils, the fuel, the use (or otherwise) sible. Areas of importance will include: of measures of weight, or volume, will all be relevant and will indicate the Locally Available Foods. These will range and complexity of the dishes that include those available from the family may be feasible for "village level" cultivation and from the shops, coupled infant feeding, as with the amount of with knowledge as to their prices and probable seasonal variations in avail­ ability. Of principal significance will be Local Status and Activity of the protein foods, including those from Women. The type of work customarily vegetable sources, but particularly expected of women will plainly deter­ those of animal origin, as these are mine whether mothers can care for their most needed, in shortest supply and toddlers adequately themselves or have most expensive, to leave them at home in the care of Local Pattern of Food Production, siblings or elderly women. Also of great including village level preservation and importance is the degree of independ­ storage. ence women possess in relation to trying "new" methods of child rearing and Local CulturePattern. The mnessage especially 1he spending of household the educator is trying to transmit to the money. Te holders of power and villager must be iowed as an inter- authority in tdie house (e.g., the grand­ action between what the educator wants mother or father) may also be of to say and what the village already importance. knows, thinks, believes, and does about the particular matter. It is important, COMMUNITY NUTRITIONAL therefore, to know the customs and DIAGNOSIS beliefs in regard to foods, especially ''he preliminary background infor­ "cultural blocks" that prevent the use collected by discussion,0 obser­ of foods that are, in fact, available. vation, or perhaps by a special survey, Other traditional feeding habits are will enable a community nutritional frequently of relevance, including the diagnosis to he made which can be con­ numbers of meals daily, and the order sidered under three headings: (1) Pat­ of feeding within a family, tern of Malnutrition, (2) Causes of Similarly, ideas concerning causation Malnutrition, and (3) Educational of disease, and various aspects of ge- Diagnosis. eral child rearing may have nutritional overtones, as with the sudden geo- Pattern of Malnutrition. The col­ graphic separation from the breast, lected data will show the commonness practiced in parts of East Africa. In of various types of malnutrition, to­ 97 PLANNING gether with their age incidence, geo- graphic distribution,atioormnfntrtoneucto and seasonal vari- Any program of nutrition education ation. should. if possible, -be based on this Casews of Malanutrition. These will type of preliminary comnmunity diagno­ sis. after which planning. within the vary from region to region and nutri- f k of available staff and fi­ tion education will. therefore, have to iance, can take the following logical be modified to suit the particular area. which go to stels Of the various "burdens" p)rod~uce a breakdown into nalnutrition, 1. Problem. What is the nutritional (or priorities) ? social. economic. cultural, priority the following 2. Nutritional Objectives. W h a t and dlisease factors alway's require onidieao should lie done about these? W h a t consideration: 3. Educational Objectives. Dbitary. Poverty (or actual ail- shouldsn be (lone about these? should ability of protein foods), and/or 4. Content of Prograin.What lack of knowledge, and/or "wrong" this corsist of? knowledge (e.g.. food prejudices), and/ 5. Method. How should this be put or defective food production and over? should carry it storage. 6. Educators. \iho should Ih v he trained? infective. Whol)ing cough, nieasles, oiut ani] how 7. Eralhution. low should the sli­ diarrhea. tuberculosis, and so forth. " ss r Other'Iise 1) asessed? Parasitic. Intestinal worms (heavy eduleatiol lrog,an(l cain fail of' the roundworm or ook- I ealth worm)roburdens for ue irni ainv ream ls. They' may be econonic w orn) si rhelated to practlial and Psycho-so,'wl. S u d d e niSeparation 'onsidlrat ions. lIley nlay not be in fromni the al'est Cl,'cially if tiltc hlli s npalhy \%illloal belifs and atti­ ba-edloil m,,l is silltaway froi mlle. family in- tides. 'l'hev ma' iuitb They stabilil. Ie,,itinal. e.ooillic, and en ideas "of learning hcehavor. ,,,ial). anlt illeitinlac\. nlavn n ii '"rprct-. Iim iethods nor emalhliae their efl'ecti\eiess. The tim' Edwucational Diagnosis. Information liit alipreciale the '.alte of programis apli-rialedl lv is also needed 11,t olyil)'i local ideas llasel oll neullatiahl' e- a. thIrl (hIlii conicerii g foils and inalnitlitio llbut Ime vi l.,_L'islmmm,.li valid. bimt Illialilprciaecd. also oilIhe literacy ofI tile conimillity, siieilificallv well-nmaning the iusual ilsli of collllntlliicatiiin .l.Itreslsiniposed by (that is. the way ideas diflise) , and the outsidrs. natural or ilformal leaders and irob- )MIPONE.NTS 0F NUTIITION able "iniintials" likely to blemost or SUpl)lortilng effective in poli ting was based chalg ill a co nllnu111nit ',or who ina ()hli:tyle health cducation itself hieniseltes be " rend-setters." ol tileidea that tile comnmunity

98 had no ideas on the subject, and was tion is that the concept of a relationship merely waiting to receive new facts in between certain foods and growth, order to act on them and achieve better health, and disease is entirely absent. health. By contrast, modern nutrition To motivate mothers to want to follow educational activities can be considered the suggestions made in the course of to have the following components: nutrition education, it is plainly im­ portant to be able to convince them that Nutrition Information. As with old- the advice given is sound and correct. style methods, information has to be This is particularly difficult to do when supplied in the process of nutrition most communities have their own con­ education. Facts should, however, al- cepts of the causes of common and iden­ ways be few in number, simple, strip- tfiable forms of malnutrition, such as ped of unnecessary cultural frills from marasmus and kwashiorkor. Convic­ the demonstrators' own community, tion is also difficult to ensure, as both and scientifically correct. the onset and recovery from almost all The presentation of facts to a group forms of malnutrition are rather slow, is certainly of importance, but is only undramatic, and a time-consuming one component of nutrition education, process. The best method of convincing par. Nutrition Demonstration. There is eots that malnutrition is due to an in­ no doubt that the best viay of both correct diet is by demonstrating a cure teaching people and also trying to con- with food, preferably alone. Thus, in vince them is to use actual live mate- hospitals and nutrition rehabilitation rials. This may not always be possible. centers (p. 186), where kwashiorkor is However, whenever feasible, actual sit- a major problem, the response of a uations and real material should be mother's child, and other children in used for demonstrations, e.g., methods the ward, to dietary treatment is valu­ of preparing suitable weaning foods. able and convincing (Figs. 13 and 14). Mothers are familiar with the ingredi- Even so, the mother may find it diffi­ ents used and more likely to follow cult to believe that the recovery is re­ advice if they are involved in the prep- lated to the better diet the child has aration, cooking, and feeding of their been receiving and may be more in­ children on the spot. lined to think of cure being effected by Probably the most effective type of various other "mystical" hospital pro­ demonstration is that involving only a cedures, such as injections, tempera­ small number of mothers or parents, ture taking, X-rays, and so forth. Under with ample opportunity for participa- some circumstances, photographs of tion and questions. This type of group children on admission and on discharge discussion-demonstration (p. 174) is may help. not only valuable as a method of nutri­ tion education but also enables the Nonnutritional Motivation. The giver to have a "feedback" of informa- commercial advertiser does not sell his tion from his audience. goods on their quality alone but also incorporates other motivations, includ­ Nutrition Conviction. A basic prob- ing status, sex appeal, convenience, and lem with much direct nutrition educa- economy. 99 3 FIGURE 1 .- Nutritional conviclion. Two-year old child with marasmus on admis­ sion to tihe Nutrition Rehabilitation Unit, Kampala While nutrition education should al- show a well dressed mother in sur­ ways be concerned with the demon. rounding that are of status value stration of actual nutritional advan- locally. A newly produced low-cost tages, therc is also every reason to try high-protein infant food should not be to incorporate nonnutritional motiva- introduced as a food for the poor, but tion as well. For example, posters en- rather for the whole social spectrum, couraging women to breast feed should especially for the well-to-do. In aieas 100 • " • ".'wi-i '

ik

FIGURE 14.-Nutritional conviction. Same child after six weeks of high protein diet based on local foods 101 where modem education is highly val- recitation from some popular book, ued and competitively limited, it may such as the Ramayana in India. be best to stress "proteini" as a brain food. Breast feeding may also be ap- GROUPS FOR NUTRITION pealing if its economy is stressed. EDUCATION In the past, foodhabtshvespontaneous lmot alaysre-changes in In general, health education may be food habits have alm ost alw ays re­ di e t d o w r th e d f e en s z d sulted from nonnutritional motivation. directed toward three different sized groups: Present methods should learn from past history. Large Groups. In developing tropical

Felt Needs. Inquiry always shows that countries, these can be reached, to a mothers in developing countries, as varying extent, through mass media­ the radio. with people anywhere, have certain the press and television, and the "felt needs"-that is, things that they In largely illiterate communities, themselves really want to do or to press may have comparatively little How­ learn about. These should be incorpo- impact, especially among women. it is rated into nutrition education activities ever, in some parts of the world, wherever practicable. They often take not uncommon for there to be some the form of sewing (especially using a literate person in the house who may machine) or learning English. read a newspaper to other members However, although paid much lip- of the household. There is considerable service, "felt needs" are not often con- evidence in many developing regions sidered. By discovering what the com- that newspapers are read by many more munity, including the mothers want, in than the individual who made the relation to any topic, it becomes easier purchase. to equate health education to local Television has great potential as a anxieties and hence to have a better medium of general and health educa­ chance of achievin[ results. It is often tion at schools. It is, however, an a question of recontiling the villagers' expensive development often com­ wants with scientific nutritional needs. menced for prestige purposes. It usually mainly reaches the well.to.do of the Entertainment. Not only should the community, except if community view­ whole presentation be as lively and ing sets are available. It may neverthe­ stimulating as possible, but it is often less have the advantage of making the practicable to include some activity di. elite aware of problems within their rectly intended to entertain. This may own country. in some communities be covered by the The disadvantages are: actual presentation itself, especially, 1. The audience is "noncaptive." for example, if slides are used in a com- 2. Advice is given in a rather im­ munity little used to this type of visual personal way. aid. 3. One cannot u.e the reaction of In addition, it may be helpful to in- one's audience as the*i are consuming elude some minor diversions, such as information; therefore, one is unable to the playing of records or reading or make on-the-spot alterations.

102 4. The families who can afford to mass media over more conventional own the receivers of mass communica- methods of health education are: tions tend to be those families who need 1. A large number of people can be help least, reached at relatively little cost. 2. The method of instruction is easy Small Groups. This is probably the to control. most effective way of putting over nu- 3. It probably reaches the most in. trition education. Examples include fluential member of the household. groups of mothrs, or preferably par- 4. Information in the press or on the ents, at community development clubs, air tends to have a special kind of in hospital wards, in Young Child authority. Clinics, and so forth. Under these cir- 5. The audience can be motivated to cumstances, face-to-face direct demon- desire certain changes by careful inser­ strations and group discussions (p. tion of ideas into programs of entertain. 112) are more convincing; and, be- ment. cause the audience is involved as par­ ticipants and in discussion, learning is SPECIAL GROUPS FOR more likely. The obvious disadvantage NUTRITION EDUCATION is that only small numbers can be reached at one time. Politicians and Administrators. Most usually, fund-controlling politi. Individuals or Families. Nutrition cians and administrators ;,i tropical education should form part of the countries are but little aware of the counseling of parents, of sick children dimensions of malnutrition as a public in hospital, or at any other time or health problem. One case of yellow place, such as during home visiting, fever, very rightly, acts as an effective Key figures and influentials in the com- stimulus to dramatic action, while munity are particularly important thousands of young children dying "targets." yearly of protein-calorie malnutrition The use of radio has spread im- may make little impact and sometimes mensely in recent years in tropical is not even known. regions, especially since the introduc­ tion of cheap transitorized sets. Many Parents of the Present. Understand. communities may have radios in the ably, it is toward this group that health market place or coffee shops. For eco- education concerning the prevention of nomically underprivileged countries childhood malnutrition is usually prin­ with widely scattered populations, radio cipally directed, via health centers, represents the most valuable type of community development activities, vil­ mass media. Nutrition education may lage clubs, and so forth. be given in special programs, or inci- In tropical communities, there is dentally as slogans, jingles, or incorpo- much need to direct nutrition education rated in drama, activities toward fathers, who often con­ These channels provide an important trol the household purse, and toward means of transmiting health instruction other members of the family (such as and motivating changes toward higher the grandmother or mother-in-law), living standards. The advantages of who may have a considerable say in the

103 method of child rearing actually car- Advertisers. In the present "age of ried out. mass persuasion," it is readily apparent A detailed discussion of how to plan that commercial advertising is having a family budget in terms of local income an increasing impact on family life ip and costs can be very helpful. In the tropical regions, especially in urban course of this, the worker can come to areas. Much of this appears to be excel­ realize the hard facts which underlie lent and, indeed, is helping to encour­ the low consumption of protein foods. age parents to more healthful and At the same time, he can go on to point modern ways of living. out ways in which protein can be pro. However, at the same time a great duced economically, the advantages deal of advertising, especially of inher­ of savings accounts, or the savings ently excellent but overly expensive that can be effected through family infant foods, has been transported en planning. bloc from affluent countries, in which An important but often neglected totally different cultural, iducational, channel through which health educa- and economic circumstances are found. tion can reach this group at a probably In particular, the ill-considered adver­ receptive time is the hospital itself. The tising of high-priced tinned milks for fact that mothers, and sometimes fa- infant feeding is to be deplored. thers, are admitted with their infants in While these food products are usu­ many tropical hospitals represents an ally of good quality and have been well often underexploited opportunity; and, tried in child rearing in prosperous if practicable, under these circum- educated groups in various parts of the stances each children's unit should have world, for the majority in most tropical facilities for simple, practical health countries they are impossibly expensive education activities, especially of the so that only homeopathic doses can be group demonstration type. afforded. At the same time, they dis­ suade mothers from breast feeding and Parents of MIhe Future. That school- create the image of bottle feeding with age children are the parents of tomor- artificial formulas as a status symbol of row is a truism that is even more correct progress and emancipation. Whereas, in many tropical communities where in the educational and environmental marriage is relatively early. Nutrition circumstances of the tropical village or education should form part of the activ- urban slum, the ill-cleaned bottle and ities of all youth clubs, including its rubber teat supply a most dilute solu­ Young Farmers Clubs; while the gusta- tion of milk and a concentrated suspen­ tory and visual aid of an inexpensive, sion of bacteria, with resulting diarrhea but nutritious school lunch based on and marasmus. local foods, can be important at this rel- The health educator has two courses atively receptive stage of life. open to him in relation to such commer­ A nutrition education program for cial advertising which, on mature con­ schools needs careful and imaginative sideration, he knows to be harmful in planning not only for the school chil- this respect. Firstly, he may orient his dren themselves, but also for teachers own health education toward neutraliz­ in training. ing the unwitting ill-health education

104 that is being generated. This is what is their activities, and should use this op. usually done but represents, as far as portunity for nutrition education which finance and organization are con- can then be related to the actual home cerned, an unequal :ontest between the circumstances. However, staff available heavyweight of commercial advertising for hom visiting are always in very and the flyweight of health education, short supply; while problems of dis­ As a second alternative more logical, tance between scattered dwellings and but of immense difficulty, is the need to the small, but significant, expense of "health educate" commercial infant travel also tend to restrict this type of food firms operating in tropical coun- activity. Workers living in rural com­ tries. At the present they are causing a munities have the opportunity of carry­ considerable amount of harm when, in ing out nutritional improvement pro­ fact, by basing their policy on the actual grams based in part on home visiting. facts of the situation, they could pro- The teaching of nutrition in the home duce great benefit. At the core of the is by no means simple, as it requires problem must be the realization that the careful background knowledge of the main need for tropical countries for community and of the particular fam­ young children is not a milk prepara- ily. The establishing of confidence and tion to be reconstituted as a liquid and rapport is important. Home visiting misfed from an infected bottle in com- must always be with the approval and petition with breast milk, but rather a understanding of local leaders and the cheap, inexpensively packaged protein families concerned, and should be with­ infant food, preferably in a powder in the framework of customary practice, form, to be used either as an additive especially in relation to acceptability of mixed with locally available foods or male (orfemale) visitors. prepared as a gruel or in a paste form. During initial visits, care should be taken not to hurry matters and attention SITES FOR NUTRITION should rather be given to discovering EDUCATION the interests of the family and especially the mother. Visits should be planned Clubs and Other Small Groups. for a convenient time of the day in rela­ Nutrition education is very commonly, tion to the mother's household duties. and perhaps most effectively, carried Useful "points of entry" may be out in the various clinics and clubs for made after a mother has returned home mothers, parents, or young people that from having a baby in a maternity cen­ are organized in the village by commu- ter, or after a child has been cured at nity development, extension agencies, a clinic. However, man'r other oppor­ religious bodies, and so forth. It is the tunities will present themselves, and the best site for the use of group discussion worker living in a rural area may be in demonstrations, an especially useful position to under­ take informal, casual, friendly home Homes. A variety of different people, visits. including public health nurses, sanitar. Nutrition education in the home also ians, and various extension workers, requires quick thipking and adaptabil­ carry out home visiting as a part of ity as the visitor will have to use situa­

105 tions as they develop and relate to This need often appears to be difficult questions that the family itself raises. for Western-trained educators to appre­ It can never be a "set-piece." ciate, largely because much that needs .With a background knowledge of the to be included in basic nutrition educa­ local situation and having established tion in tropical schools will have been rapport with the family, nutrition edu. learned at home in cultures of indus­ ction may be undertaken. This should trialized Western countries. be simple, limited in scope, and clear- As well as modification in syllabuses, cut, preferably only trying to get over there is also a need for suitable adjust­ that one idea during each visit. The topics to ment in examinations to ensure be covered should be related to priori- nutrition is given due prominence. must ties and should be carefully defined and Plainly, this means that teachers and planned. At the same time, they should themselves be aware of local health be capable of modification in the light nutrition problems and their prevention of questions and of the mother's inter- and include correct emphasis in their est. Real life situations should be used teaching. Undoubtedly, tie most impor­ as found in the garden, the food stores, tant places to inject ideas concerning and the kitchen. nutrition education into the educational are the teacher The content of the nutrition educa- system of a country tion should link up with and conform training colleges. should with teaching given elsewhere. A record Nutrition education at schools than planned les­ of what has been discusscd on each visit consist of much more likely to be should be kept, as this will assist with sons. Learning is more habit acquired continuity, achieved as a result of by repeated observation and participa­ Schools. These are particularly im- tion. Again, the practical behavior and portant sites for health education. example of the teachers will be impor­ School children may be expected to be tant. The involvement of pupils in the less fixed in their food habits than growing cf locally suitable, nutritious adults, and the learning of new ideas foods in a school garden (p. 166), and about food will fit into the concepts of the provision of school meals can be of schools being "places of change." value as forms of practical nutrition Health education should be incorpo- education. rated into the syllabuses of all schools. Effective nutrition education in This may be included as separate classes schools may in some circumstances be or sessions, or may be woven into carried home and affect or, at least, courses of science, nature study, health stimulate parents and others in the science, and so forth. The revision of household. However, its main signifi­ many syllabuses for school children in cance is that the school children them­ many parts of the world is long over- selves will shortly become parents with due. Too frequently, these have been responsibilities for rearing and feeding imported from elsewhere without suffi- their own offspring. cient modification. Examples should of always be from the local scene and a Hospitals. Wards and out-patients as be­ nutrition education message included, hospitals are frequently regarded wherever possible. ing exclusively concerned with curative

106 work. This should not be the case and Wherever possible, hospital nutrition planned nutrition education should be education should be linked up with incorporated into all possible health other parallel activities in the neighbor­ work. In many children's wards in trop- hood, such as may be occurring in farm ical countries, mothers come in with institutes and village clubs. their infants and young children. This As well as planned health education is a valuable custom because it reas- sessions, the general activities of the sures the child, encourages the mother ward may be expected to influence in to carry out some of the nursing in some degree the ideas and subsequent understaffed wards, and permits the behavior of mothers. It is, therefore, continuation of breast feeding. obviously important to ensure that what Also, it offers an opportunity for is taught is actually practiced. For nutrition education not only by indi- example, the foods served to both moth­ vidual counseling but also by means of ers and young children should conform, small group discussion demonstrations, as far as economically possible, with the at a time when, if their children are teaching mothers have received, and recovering, mothers may perhaps be should be used as visual aids for dem­ likely to be receptive to new ideas. In onstrations on how best to use local addition to the children's wards, the diets for young children. outpatient clinics, prenatal clinics, new- The special value of nutrition reha­ born and premature units, and so forth, bilitation centers in health education is should be included, discussed later. Every mother being delivered in a maternity center or hospital today TEACHING AIDS should be offered the knowledge of how Varius teaching aids may be used in she can postpone her next pregnancy nutrition education. All, it must be until the newborn infant has been grad­ ually weaned. In this way, many cases s e , e merel "is tfocope PCM can be prevented. ment the teacher's own efforts. of Aids should aim at being attractive, In planning tropical children's hos- simple, short stimulating and factually refer to "usall pitals, accommodations and other facil- correct. They should ities for mothers must be considered, as that is, the local community-as well as a suitable area in which to carry regards appearance, dress, foods, and out demonstrations and a simple -ac- customs. They should always be "pre­ gen­ tice kitchen in which mothers can par- tested" on the "consumer" before In ticipate in the preparation of dishes. possi­ some places, a low-cost model house eral use. They should, wherever participation. may be built adjacent to the ward, if ble, lead to audience possible with a demonstration garden, Audiovisual Aids. Different audio. growing highly Putritious foods, such as visual aids may be appropriate and good quality legumes and dark green feasible for different situdtions, topics, leafy vegetables, with a compost heap, sites, and groups. They should always improved village-level food stores, and draw attention to the problem, suggest seeds and insecticide on sale at reduced improvements, and, if possible, moti­ rates. vate people to want to change. When

808-112 0---6---8 107 considering the desirability of prepar- infants' foods hanging in child clinics, ing particular audiovisual aids, the or the distribution of largely carbo­ following must be considered: (1) type hydrate diets to hospital patients, or the and level of nutrition education use of bottle. feeding of young children planned, (2) the proposed audience, in pediatric wards. (3) the site, and (4) the aim and pur­ pose. Training in the practical use of Visual Aids. A variety of visual aids visual aids is most important and often of different levels of complexity can be overlooked, employed. Posters. Posters are very widely used Real Life Situations. While a wide in most countries. Their effectiveness is variety of visual or audiovisual aids can usually unknown but often may be be used, there is little doubt that a real either slight or unexpected. Village life situation, using actual material, is ,)eople who have been brought up with­ the most vivid teaching aid, most likely out becoi. ing accustomed to the con­ to be understood and most certain to ventions that even simple drawings produce a lasting impression. Thus, the contain, such as perspective, shadow, most effective visual aids to demon- and relative sizes, may completely mis­ strate improved infant feeding to tropi- interpret what is shown them. A sewing cal mothers are the actual foods, machine may be perceived as a loaf of cooking pots, and other kitchen para- bread: shading to show highlights on a phernalia to which they are thoroughly face may be thought to be leprosy. accustomed and with which they work Also, the local cultural significance each day. They should be involved in of different types of clothes, colors, preparing and cooking the foods and in postures, and ways of depicting people subsequently feeding them to their own and scenes will certainly affect the way children at the time. posters are perceived. Educational situations include a For these reasons, posters, and, model school vegetable garden, produc- indeed, all visual aids are best produced ing a high yield of beans, or the living in the particular region, rather than visual aid of a child actually gaining in using material imported from else­ weight while recovering from kwashior- where. However, both will often have to kor, or an improved village level be used, but, in either case, it is vital to kitchen. Demonstrations by visual com- pretest the material before using it parisonshould be the aim. widely. The most outstanding visual aid is a Posters have the advantages of mother who has been convinced of the cheapness and, at least in theory, of value of, say, the need for protein foods reaching large numbers of viewers. for young children. She should be given However, there is no feedback and too a major role in nutrition education of often they only "decorate" a wall. her fellow villagers. Posters should, as far as possible, It is also well to remember that "ill. have a single, straight-forward message health education" can unwittingly be which "speaks for itself" (Figure 15). carried out, as by having calendar Any text should be minimal, clear, and p o s t e r s advertising inappropriate serve to further clarify the point already

108 AMABEERE GEAKIRA ECCUFA

FIGURE 15.-Straightforward understandable poster, with few words and one obvious message. ("Breast feed; don't bottle feed").

109 made visually. Posters may also be pose of satisfying the need for more used as well as charts in talks and reading material and also for intro­ demonstrations. ducing nutrition education into the Animated Visual Aids. Various ani- community. mated visual aids may be used to It is often useful to prepare a simple, enliven and make demonstrations more single-page handout sheet in the vernac­ vivid. Whatever animated visual aid is ular by the mimeograph process. It used should tell a clear, straightfor- should be limited to one subject, such ward, simple story. These include such as "How to Prepare a Protein Mixture simple devices as flannel graphs, flip for Young Children," or "What Every charts, and flash cards or more complex Man Should Know About Family methods ranging from puppets and Planning." plays to series of color slides, film In all instances, the language must strips, films, and television programs. be simple and clear and the message With less sophisticated audiences "pretested" on the group for whom it is there is a danger that interest, at ieait inte~ided. Seoiantic problems are very for initial "exposures," may be moie !ikely. If no word exists for a certain focused on the novel gadget than the concept, a new one may have to be in. message. Also, problems of cost, elec- troduced, as with germsi or proteini. tricity supply, projection facilities, and Also, a single word may be used for a maintenance have to be boxne in mind. range of different variants. For ex­ for At the less "animated" end of the ample, there is one Luganda word round. scale, the flannelgraph and the series of "worms," including earthworm, color slides deserve special mention. worm, etc. They can be cheaply prepared with local Auditory Aids. In addition to tele. relevance and can be used in demonstra- vision and radio, nutrition education tions at a pace adjusted to the particular may sometimes be possible by means of audience. prerecorded talks or slogans, or by An economical homemade flannel- music or songs played by tape recorder, graph can be improvised with cutout or with a live band. The usefulness of illustrations stuck on sandpaper and a this is mainly limited to certain blanket. crowded situations where no other ap­ Written Material. Visual aids incor- proach is practicable, as in hospital porating written material plainly have a outpatient clinics or markets. limited value in largely illiterate com­ munities, although, even here, the writ- NUTRITION EDUCATION ten word often has a certain prestige TOPICS ("ego boosters"), and it is possible that a member of the household may be able Priority topics will need to be se­ to read it to the mother. lected. These will vary from place to There is often a great shortage of place and will be indicated (1) by local simple reading material in the vernacu- forms of malnutrition, conditioning in­ lar, so that it may be possible to produce fections, food production problems, and simple stencilled booklets, texts, bro- environmental factors; (2) by the selec­ chures, or pamphlets with the dual pur- tion of conditions for which health edu,

110 cation can be demonstrated clearly and weaned slowly over the last six weeks convincingly; and (3) by the villagers' of this period. The economy, prestige, own felt needs. and moderness of breast feeding require Nutrition education in the widest stress. sense should be designed to improve tie Dangers of Bottle Feeding.The dan. diet of the whole family with specific gers of infection and the high cost reference to young children. It should should be empha-ized. Methods of pre­ also encompass methods of improving paring artificial feeds for use, prefer­ village food production, storage, and ably with a feeding cup or cup and preservation, as well as the prevention spoon, are best demonstrated individ­ of infections and of customs that have ually for those cases where it is really important nutritional significance, required (e.g., twins or orphans). Relevant topics cover many aspects Types of Foods. Different methods of life. Local priorities will have to be may be employed and the most appro­ selected from the following or from priate for the sophistication and prob­ other topics not included here: lems of a particular community will Dietary Topics. Points of emphasis have to be selected. will vary with the local pattern of Sometimes it may be practicable to childhood malnutrition. Special topics classify into three groups--"body­ may be required in some regions. For building foods" (proteins), "energy example, the use of red palm oil for foods" (carbohydrates), and "protec­ young children may need inclusion, if tive foods" (vitamin rich fruits and vitamin A deficiency is common (p. vegetables). From this basis, the idea 86), or the feeding of thiamine-rich of a complete or balanced diet may be foods in areas where infantile beriberi developed. occurs (p. 88). In other communities, there is little However, in all developing countries, current evidence of vitamin deficiency, a major emphasis will be on the preven- so that advice on :nfant feeding may tion of different forms of protein-Calo- best be concentrated on the protein­ rie malnutrition (p. 75). With this in foods needed to make the child grow mind, the following topics will usually well, to make him more intelligent at need emphasis: school, and to prevent kwashiorkor. Diet for Pregnant and Lactating Another practical approach may be Mother. Emphasis will be given to avail- to emphasize that the child needs some able sources of protein, vitamins, and of four foods each day-staple, legume, iron, especially the best use of legumes dark green leafy vegetable (or orange­ and dark green leafy vegetables, pigment vegetable or fruit), and, if Value of BreastFeeding.This should possible, animal protein. These should be started as soon as culturally accept- preferably be given as mixtures of all able after birth, given permissively- four foods. that is, whenever the baby indicates Preventionof Protein-CalorieMalnu­ hunger, alone for 4-6 months, and con- trition.Mothers can be taught to recog­ tinued for 1-2 years. If pregnancy oc- nize the early and late signs of PCM, curs, breast feeding should be continued especially failure to gain weight. The for the first three months and the infant dangers of the weaning period need

111 stress as well as the protective value of when they are of nutritional importance protein foods and the need to prevent in a locality. Again, these will vary infectious diseases. from place to place but will often Weaning Foods. These should be include the following: commenced at 4-6 months, depending 1. Purpose and value of health serv­ upon the lactation ability of the moth- ices, including hospitals, prenatal crs in the region. The following require clinics, family planning clinics, chil. stress-the type of food; its prepara- dren's clinics, and so forth. tion, cooking, and serving; quantities; 2. Bacteriai cause of infectious and timing. They should aim at sup- diseases; plying as much protein as possible 3. Immunization against some infec­ often as "nmultimixes" (p. 130). tious diseases; Harmful Foods. This should be con- 4. Prevention and early management cerned with trying to persuade parents of diarrhea; to avoid spending money on such non- 5. Cause and effects of common nutritious or highly expensive items as intestinal worms; carbonated drinks, patent infant foods, 6. Emotional problems of too sudden and so forth. stopping of breast feeding; Use of Protein Supplemnents. Various 7. Cause and prevention of malaria; protein foods suitable for young chil- 8. Importance of cleanliness-per­ dren may be available in shops or be sonal (including bathing young chil­ issued free or preferably sold at low dren), feeding utensils, house; cost by the health services. These 9.Improvement of village housing, include dried skimmed milk and, in i irv ent l aehun latrine, water sup. correctCentral useAmerica, can be an"Incaparina." important topicTheir in ply,including and householdkitchen, water storage; nutritonsedcatn.bea10. nutrition education. Avoidance of harmful local cus­ toms (e.g., purgation or starvation in Food Production. The topics to be diarrhea); covered may include: 11. Advantages of child spacing, 1. Introduction or increased cultiva- including cheap, simple methods; tion of beans, dark green leaves, other 12. Budgeting, including food prior­ vegetables, fruit bushes, and trees; ities, use of markets, and ways to aug­ 2. Animal protein production, such ment mother's income. as poultry or rabbits or the use of fish ponds; GROUP DISCUSSION- 3. Improved village level food pres- DEMONSTRATIONS ervation and storage, including the use Principles.The most effective form of of insecticides; 4. onsectro fsoi enutrition education is undoubtedly by 4.Cnrasn soil fertio; emeans of a demonstration, given in a 5. Increasing soil fertility, especially lively, stimulating way with full use of by the use of acompost heap. visual aids, especially of actual live

Miscellaneous Topics. Various mis- materials, such as foodstuffs, curibined cellaneous topics may require high- with group discussion and as much lighting in health education, especially audience participation as possible.

112 This method caters for only a limited tions should be avoided. Local materials small group of up to 20 persons but, if should always be used as, for example, skillfully handled by an experienced clay cooking pots in some parts of the discussion leader, can lead to much world rather than aluminum. If new greater interest and involvement by the ideas are introduced, these should be people concerned, as evidenced by within the economic reach of the par­ questions and answers. It also gives the ticular group. demonstrator an opportunity to gauge Demonstrations zhould be planned to the interest and to sone extent the effec- last for a relatively short time, possibly tiveness of the demonstration, as the 15-20 minutes but ample time should questions also act to some extent as a be available to permit an indefinite pe­ "feedback." riod of discussion and decision making. The principles involved are of prac- The demonstrations should be care­ tical importance. Firstly, they are fully thought out, planned beforehand, usually best carried out by someone of and rehearsed, with regard to their con­ the particular community, speaking the tent, sequence, and visual aids. vernaculac fluently. They should be given by someone of suitable status. Planning a Group Discussion. For example, many village mothers find Demonstration. The planning of a it difficult to take advice on prenatal group discussion-demonstration can be care from a young unmarried girl. It considered under the following head­ may sometimes be profitable for foreign ings: staff to participate in a joint demonstra- 1. Aim(s) of Demonstration tion as this may add prestige. 2. Socio-Fconomic Factors Respon­ Also, under some circumstances it sible may be very valuable to enlist the assis- 3. Cultural Attitudes ("Blocks" tance and participation of a village and "Links") mother, or leader, who has already been 4. Presentation exposed previously to the same demon- a. General-logical, realistic, step. by-step development of theme; stration, and preferably has become b. Visual Aids-To inform, to sus­ convinced of the desirability of the par- ta iterest, to in , to ue ticular change. tain interest, to convince, to change. Thamshange sIn the presentation of a group dis­ The tmophershuldbe iforalcu~sion it is often possible arnd useful Seating should intimate, and relaxed. to use analogies well-known to villag­ be comfortable and as is customary in or the particular community, possibly ers; for example, comparing plant seeds therefore on mats or on the grass. A with bacteria-spreading disease, or a schoolroom atmosphere with someone drooping wilting plant with a dehy­ lecturing from behind a raised table to drated child. However, these may quite a group of mothers seated on the often be over-imaginative, and need to ground in the near distance should be be pretested to determine local response. avoided. ' Some aspects of the local culture pattern may tend to make nutrition education more The seating, lighting, and acoustics difficult ("cultural blocks"), while other fac. should enable the demonstration to be tors may be helpful ("cultural links"). The former should be avoided, if possible; the watched easily; while external distrac- latter should be incorporated.

113 A sequence used in planning a dem- The close contact that field workers onstration in East Africa is given in may have with families in rural villages Appendix IV. or in urban slum areas may give oppor- It is also valuable for a group tunities for estimating the effectiveness discussion-demonstration to start by of nutrition education by informal finding out all that the group already direct observation as to whether what knows about the particular subject and has been advised is, in fact, actually to finish by the group deciding what carried out or not. they are going to do when they return 1 home with their new knowledge. FURTHER READING A. BURGESS, "Nutrition education in public EVALUATION health program-What have we learned?" Amer. J. Publ. Health, 51, 1715, (1961) A much neglected aspect of health (T). A. BURGESS and R. F. A. DEAN, Malnutri. education is its evaluation-that is, tion and Food Habits,Tavistock Publications, assessment of its effectiveness or other- London (1962) (T). .This is, of course, difficult to do M. BYRNE, "Nutrition education in the wise. home," J.Trap. Pediat.8,22, (1962) (G&T). because of problems of measuring A.C. HOLMES, Health Education in De­ Thomas Nelson, London changes in attitude and behavior. veloping(1964) (:;&T). Countries, be (but rarely is) D. B. JELLIFFE, "Childhood malnutriticn Evaluation should and health cducaiion," PediatricsDigest, 8, consider, d at an early stage of a pro. 79, (1965) (G&T). D. B.JELLIFFE and F. J. BENNETT, Health gram. It can be carried out by one or Education of the Tropical Mother in Feeding more of the following methods: Her Young Child, Children's Bureau, U.S. 1. a questionnaire showing change Dept. of Health, Education, and Welfare, in knowledge; Waqhington, (1964) (G&T). V kJ. RITCIE, Learning Better Nutrition, 2. a change in behavior by parents FAO, Rome (1967) (G&T). Joint FA (e.g., infant feeding, food storage, and WWrleh Oanization, so forth) ;-P'nning and Evaluation of Applied Nutri. soforth) efetion Programs,,Technical Report Series No. 3. the effect on the neighbors; 3,10, Rome, (1966). 4. the long-term alteration in inci- J. YUDKIN and J. C. McKENZIE, Changing MacGibbon and Kee, London, dence of the particular condition at Food(1964) Habits,(G&T). aimed (e.g., less which prevention is marasmus seen, or better weight curves I G=Rccommended for the general reader. T=Rccommended for the technically trained at Young Child Clinics), health worker.

114 chapter vii

COMBATING MALNUTRITION

All aspects of modern "development" obviously depend upon the particular are aimed at raising the standard of region. Large-scale farming, entailing living and hence, it is hoped, the nutri- some form of land consolidation, seems tional plane of the family and the com- inevitable if modern methods of high­ munity. A better-educated population yield agriculture are to be introduced may be expected to have more modern with the best use of mechanization, knowledge of health and nutrition and fertilizers, and pest control. also, through the medium of the Improved comnunications are also printed word, to be accessible to infor- of obvious benefit to the nutrition of a mation, both on general topics and on country, enabling foods, especially the health, nutrition, and food production, more perishable type, to travel longer Improvement in the economic level distances to market. of a country by means of industrializa- Lastly, to ensure increased agricul. tion, or modernized, diversified agri- tural development it is necessary to per­ culture, or preferably both of these, suade farmers to use modern technology will lead to an increased national reve- and to make available supplies and nue with more money available to fam- equipment (usually implying some ilies for purchasing food and with form of credit system), to organize bigger budgets for government to spend assured markets for their produce and on necessary further development proj- above all to introduce locally meaning­ ects, including schools, food production ful incentives for higher production. schemes, and health and other social At the same time, at the village level services. much can be done to improve food pro­ I n c r e a s e d food production is duction by the introduction of simple required all over the world because it but effective modifications of tradi­ is often increasingly insufficient in tional methods of growing, storing, quantity and even more so in quality, preserving, and preparing essential especially as r e g a r d s "protective food. foods," particularly those containing This book is focused almost entirely protein. How this is to bc achieved will on the grave nutritional problems of

115 young children. At the same time, there sent only the percentage of really sick is no doubt of the desirability of children who have been admitted to hos­ improving the diet of the whole family. pital. They are, therefore, biased by Not only are they all frequently in such factors as the particular popula­ need-the father as the supporter of tion's belief in the effectiveness of mod­ the group and the mother as the child- ern medicine, by local communication bcarer-but also because a more gener- problems, and by the number of hos. ous and balanced family diet will, to at pital beds. They can, however, give a least some extent, lead to improvement rough idea of the nutritional problems in the foods available to young chil- likely to be found in a particular region. dren. This is especially so when it is The incidence of malnutrition in the realized that the "weaning foods" of community itself may be assessed by a many communities are not especially survey to examine children of the vul­ prepared for young children but are nerable age group. This may be done portions of the adult diet. by a small, simply equipped team or may be nuch more elaborate with a AMONG PRESCHOOL large group carrying out a wide range CHILDREN of laboratory tests. The number of examinations and Young children of preschool age are Tenme feaiain n Youg hinrosuffn preshol ae arc tests carried out will plainly vary, both therou ainsuferin frm manu- with the size and complexity of thme in­ trition; hience, the principal target for ihteszadcopxtyftein mitrition work. vestigating team and with the objective of the survey. Investigations may in­

Informauion Needed. Before an ap- elude: (1) examination for clinical propriate program to combat malnutri- signs of ralnutrition, appropriate bio­ tion in young children can be planned, chemical tests and anthropometry it is necessary to try to obtain prelimi- (body measurements), (2) studies of nary information. This is needed to dietary intake, either by questionnaire know where to apply the program, to or by direct measurements of food dur­ what age groups. for the prevention of ing home visits, and (3) assessment of what types of malnutrition, and labtly, the factors responsible for malnutrition if possible, to have statistical informa- irn the particular community, including tion on the size of the problem, so that conitioning infections (p. 72), food the effects of any measures taken may production, and so forth. be assessed later. Cross-Sectional Surveys. The advant­ Magnitude and Distribution o/ the age of short "cross-sectional" surveys Problem. Information is needed con- is that the), are relatively speedy and cerning the types of malnutrition pres- can give insight into the approximate ent in a community, the size of the size of nutritional problems in the local­ problem, and its geographic distribu- ity. They have the distadvantage that tion. Some statistics may be available they give information only for the par­ from the health services, especially hos- ticular time of the year during which pitals and health centers; and, although the survey was undertaken, although these may be all that is available, their this may be compensated for by repeat­ usefulness is limited because they repre- ing during each season. Also, they give

116 little knowledge concerning the inci- in different 10 percent levels below deuce of more acute illnesses, such as standard (p. 76), especially in 1-2 year infantile beriberi (p. 19), although olds. some information on these conditions In addition, workers living in rural can be ohtained from records at the dis. villages can obtain useful longitudinal tricts' hospitals and health centers, data in their area, especially if an Longitudinal Surveys. A better idea initial census has been carried out, in­ of the full impact of malnutrition on a cluding the general incidence of differ­ community can more appropriately be ent forms of malnutrition each year, obtained by a "longitudinal study," by the family prevalence and the mortal. which the young children in a particular ity rates in infancy and 1-4 year olds. community can be observed over a pe- Causative Factors. As stressed riod of time, preferably several years. earlier (p. 75), malnutrition, especially To carry out this type of study scien- in the preschool child, is always a com­ tifically is, however, obviously time- plex matter with many different fac­ consuming and expensive in terms of tors responsible. If a preventive pro­ money and personnel. Also, a problem gram is to be carried out realistically, with this type of project is that the effectively, and economically, it is presence of the investigating team will necessary to ascertain the vari. to some extent affect the situation, es- ous causative factors responsible in the pecially as humanitarian considerations particular community and to select will mean that treatment will have to be those that appear both to be priorities made available for sick children, and also to be most likely to be amena­ Especially if ages can be estimated ble to simple preventive measures. with some certainty, a simple "cross- Reasons or Dietary Lack. The ques. sectional" survey may be carried out on tions that have to be answered are the all children in the community up to relative responsibility of poverty, lack their fifth birthday by weighing, by of availability or production of foods, measuring their arm circumferences inadequate knowledge by the parents, (p. 76), and by inspecting for kwash- and the existence of harmful cultural iorkor, as judged by the presence of beliefs. Sometimes one of these may be edema (p. 76). dominant, although, quite often, sev­ Results for the survey can then be eral may play a part. expressed as follows: Injections and Socio-Cultural Fac­ (1) percent with severe PCM (chil- tors. In addition, the locally important dren with kwashiorkor plus those with conditioning infections (p. 72) and 60 percent of weight-for-age or less) in socio-cultural factors (p. 72) must be the whole group, and in each year known. If severe protein-Calorie mal­ (e.g., 0-1 years, 1-2 years, and so nutrition is principally due to poverty, forth) ; lack of availability of protein foods and (2) percent with moderate PCM a high incidence of measles, then the (children with weight-for-age between preventive program most suitable will 80-60 percent of standard) in whole be very different from a community group, and in each year; in which kwashiorkor occurs because (3) percent with arm circumference cultural attitudes prevent the young

117 child from being fed available proteln and available foods, follow standard foods and where severe roundworm methods employed in North America infection is common and important as and Europe. a conditioning factor. The second group, the "under­ Some of this information may al. privileged," who make up the vast ma­ ready be obtainable from nutritionists, jority, either live in villages or in scat­ pediatricians, and others working in tered homesteads in rural areas, or this field. If not, approximate infor- have flocked to the "septic fringe" mation can sometimes be gathered by slums, or, if more fortunate, to low­ the field worker by direct observation rent urban housing estates. This group of feeding practices in the community, often has little or. no modern educa­ of customs with regard to child rear- tion, very little spending money, dirty, ing, and of obvious clinical condition- fly-ridden kitchens with few cooking ing infections, such as whooping cough pots, limited fuel and storage facilities, and measles, and an inadequate water supply. Thiis Background Information. In is the group whose children develop most regions of the world, there are malnutrition, especially PCM (p. 73), often a large number of different and who require priority attention with ethnic, religious, dietary, and socio- regard to practical and practicable ad­ economi' subgroups all with their own vice on infant feeding. Even here im­ nuLtitional problems. However, for portant subdivisions will be found, as, practical purposes, there are usually for example, those with land and those two main groups in the present day without, and also those who rapidly tropics as far as the feeding of young accept new ideas and those who are children is concerned, although, of more conservative traditionalists. course, many fall between these two Before planning the best form of in­ extremes. fant feeding for a particular community The first, the "privileged," consists within local resources, it is necessary to of a usually small, well-to-do minority have as much background information of whatever ethnic group, who have a as possible. Areas of importance will house with an adequate kitchen with include: running water, storage space, and 1. Local Methods of Child Feeding even occasionally refrigeration facili- 2. Local Pattern of Malnutrition ties, who earn sufficient money to be 3. Local Pattern of Childhood Dis­ able to buy usually high-priced protein ease foods, such as milk, in suffi- 4. Local Culture Pattern cient amounts for their young children, 5. Local Status and Activity of and who have received enough modern Women education to be able to understand and 6. Locally Available Foods carry out practices, based on quantities 7. Local Home Economics and dilutions and especially appreciate the need for cleanliness. infant feeding Approaches to the Problem. The for this group can, with minor modifi- improvement of the nutrition of young cations for local customary practices children is plainly a highly complicated

118 affair and has to be planned for the par- to approximate the same gross compo. ticular circumstances in a community. sition of breast milk; but, although in. However, a program often includes one fants can plainly digest cow's milk or, more usually, several of the follow- formulas and grow well on them, the ing overlapping approaches: precise constituents of breast milk can­ 1. IMPROVED FEEDING OF not be mimicked. YOUNG CHILDREN Breast milk can, in general, be re­ 2. E A R L Y RECOGNITION OF garded as supplying by itself a nutri­ LESS SEVERE MALNUTRITION tionally adequatediet for childrenup to AND SUPPLEMENTARY FEEDING 4 to 6 months of age. It is uncontami 3. PREVENTION AND MANAGE- nated, easily availableand requires no MENT OF C 0 N D I T 10 NI NG culinary preparation.It is economical, INFECTIONS if the mother is receiving an adequate 4. IMPROVED TREATMENT OF diet, especially containing vegetable SEVERE MALNUTRITION protein foods. 5. IMPROVED VILLAGE-LEVEL Problemsof Artificial Feeding.Con. FOOD PRODUCTION versely, there are many problems with 6. CHILD SPACING the alternative to breast feeding, that 7. PROGRAMS is, artificial feeding with animal milk, often using a feeding bottle. For the 1. Improved Feeding of Young average mother in tropical circum­ Children. stances, artificial feeding is extremely The most natural way to feed a difficult to carry out successfully. young baby is with human milk, and Firstly, the cost of cow's milk (even it is only in the last few decades in the if this is available) is usually prohibi. Western world when various forms of tive. For example, in Uganda, it has canned milk have become widely avail- been calculated that to feed a three. able and within the economic reach of month old baby with adequate quan­ the vast majority that bottle feeding tities of full cream powdered milk with cow's milk formulas has increased would take about one third of a labor­ to its present dominance. er's basic wage. Advantages of Breast Feeding. In all Secondly, both in rural villages and parts of the world, breast feeding has in slum areas, the low level of home certain advantages. The composition of hygiene makes the clean preparation human milk has been adapted for the of feeds and their storage almost im. human infant over thousands of years. possible. Water may be brought from It contains protective substances (anti- a nearby pond or spring. Feeds are bodies) against certain infantile dis- liable to be contaminated by dust or in. eases, whiletactbetwen the closeothe and an natural neworn con­ sects. Limited fuel may make frequent tact between mother and newborn p e a ai n o e d e y d fi ut assist in the development of beneficial preparation of feeds very difficult. emotional links between mother and Thirdly, most tropical mothers will child, not have been reared in a "mathemati­ Breast milk has a different composi- cal" atmosphere, such as is customary tion from that of cow's milk (p. 36). in the Western world and may have had It is possible to "humanize" cow's milk little or no schooling. They will, there­

119 fore, often find difficulty in following although small, often being about 10 instructions as to the mixing of dif- fluid ounces (250 cc). ferent types of feeds. As discussed, the Another phenomenon in many tradi. results of artificial feeding for the ma- tionally breast feeding communities is jority in tropical countries are usually that of induced lactation. In this, the most unsatisfactory. Very dilute feeds baby of a mother who has died in child­ are usually given in a dirty contain- birth is given to a non-lactating female inated bottle, so that the result is a relative to rear. The infant is put to the starved, marasmic baby with infective breast very frequently and a variety diarrhea, of different herbal medicines may be used, Traditional Breast Feeding. In more and probably have mainly a psycho­ traditional communities, including the logical effect. After a few days of this, U.S.A. and Europe until quite recently, lactation is induced, although the breast feeding was universally carried quantity of milk produced is usually out, for the most part uneventfully, and insufficient vlone, and the baby will permissively-that is, with feeds given often have to be given some other food, at irregular intervals during both day usually in the form of a gruel. Induced and night whenever the child indicated lactation comes about as a result of he was ready. This is still the case in what is called the prolactin reflex most rural areas in tropical countries (p. 122). but, as mentioned elsewhere (p. 123), Increasing Lactation Failure.There the situation is changing for the worse is increasing evidence from all parts of in town and periurban areas, the world that the trend away from In various communities, different breast feeding toward artificial bottle customs prevail concerning the use and feeding with cow's milk formulas is oc­ choice of wet nurses, the "testing" of curring increasingly, not only among the suitability of breast milk for a par- the educated elite, but also among the ticular baby, and herbal medicines de- general population in trcpical towns signed to increase the flow. and in adjacent periurban areas. The Traditionally, breast feeding is car- consequences of this disastrous trend ried on for what would nowadays be seem clear. It is certain that there will regarded as a prolonged period-that be an increasing incidence of nutri­ is, up to one to three years, or most tional marasmus and infective diarrhea often, until te next pregnancy. This due to the over-dilute contaminated pattern is still conmmon in many rural feeds given. At the same time, infantile tropical communities although many scurvy, due to lack of ascorbic acid, differentdiffrntrl minoromn iatins ouhpae will be seen more frequently (p. 89), variations of practice and, if cheap dried skimmed milk is are to be found. It has been shown in used for bottle feeds, as is very likely many parts of the world that the pro- to be the case, then severe vitamin A tein content of the breast milk of "late deficiency may occur, with the eye lactating" women is of a normal value signs mentioned elsewhere (p. 87), (1 percent). The volume produced in including possible blindness. the second year of lactation, even in From another point of view entirely, poorly nourished women, is significant a wi6espread failure of lactation in a

120 tropical country could have much wider method, or because "there wasn't economic and agricultural uonse- enough milk" or "the milk didn't suit quences, because, if breast milk is no the baby." longer widely available, plainly an al. The sequence here is that an unin­ ternate, easily digestible source of formed, inexperienced, anxious mother protein suitable for babies, probably a puts the baby to her bredst. Here he form of cow's milk, would have to be obtains some milk, but, because of produced or imported. anxiety inhibiting the let-down reflex, Lactation failure can occur in women he is unsatisfied, cries, and sucks at the with severe maternal malnutrition or nipple vigorously. The dissatisfied advanced illness. However, it is sur- baby, the sore nipples, and the some­ prising how satisfactorily poorly nour- what congested breast mean that the ished and far from well women appear mother will approach subsequent feed. to be able to lactate in traditional ings with even more apprehension. communities, The end result of this cycle is usually that Also, failure to breast feed can be the baby is taken off the breast due and to a feeble baby, such as in pre- given bottle feeds. maturity or cerebral birth danage, or Mothers in the lower socio-economic to mechanical difficulties in feeding, as group in urban tropical circumstances with a cleft palate or abnormally shaped have probably been brought up nipples. in a breast feeding environment, but have The two commonest causes of lacta- also been exposed to two other types; tion failure are in no way related to of behavior-molding experience. the nutrition or physical health in the First, they will be avare of the prac­ mother or baby. Rather, economic, cul- tice among upper socio-economic group tural, psychological, and social factors women of successfully bottle feeding associated with the process of urbaniza- their babies, and they will lend to want tion and sophistication seem to be to imitate them. because responsible. they will be. lieve this to be a status symbol and the One form of lactation failure is more modern method. obviously and directly linked to eco- Secondly, mothers under these cir. nomic and cultural circumstances. This cumstances will have been increasingly is in the mother in the tropical town exposed to advertising by milk corn­ who goes out to work in some employ- panics. Even for illiterate women, post­ ment where breast feeding is not per- ers in the shops and the pictorial ad. missible because of the unfortunate vertisements in the news)apers make modern Western convention concerning their message clear. It is not, it must 1 "modesty." Sometimes partial breast stressed, that the milk products con. feeding may be attempted during the cerned are poor quality. It is, rather, night, but this usually soon ceases, that the content of the advertisement More important and more common is inappropriate in tropical circum­ are the increasing numbers of urban stances in that it further impels mothers tropical mothers who change to bottle to abandon breast feeding, when there feeding in preference to breast feeding is no practical possibility of their being because they believe this is the modem able to carry out bottle feeding at all

121 adequately for financial, hygienic, and and the baby is enabled to have a full educational reasons. and satisfactory feed. Reflexes and BreastFeeding. To un- However, the let-down reflex is a derstand the mechanism at work, it is psychosomatic reflex-that is to say necessary to realize that successful it has a psychologic component as breast feeding depends upon a set of well as a somatic or bodily aspect re­ subconscious reflexes, possessed both suiting from stimulation of the nipple by the baby and by the mother. by the sucking baby. In practice, this (a) Baby. The healthy, mature new- means that anxiety can interfere with born possesses both sucking and swal- and inhibit the let-down reflex, while lowing reflexes, which permit him to tranquil confidence can enhance it. squeeze out and to swallow milk from Examples of psychologic interference his mother's breast. with the let-down reflex are common­ (b) Mother. The mother's reflexes place. For example, there is the woman also need to be understood, and, in view who is successfully breast feeding her of the importance of breast feeding in baby, but whose milk "dries up" after infant feeding in developing regions, sudden news of a family tragedy. Also, the basic physiology has to be examined farmers are well aware that an unfa­ briefly. miliar milker produces a lower yield Prolactin Reflex. When the baby from a particular cow, again because takes the breast, two maternal reflexes of the anxiety produced in the animal are brought into play. The first of these interfering with the let-down of milk. is the prolactin reflex, in which the Let-down Reflex in the Vilage stimulation of the nipple by the feed- Mother. The traditional village mother ing infant sends impulses up nervous approaches breast feeding with no pathways to the anterior part of the anxiety and with no easily accessible pituitary gland, which liberates a hor- alternative. She will have been sur­ mone, prolactin, into the bloodstream, rounded by lactating relatives and which, in turn, passes back to the neighbors during her own childhood breast and is responsible for the secre- and will regard the whole process as tion of milk. commonplace and normal. She will also Let-down Reflex. The sucking on the be used to handling young children breast by the newborn infant also sends and will subconsciously have learned a impulses to the posterior part of the great deal of the technique of breast pituitary, which releases a substance feeding by observation of relatives. known as pituitrin into the bloodstream. In most cultures, if the baby is ma­ This passes back to the breast and acts ture and vigorous, he will be put to on small muscle cells surrounding the the breast at once after delivery, or milk producing ducts in the breast. This after at most a short delay after birth, concerted muscular action forces the while neither the mother nor child will milk down into the terminal milk ducts be in a sedated condition. The out­ -the so-called "let-down" reflex, or the come will almost always be an unin­ ":milk-ejection" reflex. By this means, hibited let-down reflex and contented the breast is emptied more completely baby, breast feeding permissively.

122 Let-down Reflex in Western Women. to breast feeding by involving promi­ By contrast, a young woman in Western nent local ladies in the community in society may never have seen an infant the health education program (e.g. the breast-fed. Her knowledge of the proc- President's wife), or by stressing the ess may be colored by stories of diffi- recent move toward breast feeding by culties and complications, while safe, an increasing number of well-educated economical, convenient alternatives are American ladies. rlhe latter group, at hand. Likewise, the modern ten- known as the La Leche League (LLL), dency to regard the female breast al- produce a monthly bulletin which can most exclusively as a symbol of sex be very useful in this regard, showing, may also make her less inclined to as it does, a modern group of women "risk losing her figure." Also, it must in an affluent society who believe that be admitted that many of the doctors breast feed'ng is worthwhile achieving. anJ nurses in the U.S.A. and Europe (b) Control of Unsuitable Adver­ appear to have little knowledge of the tising. There is little doubt that much advantages of breast feeding and al- advertising in tropical countries is of most routinely start on artificial bottle great value health educationally and feeds. assists in improving the level of living In many cases, Western mothers of populations. Equally, there is much may not breast feed at all, either be- advertising, particularly in the field of cause they believe that bottle feeding infant nutrition, that is highly inap­ is the modern method or because of the propriate and, indeed, dangerous. The need for them to go out to work. How- desirability and the feasibility of cen­ ever, just as commonly the mother at- soring inappropriate advertisements in tempts to breast feed, but is unsuccess- the press, radio, stores, and TV has been ful, usually because "there was not often suggested, but is extremely diffi­ enough milk" or "he milk didn't suit cult to put into practice. Government the baby." agencies usually control the radio and Reversal of Present Trend. The move TV, and require the income from adver­ away from breast feeding toward at- tisers, while examination of advertise­ tempted bottle feeding continues to in- ments would require some form of cen­ crease in tropical regions and repre- sor board, and neither staff nor finance sents a real problem both for the would be available for this. present and still more for the future. Nevertheless, this type of approach Methods of attempting to reverse this certainly deserves further considera­ trend are difficult to formulate. tion, as, at the moment, the toll of death If, however, the pattern of infant from marasmus and infective diarrhea feeding has already altered with bottle in tropical infants as a result of arti. feeding on the increase, then the fol- ficial feeding is probably greater than lowing approaches may be feasible: that due to cancer of the lung resulting (a) Raise the Status of Breast from cigarette smoking, for which leg. Feeding. Bottle feeding is spreading islation to modify advertising has been largely because mothers feel that this introduced in some Western countries. gives them both status and modernness. (e) Health Education. If breast To counteract this, status may be given feeding is proceeding normally in a

80-112 0--68----0 123 community, no health education at all food, water, or feeding utensils. For is required, except perhaps in relation example, there is no need for orange to dangers of artificial feeding. In fact, juice or other source of ascorbic acid tinder these circumstances, the more for breast-fed tropical infants, among attention that is drawn to the process of whom scurvy is virtually unknown. breast feeding, the greater the likeli- Successful breast feeding can be hood of the development of anxiety and judged by a contented, well-formed, doubt in place of previous untroubled active baby, who is gaining weight confidence, satisfactorily. By contrast, in areas where breast There are few absolute reasons for feeding is on the decline, health educa- not breast feeding, notably very severe tion may be directed toward this sub. maternal illness or mental derangement ject, particularly for school children (at least temporarily), and absence of and for mothers during the pre-natal the mother, if the baby has been period. For the latter group, un- deserted. doubtedly the best health education and Maternal pulmonary tuberculosis or instruction can be given with the as- leprosy are no longer regarded as sistance of the woman who is already contra-indications, provided measures successfully breast feeding her baby. are taken to prevent infection occur. (d) Legislation. For working moth- ring, including the prophylactic use of ers in towns, the possibility of legisla- appropriate antibiotics for the baby. tion deserves consideration, perhaps by Introduce Supplements to Breast providing nurseries (crhches) at fac- Milk from 4 to 6 Months. After the first tories, or even "lactation bonuses" for 4- to 6 months, breast milk is never mothers while breast feeding their nutritionally adequate alone ("breast babies for 4 to 6 months, starvation"), and the child always re­ Principles of Breast Feeding for quires additional food as well. TropicalMothers. A working hypothe- Semi-solids need to be introduced, sis with regard to breast feeding for based especially on protein foods avail­ mothers in tropical regions can be able (p. 149), so that the diet includes based on the following six principles: all items of the adult diet at least by the BreastFeed Alone for 4 to 6 Months. time the child is 1 year old. Kwashior. Breast milk is the mainstay of protein kor occurs most commonly in the sec­ nutritionfor the first 4 to 6 months of ond year of life. Its dietary prevention life and is usually all that is needed for should commence in the second six this period, months of the first year. It is also the cheapest, cleanest, most Breast Feed for 1 to 2 Years. So easily available and digestible source of called "late lactation" (e.g. up to I to 2 protein. Any other additional food con- years or more) was usual in the West­ sidered (luring this early period must ern world until the comparatively re­ be either really nutritionally necessary cent "milk revolution," with its im­ or of great cultural significance, and its proved dairying and milk conservation. alleged advantages have to be weighed In late lactation, the breast milk of against the considerable risks of pro- poorly fed tropical mothers has a low ducing infective diarrhea with unclean normal protein content, although the

124 yield is rather low. However, the nutri- tice is being used in the traditional tional drain on the mother is cumula- method. tive with successive pregnancies and Artificial Feeding is Dangerous. As protracted lactation, and emphasizes has been stressed, bottle feeding with further the need for attention being cow's milk formulas is increasingly be­ given to the mother's diet in pregnancy coming the competitor of breast feed­ and during breast feeding. ing, especially in tropical towns. The However, at the same time, lactation standard pediatric textbook arguments prolonged for 1 to 2 years, depending concerning the relative merits of human upon local cultural acceptability, repre- and cow's milk are entirely secondary sents a significant partial protein pre- and academic as far as infant feeding of ventive against the development of the underprivileged in tropical regions kwashiorkor. It must always be re- is concerned. garded as a small, but valuable, pro- Basically, with few exceptions, the tein supplement to a mixed diet based majority of tropical mothers have nei­ on all availablelocal foods. tiler the money, nor the education, nor Feed the Pregnant and Lactating the kitchen facilities, so that bottle feed­ Mother. Attempts must be made to per- ing means the giving of an over-dilute, suade mothers to feed themselves better contaminated mixture, low in nutrients, on locally available foods, especially and high in bacteria, with the resultant rich sources of protein, such as legumes combination of infective diarrhea and and dark green leafy vegetables, during nutritional marasmus. pregnancy and prolonged lactation. Weaning IDiets and Local Foods. A Avoid Advice on the Technique of basic problem in infant feeding any­ Breast Feeding. The world's experts on where in the world, especially in the practical breast feeding are unsophis, difficult circumstances found in devel­ ticated village mothers, among whom olping tropical regions, is to introduce it is carried on as naturally as are such a nutritious, digestible "weaning" diet, similar physiologic events as swallow- containing sufficient quantities of pro­ ing in other parts of the world. Con- tein, calories, vitamins, and minerals, scious, planned "technique" with re- during the so-called "transitional peri. gard to nipple preparation, positioning od" between the tinme a baby receives of the baby, regularity of feeds, fully adequate nourishment on breast milk emptying the breast, burping, and so on alone, and the time when be is receiving is usually minimal or non-existent. Suc- a fair share of the full range of the adult is uualy omnimlrio-exstet. uc-diet. cess is based on subconscious imitation d iet. of female relatives observed in child- Weaning in the Western World. In in­ ofreativs fmal osered i chld-dustrialized countries in North America hood, and the unruffled, unthinking nor­ mality of the whole process, in which 'The term "weaning" (Anglo-Saxon doubts or hopes as to success or failure wenian, to accustom) is used with various figure not at all. different meanings, including "accustoming to foods other than milk" and "the stopping of Advice oil the technique of breast breast feeding." It is here used in the former feeding should, therefore, only be of- sense to refer to the gradual process of intro. ducing other foods than milk, whether human fered if some definitely harmful prac- or cow s.

125 and Europe, the weaning process is not It is, unfortunately, unusual for even usually very difficult. The initial period the full range of the still limited foods of feeding with breast or cow's milk is that comprise the adult diet to be used supplemented by a wide range of other for infant feeding. Likewise, the prep­ foods introduced gradually. These may aration of special dishes for young chil­ be home-cooked or, more likely, ob- dren is uncommon. The need for young tained in convenient, pre.cooked por- children to have more frequent meals tions prepared in small cans or glass than adults is often not appreciated. containers. There is no doubt at all that much Weaning foods in the Western world could be done to improve infant feeding are, therefore, often based on vegetable in many tropical countries, if the pres­ purees, soft egg dishes, minced meats, ent range of foods available and al­ mashed fish, and so forth. In all cases, ready used by the adults, could be the new semi-solid foods introduced prepared suitably and fed to young will be fed with the continuation of the children for at least four meals a day use of cow's milk. from the second six months of life on. At least by the time the child is 1year Time to IntroduceSemi-Solids. There old, he will be having almost the full is much controversy with regard to this range of the adult diet, although with timing in the Western world and else­ the food suitably cut up into small where. For example, there are extreme pieces. schools of thought which suggest that Traditional Weaning. It has been young children should be given semi­ noted (p. 39) that many traditional, solid foods from a few weeks old. customary diets include a relatively (a) Relation to Growth and Nutri­ limited range of foods, usually based tion. The matter has to be judged on rather coarse, bulky vegetable foods, rationally in relation to the particular and especially on one or more staples. circumstances of the tropical child. It is usual, therefore, that the "transi- Firstly, as has been noted elsewhere tional diet" given to young children in (p. 56), exclusively breast-fed infants tropical circumstances consists of the usually grow extremely well during the softer portions of the adult diet, very first 4 to 6 months of life, show little in frequently largely carbohydrate foods, the way of malnutrition of any sort, sometimes made into pastes or gruels. and are highly susceptible to diarrheal The process of introducing semi- disease froni contaminated food, dirty solids is often abrupt, and on to rela- water, and unclean utensils. Breast tively indigestible, coarse vegetable milk, together with the stores the infant foods of low nutritional value. Diarrhea has acquired from his mother while in is likely from infection introduced by the uterus, are together more than ade­ unclean utensils, and from poor diges- quate for this early period of life, with­ tion of the foods taken, leading to de- out the addition of other foods. fective absorption. The process may (b) Relation to Development. The also be complicated by the psychologic fact that teeth erupt in the baby from upset of the associated sudden separa- about six months and the mouth's move­ tion from tle breast, and by innumer- ments become coordinated to be able able general infections, to deal with semi-solids suggest that this

126 is physiologically the time when foods solid foods, possibly as early as four other than breast milk are required. months. (c) Relation to Diarrhea Preven- Types ol Weaning Foods. The types tion. Lastly, and very importantly, in of foods most suitable for feeding to tropical circumstances whether in rural infants during the weaning period will areas or in towns, the risk of intro- depend very much on whether it is ducing bacteria to the young child, and thought practicable to cook separate hence intcstinal infection resulting in dishes, which are preferable for young diarrhea, with its great risk in the early children, or whether it will be necessary months of life, have to be taken into to use foods already preparcd for adults. account. GradualChange. The process is ini­ Breast milk is clean and uncontami- tiated by offering small quantities of nated. As soon as other foods are iii- ,eii-solid food once daily. Thereafter, troduced, whether these are cow's milk the quantities are increased, the range or semi-solids, the risk of infective of food taken is widened, the numbers weanling diarrhea increases greatly. It odaily feedings inreased, and the does, therefore, seemn important from consistency of the dislies used is thick. this point of view to introduce foods ened, until solids are being eaten. other than breast milk only when the The weaning process should be a in any part of the world child really needs them. andgradual should one aini at a change fromn milk Food prepared for young children s to a wider should be well cooked, fed with clean7 diet, consisting of milk to­ shoud bewellcooed,ed wth cean gethler with a full range of other foods feeding utensils, and stored after prepa- ID ration to avoid contamination from available. In a Western sense, it often ieans the chanugeover, or accustoming flies and other insects, and dirt. Before feeding children, mothers should be el- period, from cow's milk to a mixed diet, including cow's milk. In most tradi. c ,ouldol w i r han, and tional tropical circumstances, it can be shouldbold aertonly givetrChideodik clean, preferably regardedrcalda as a changehnefoibesfrom breast milkil boiled water to their children to drink. to a mixed diet, in which breast milk is (d) Variation with Breast Feeding continued up to 1 to 2 Years. Ability. It is probably unwise to gener- This phase of Child feeding has well alize too widely, as the ability to breast b described as "a danger period," feed does appear to be less good in some because the chil has to become aecus­ tropical communities in certain parts tomed to the taking and digesting of of the world. Possibly the best way to these new fooLs and, at the same time, judge e correct time to introduce is susceptible to the various infections semi-solid fos, s in relation to the cus- of the intestinal canal that are likely to tomary growth, as evidenced by weight be introduced in unclean foods and curves seen in the particular region. utensils. Usually, these will be excellent for the In tropical regions, infant feeding first six months, but, in some places, the will almost always have to be based on slowing of weight gain may commence the fact that animal protein, including earlier than this, indicating the need for milk from the cow or other manimal, somewhat earlier introduction of seni- will be uncommon and expensive, and

127 consequently can play only a very locally available foods, economical, and limited part in the diet of the young nutritious, with special reference to child. protein. First Semi-Solid Food. In many Almost universal problems in the communities, the initial food given to tropics are the uncommonness and ex­ young children will consist of one of pense of animal protein, the compara­ the local largely carbohydrate staple tive costliness and relative indigesti. foods, sometimes as cooked for adults bility of legumes, and, sometimes, the or sometimes prepared specially for the bulky, high water and cellulose content child, either as a paste or gruel or mash. of the staple. There need not be any objection to this, (b) Aims. In view of the common­ provided the carbohydrate food is en- ness of protein-Calorie malnutrition of riched thereafter with other items from early childhood (p. 73), the main aim the local diet with a high content of is to introduce a soft, digestible diet protein, vitamins, and iron. containing adequate protein and Cal. Suitable soft foods include gruels of ories, based on indigenous foodstuffs semolina (the sugi of India), corn flour and on the local kitchen potential, which (the ugali of the Swahili-speaking should, when possible, be taken together world), taro (the poi of Polynesian with the small, but important, amount Hawaii), or rice (the soft boiled nasi- of breast milk from the mother, tim of Indonesia). which should continue during and Various soft, "natural convenience after the weaning process, if culturally if acceptable. foods" can be fed to young children. freshly prepared in a clean fashion-the However, although protein is the cadloripe sweetand thebanana, immature the papaya, coconut the jelly',avo­ prime concern in most parts of the world during the weaning period, it is All can serve as a base ii.to which pro- also necessary to ensure that the child's rein foods can be mixed. renfoods Fabeixed. Tetransitional Freque nc y o l Fee diet should contain natu­ ds. Th e y o ung r l y o c r i g v t m n n i e a s child's capacity is small, so that it is rally occurring vitamins and minerals, best to try to use less bulky foods for especially vitamin A and its precursor, children, particularly compact sources earotene (p. 15), and iron (p. 15). In of Calories and protein, and, at the tropical circumstances, this may be same time, to offer four feeds daily, in done by introducing egg yolk and liver, the form of hot meals or cold snacks, whenever practicable, and dark green This is often easier to do if a separate leafy vegetables and yellow pigment preparation is made for the young child fruits and vegetables into the diet. and preferably served before the adult's Also, in some communities, special meal. problems may have to be considered. Village-Level Weaning Foods. Thus, for example, in regions where (a) Characteristics.The characteris- severe vitamin A deficiency is common tics of the weaning process are the same (p. 86), particular attention must be anywhere. Firstly, the food preparation given to the introduction of rich sources used should be soft, easily nmasticable, of carotene, such as red palm oil or of digestible, not too bulky, clean, non- vitamin A, such as egg yolk, liver, or irritant, culturally acceptable, made of fish liver oil.

128 (c) Composition ol Weaning Foods Because of their undoubted poor (i) The Staple. The main source of digestibility, it is importantl to see that Calories in a weaning food will be the legumes are well cooked and carefully local staple. If alternative staples are prepared. For example, the skins available in the particular community, should be removed from dried red the moit nutritious should be used, with beans (Phaseolus v: garis) before special regard to the protein content. cooking by soaking or scalding, or after In particular, if culturally acceptable, cooking by sieving. As noted earlier a cereal grain should be employed in (p. 31), particular care is needed with preference to a tuber. the soybean. An often under-appreciated problem (iii) Animal Protein. In almost all may be that if the staple is a tuber or places, animal protein will be in very plantain, it will itself be bulky, high in short supply, so that it is important to water and fiber, and a poor source even use it most advantageously. of Calories, especially small capacity. with a child's .Firstly, attempts shoul e made to smac ity.refore eincorporate portions of all available animal protein into the weaning food. consider the feasibility of adding "corn- , i pact Calories" to dishes. In West Africa, These may include protein foods widely this has been carried out with red palm used in the Western world, such as oil, anl in East Africa, with other vege- eggs, fish, meat, and cow's milk, ut table oils (p. 174), and with sugar. An- other more unfamiliar sources should other source of ready-to-eat, easily be considered, such as acid milk prep­ mashable "compact Calories" is the arations, village cheeses, duck's eggs, avocado pear. fermented shrimp paste, edible insects, (ii) Legumes. Protein will almost and so forth. certainly have to be derived mainly Secondly, if possible, the available from legumes. Selection will depend on animal protein should be given local availability and cost, properties throughout the day and eaten in small as regards cooking and apparent di- amounts intermixed with as many gestibility, cultural attitudes, and suit- meals as possible. ability for young children, as well as (iv) Dark Green Lcafy Vegetables. the protein content. These are often much too little used by

Table 3.-APPROXIMATE PROTEIN CONTENT AND AMINO ACID DEFICIENCY OF MAIN CATEGORIES OF VEGETABLE FOODS USED IN MULTIMIXES

Protein T)pe of Food (approx. Amino Acid Lh- iciency percent) ruber-plantainI ...... 1-2 Lacking in Lysine. Cereal grain ...... it 1I Legumes ...... ) acking i Dark green leafy vegetable 3...... -. 1 in Methion.i...

I Dried: 3 percent. 2Soybeans: 40 percent. 3 Dried: 30 percent.

129 tropical communities, especially for in. (i) Double lixes. These consist of fant feeding. The> represent an excel- the local staple (preferably a cereal lent source of carotene, vitamin C, and grain, if more than one staple is used iron. the B complex, as well as protein, by the community), together with the whose amino acid composition comple- most suitable legume, or animal pro­ meits that of staple foods. tein. or dark green leafy vegetable. (d) Principle of Atltimixes. Most The staple :legume double mix can communities have by age-long experi- commence with 4 :1 proportions, fol­ ment cone to use foods in mixtures, so lowed by a gradual increase in the that their nutrients complement one legume, until a 2 : I mixture is used. another. Nutritionally, the essential amino In fact, ai important generalization acid deficient in the staple, lysine, is in relation to human diets is that the supplied by the legume, which is it. wider the range of foods inchided and self lacking in methionine, available tle greater the variety the less the like- from the staple. lihood of nutritional deficiency. Traditional double mixes sometimes The blnt way of planning a nutriti- used for infant feeding in different oils, village-level weaning food is as a parts of the world include sweetpota­ mixlure of ingredients. dlsigned to toes-red beans (Ruandat, and rice­ conipleinent and intltually reinforce one so%-beans (Indonesia). anotler. in particular to ensure an in- Alternatively. the staple can be di. lake (if Ilil full range of eight essen- retelly reinforced with all anilial protein Gal anmin arids at tie particular meal. %%ith its abundant surplus of essential With this wimciphl in mind. three amino acids. Examples include various I%-pes of ilixtures cal lie considered. cereal p)lridges %itihadded egg or milk. AIlare built around the slape, with Less satisfactorilv, tile staple ca i be addlion of one, two, or three other mi xed with dark green leafy vegetables. foods-double mixes, triple mixes, and (ii) Triple Mixes. Sometimes it may quadrimiixes. Recipes from different be possible. if only for an occasional parts of the world are given in Ap- preparation, to reinforce a "double pendix V. mix" of staple and legume with small

Table 4.-VILLAGE-LEVEL MULTIMIXES

Ingredients

JDiouble Mix ...... Staple+legume. (or) Staple -animal protein.' (or) Staple+ dark green leafy vegetable (I)GLV). '.Priple Mix ...... Staple+ legume+ inimal protein. (or) Staple+ legume+ DGLV. (or) Staple + DC LV+-animal protein. Quadrinix ...... Staple + legume l"DGLV -animal protein.

I Mixtures with animal protein preferable in all mixes.

1.30 amounts of animal protein, thereby con- Typical recipes of multimixes are verting it into a "triple mix." This ap- given later (Appendix V). Suitable mix­ proach ensures that the child will be tures based on local foods and cooking receiving Calories, while the surplus methods can often be devised by prac­ essential amino acids (p. 16) from the tical observation and by trying out suit­ animal protein food will be available to able recipes oneself in an actual village complement and reinforce still further kitchen. the essential amino acids of the vege- (e) The Three Plank Protein table protein mixture. Bridge. In this consideration of wean. Typical examples of triple mixes used ing food mixtures, adequate stress for infant feeding include plantain, needs to be given to the fact that breast pounded groundnuts and egg in Bu- feeding, continued at the same time as ganda, East Africa, and a mixture made the food mentioned, is supplying a of soft boiled rice, Bengal gram (chick. further small amount of protein of good pea) and milk in Bengal, India. biological value. Alternatively, triple mixes may be As protein is the critical need in feed. prepared from a mixture of staple, dark ing young children in developing tropi. green leafy vegetable (or orange-pig- cal regions, the concept of the "Three ment vegetable), and a small quantity Plank Protein Bridge" has the value of of animal protein; or from staple leg- simplification and emphasizes the need ume and dark green leafy vegetable, for the use of all proteinsources,repre­ (iii) Quadrimixes. If local food re- sented pictorially by the three "planks" sources and cooking practices permit, of prolonged breast feeding, and mix­ the staple-legume-animal protein "triple tures of animal and vegetable protein mix" can be converted into a "quadri- foods, if the child is to bridge the nu­ mix" Ly adding small quantities of dark tritional divide, between the age of 6 green leafy vegetables (or orange- months and 2-3 years, without develop. pigment vegetables), both of which are ing kwashiorkor. sources of vitamins A and C. Of the (f) Quantities. A most difficult as. two, the dark green leafy vegetables are pect of feeding during the weaning or preferable because of their content of transitional period is that it is a gradual protein and iron. process of "accustoming," with increas­ The various weaning food mixes sug- ing numbers of feeds made up princi. gested are increasingly nutritionally de- pally of semisolids and with increasing sirable the greater the number of in- quantities of food taken. It is, there­ gredients. In other words, quadrimix fore, difficult to suggest amounts re­ recipes are ideal, followed by triple quired for this period of change. mixes and with double mixes as next Nevertheless, it is necessary to try to best. Planning of mixtures should, give guidance in regard to quantity of therefore, be aimed at using the largest foods to be used in preparing infant number of these ingredients, especially recipes. This is usually best undertaken small quantities of animal protein but by approximate "domestic" advice­ one should be prepared to use vegetable that is to say "use one handful of beans" protein double mixes, if need be. each day, or to make use of locally

131 available measure, such as bowls or daily, thought should be given to suit­ gourds. This can most usefully be able preparations which can be fed to taught by means of demonstration, children safely between cooking A further problem is that with lim. periods, if warmed up or if cold. The ited resources the mother can obviously use of cold dishes, such as bean cakes, not afford to prepare over-large, waste- may play a significant part in some ful quantities. The best that can often cultures. be done is to have approximate recipes If special dishes prepared sepa. based on the needs for the second six rately for the young child are not cul­ months of life, and then the second year turally or domestically practicable, of life. weaning food mixtures can be prepared (g) Preparation.The preparation of from the adult diet, by removing suit­ suitably cooked, soft, digestible high able portions and mixing them together protein mixtures poses problems in ill- to form multimixes. equipped village kitchens, and always Ingenuity may be required. For ex­ takes time. ample, in some communities ingre. Preliminary soaking and skinning of dients will have to be used before the legumes may be required. The final final very hot spices are added. In oth­ product needs to be made into a suit- ers, methods of softening the locally able masticable consistency by mnsh- prepared unleavened bread, such as ing with a fork or spoon, by pounding tortillasor chapatis, will have to be con­ or crushing with a pestle and mortar, sidered. In others, a larger helping of by sieving or straining, or by grating. thicker protein-containing sauce must The difficulties in carrying out these be reserved for the young child. seemingly simple procedures in village It may be valuable to make a small kitchens must be appreciated. Sug- spoon easily and cheaply available at gestions have to be as simple and con- Young Child Clinics (p. 172), if this is venient as possible, based on personal not customary in the community, as experience, this may ensure a much greater intake Supplementary weaning mixtures of food than if an inexperienced young should, if possible, be cooked separate- child tries to eat semi-solids with his ly for young children, as this means fingers. forthat younga special nutritious preparation children can be made and -Artificial Feeding. Breast feeding forchidre oun ca be adeand is fortunately still the normal manner served, without the child having to take is fort un stie noa ma his (usually low) place in the priorities o ing ounbies intost rua of intra.familial food distribution, tropical communities, although de­ A sof ithtra-famkid uisribulln creasing in urban situations. As dishes of this kind usually need However, anywhere in the world cir­ special preparation, small cheap cook- cumstances may arise when breast feed­ ing pots with lids may be required, and ing is impossible, as, for example, if it may be necessary to make these the mother dies in childbirth or be­ available at low cost at Young Child comes mentally deranged. Clinics (p. 172). If, as is often the case, In some societies these emergency cooking is only possible once or twice situations may be dealt with by ac­

132 cepted cultural technics, whereby a Unless from a reliable source, fresh wet-nurse may be hired, or anotiher lac- liquid cow's milk is often a rather un­ tating relative will breast feed the certain, dangerous fluid, as, in many orphaned child. Alternatively, lactation tropical countries, it is likely to be con­ may be induced in a selected female in taminated, diluted and adulterated. the extended family, largely by putting Dried Powdered Milk. Dried or the baby to the breast frequently, re- powdered milks are made in innumera. suiting in prolactin production (p. bly different forms by large numbers 122) and, hence, secretion of breast of companies. Some are prepared for milk. particular purposes, such as for chil­ If the mother is not available to dren who are allergic. However, there breast feed and if there is no cultural are really little important differences method of dealing with the situation, between these milk preparations, apart the child will have to be reared artifi- from their fortification with various cialy-that is, by feeding with some vitamins and minerals, despite the form of modified mammal milk, usually manufacturers' claims. Most hospitals cow's milk. The dangers of this have al- in the U.S.A. use simple formulas based ready been stressed (p. 36) and, in on evaporated milk; while in Britain many tropical lower socio-economic cir- in World War II only one preparation cumstances, chances of success are of full -ream dried powdered milk was slight. The result is only too likely to be availalle, and the health and nutrition a development of nutritional marasmus of young children improved. from over-dilute feeds, and associated Full Cream Powdered Milk. If infective diarrhea from the use of con- dried powdered milk is to be used for taminated foods given in unclean the hazardous process of artificial feed. utensils. ing in tropical circumstances, then the (a) Type oj Milk. Numerous differ- cheapest reputable brand of full cream ent animal milks may be used for feed. dried milk that is available locally ing young babies from birth onwards. should be employed. These include the milk of the cow, Powdered milk has the advantage of buffalo, reindeer, and many others, being compact, light in weight and Most usually cow's milk is employed, hence, easily transportable. It is also either fresh or in one of its processed, sterile until the tin is opened, when it tinned forms. The latter include pow- soon becomes contaminated. dered milk, evaporated milk and con- Cow's milk can be approximately re­ densed milk. constituted by adding 1 rounded tea­ Essentially, cow's milk contains about 2-3 times the content of protein, spoonful (with a volume of about 5-6 especially relatively indigestible casein, c.c.) of full cream powdered milk to 1 the same amount of fat, and about half ounce of boiled water. as much milk sugar (lactose) as is This method is very approximate, as found in breast milk. the compactness of different brands of Fresh Cow's Milk. This has to be dried milks varies. However, the need boiled, both to kill harmful bacteria, for simplicity in preparation of these and because the heat makes the cow's milk mixtures cannot be over-stressed. milk protein more digestible. The likelihood of their being carried

133 out incorrectly in the home by the may be found on sale in a number of mother on her return is extremely great. tropical countries. It can be used very Therefore, the technic of preparation conveniently and easily for infant feed. should be as basic as possible. ing, and is sterile until opened. It is, Dried Skimmed Milk. Dried however, costly and rather bulky and skimmed milk is available in stores in difficult to transport. some parts of the tropics and certainly Full strength cow's milk may be re­ has been used all over the tropics as a constituted from it by adding 1 part of result of UNICEF supplies being made evaporated milk to 1 part of water. available. Condensed Milk. This type of Dried skimmed milk should not usu- milk preparation is not only highly con­ ally be used for artificial feeding of centrated, but also has had very large young babies. It is low in calories and, amounts of sugar added (30-40 per. much more important, it has had re. cent). This bas the great advantage that, moved from it the essential fat soluble in tropical climates, the opened tin can vitamins, especially the vitamin A re- remain unrefrigerated for days without quired to protect the eye. However, souring. recent shipments of dried skimmed milk Condensed milk is not at all suitable from UNICEF have been reinforced by forthe feeding of young children.First­ both vitamins A and D. ly, it is often made of low-fat, skimmed However, if no other form of milk milk, with the great risk of develop. is available, dried skimmed milk may ment of vitamin A deficiency, also, its have to be used for infant feeding in high sugar content unbalances the diet the first months of life. It should be re- towards the carbohydrate end of the constituted for young babies using one scale; while the extreme sweetness often level teaspoonful of powdered dried tends to make mothers "stretch" the skimmed milk to each ounce of boiled milk by the addition of water, so that water, and with 1 level teaspoon of it becomes a very thin homeopathic sugar to each feeding. In addition, un- solution indeed. less it has already been reinforced, If no other milk is available, con. vitamin A should also be given to the densed milk may have to be used from child, either in the form of vitamin con- (p. 36). Again, if prepared sources of vitamin centrate, red palin oil, fish liver oil, or, skimmed milk, other long acting intramuscular in- A will have to be given. possibly, (b) Economics of Animal Milk. All jection, forms co cow's milk are usually rela. Dried skimmed milk is best used, not tively scarce and expensive in tropical as a reconstituted liquid for the feeding regions. It is for this reason that moth­ to try to use less of young babies, but rather as a pro- ers will be tempted costly dried skimmed milk. It is im­ tein additive mixed with food as a pow- der during the weaning period (p. 72), portant to know the price range of or in the preparation of a formula for various commercial types of milk avail­ the treatment of kwashiorkor or moras- able in the shops in the particular mus. region. Evaporated Milk. Evaporated What is needed is to know and use milk is widely used in the U.S.A., and the cheapest reliable form of locally 134 availablefull creamcow's milk, whether (d) Daily Milk Requirements. The fresh, or powdered, or evaporated, appetites of babies and their nutritional It still will be unlikely that most needs vary from one to another. How. mothers will be able to afford to artifi- ever, as a rough guide, young infants cially feed their young babies on even in the first six months of life need ap. the cheapest brand, so that, if artificial proximately 21/2 ounces per lb. body feeding is really required, it may be weight per day of modified cow's milk necessary to supply milk free or to sub- (p. 119), prepared from either fresh sidize the feeding process, as by pur- liquid milk, or powdered milk, or chasing tinned milk by the crate and evaporated milk. It is then possible to selling at eost. calculate the child's approximate daily (c) Modification of Cow's Milk. All needs by knowing his weight. forms of cow's milk need to be modified Number and Timing of Feedings. for use by young babies in the first Ideally, in artificial feeding, as in three months of life, by slight dilution "natural feeding" on the breast, the and the adding of sugar. baby should be allowed to develop his Modification of fresh cow's milk for own rhythm of feeding and sleeping. babies under 3 months can be carried However, usually this will settle into out by (1) dilutingwith water (2 parts an approximate pattern of 3-4 hourly of boiled milk : 1 part boiled water) ; feedings. (2) adding sugar (1 level teaspoonful Volume per Feeding.For practical of household sugar to each feeding). Shutabl a roaeeding) offullpurposes, the total calculated quantity Suitable approximate dilution of full of milk needed for the whole day can cream powdered milk can be achieved be divided into five parts, and one fifth by adding 1 level teaspoon to I fluid of the total offered to the child at ap­ ounce of boiled water, and with evap- proximately 4 hourly intervals (6 a.m., orated riilk by adding one part milk to 10 a.m., 2 p.m., 6 p.m., and 10 p.m.). 3 parts of boiled water. Sugar should Alternatively, if five feedings are be added to both. givenaily eedinsal u After 3 months of age, boiled cow's given daily at a calculated total volume milk can be given undiluted with added of 2t/e fluid ounces per lb. body weight, sugar. Full cream powdered milk can then the volume for each feeding (in be used at the strength of 1 heaped tea- fluid ounces) can be rapidly calculated spoon to 1 fluid ounce of boiled water, by dividing the child's weight in lbs. and evaporated milk can be diluted 1:2 by two. with boiled water. Sugar should be PracticalApplication in the Vil. added to both. lage. The successful practical applfica­ Many other animal milks are cus. tion of these principles is very difficult tomarily used in different parts of the in village circumstanccq. world, and can be employed in much Firstly, the volume of each feeding the same way as has been suggested for (in fluid ounces) is calculated by halv­ fresh liquid cow's milk. Even buffalo ing the child's body weight in pounds. milk, which has a much higher fat con- The container, such as a cup, and tea­ tent (9%), can be diluted and re- spoon available to the relative should inforced with sugar in the same manner, be brought for inspection, and

135 Table 5.-SIMPLIFIED USE Or, COWS MILK AND ITS PREPARATIONS IN THE FEEDING OF BABIES UP TO THREE MONTHS OF AGE

FreshCow's Milk Full Cream Powdered EvaporatedMilk Milk

Dilution ...... 2 parts boiled milk I level teaspoon milk I part evaporated + powder + milk + I part boiled water. I fluid ounce boiled 2 parts boiled water. water.

Add sugar ...... I level teaspoonful household sugar per f&edig.

Calculate Daily 2% fluid ounces per lb. body weight per day. Volume

Calculate Volume One-fifth of daily total at each of five feedings at 4 hourly intervals. per Feed.

Table 6.-SIMPLIFIED USE OF COW'S MILK AND ITS PREPARATIONS IN THE FEED- ING OF INFANTS OVER THREE MONTHS OF AGE

Fresh Cow's Alilk Full Cream Powdered EvaporatedMilk Milk

Dilution...... Undiluted boiled 1 rounded teaspoon 1 part evaporated milk. milk milk + + 1 fluid ounce boiled I part boiled water. water.

Add Sugar ...... I level teaspoonful household sugar per feeding.

Calculate Daily 2%fluid ounces per lb. body weight per day. Volume.

Calculate Volume One-fifth of daily total at each of five feedings at 4 hourly intervals. per Feeding. should then be used for practical If full cream powered milk is avail­ demonstration, able, the relative should be shown how Depending upon the type of milk much 4 fluid ounces are in the cup preparation available, the relative who (probably about half full), how to will be responsible for feeding the baby measure out 4 level teaspoons of full should be shown how much milk, boiled cream powdered milk and 1 level tea­ water and sugar to use for each feeding. spoonful of sugar, and how to mix For example, an 8 lb. baby of 1 them together for each food. month will need 4 fluid ounces of for- The demonstration should be fol. mula at each of five hourly feeds. lowed by the relative carrying out the

136 procedure. Cleanliness of the feeding cleanliness of bottles for artificial feed. utensils will also be stressed. If practi. ing in tropical home circumstances. cable, follow-up should be carried out Many workers, therefore, prefer to ad. by home visits, vise the feeding of cow's milk to young (e) Method ol Feeding. In Western children not by the bottle, but by means countries, artificially fed babies are of a feeding cup (Figure 16) or with usually given cow's milk formula with cup and spoon. Both of these are much one or other variety of feeding bottle, longer to use. In good hygienic circumstances, this is (f) Acid Milks. Acidification of a harmless procedure. milk can be used to reduce the risks of In tropical suroundings, the problem bacterial contamination leading to in­ of contamination of the feed is always fective diarrhea. After adequate acidifi­ great and is made even more so by the cation unrefrigerated milk keeps with­ use of the feeding bottle, which is nar- out souring for about 24 hours. row-necked and difficult to clean. This can be accomplished by adding The feeding bottles seen in many 1 teaspoonful of 85 per cent lactic acid countries amply emphasize the part they (U.S.P.), or 1 teaspoonful of white play in the development of diarrheal vinegar (4 percent) to 16 fluid ounces disease. They are, only too often, coy- of milk formula. Fresh lemon juice can ered with dirt and mold, and with filthy, also be used. cracked and encrusted rubber or plastic (g) Vitamins andArtificialFeeding. nipples. The ascorbic acid of cow's milk is de. If, then, artificial feeding with cow's stroyed during the boiling of liquid milk formulas has to be undertaken, the milk, or in the processing of dried question of the best method of giving the feeding is very important. Feeding Bottles. In some circum­ stances, it may be possible carefully to instruct and to demonstrate to mothers how bottles should be cleaned and sterilized, and to follow this up with supervision by means of home visiting. If available, widenecked bottles are preferable. Two methods can be used­ boiling or sterilization with hypochlo­ rite solution (Appendix X). Consideration of the time required to prepare five feedings daily with one bottle, limited fuel, unclean water and lack of refrigei'ation make the likeli. hood, or, indeed, practicability, of home sterilization of bottles most improbable. Other Methods. Only too often, it FIGURE 16.-Plastic feeding cup, easier is virtually impossible to ensure the to keep clean than feeding bottle.

137 evaporated products. Vitamin C should, their money, even if they have but little there!,re, be added to the diet from one of it, on advertised goods. These in. month of age, either in the form of clude infant foods, which may be quite clean fruit juice (prepared from the inappropriate, both nutritionally and best local source of vitamin C), or as as regards the budgets of tropical fami­ ascorbic acid tablets (30 mg each day), lies. One reason for the development of which are often cheap and with no risk a low-cost, high-protein food for young of causing infective diarrhea p. ].45). children is to cater to this trend towards This should be continued until the child goods bought from the store, especially is on a mixed diet which includes for the increasing segment of the pop­ ascorbic acid-containing foods. ulation living ;n urban regions on a In tropical countries, extra vitamin D cash economy. is not required, unless special local en- Also, in some parts of the world, no vironmental or cultural factors prevent suitable foods may be available at the the infant from being adequately ex- village level for infant feeding, or there posed to sunshine. may be great difficulties in preparing If any skimmed milk preparation has these foods for young children. Again, to be used for the feeding of young a commercially processed product may infants, vitamin A must be added to be valuable in filling this gap. the diet. Scientific Considerations. Nutri­ (h) Supplementary Foods and Arti- tionally, a suitable food for young chil­ ficial Feeding.As artificial feeding with dren would have to be high in protein covi's milk in tropical communities at and, if possible, reinforced with vita­ once introduces the risk of infection mins and iron. It may be produced as of the alimentary canal, and as it is a complete food-that is, containing not likely to be carried out adequate- carbohydrate calories as well and in­ ly-that is, with sufficient amounts of tended as a balanced intake of nutri­ milk of adequate strength-it is some- ent. Or it may be intended as a pro­ times desirable under these circum. tein additive-that is, as a food which stances to introduce the transitional diet can be added to, and mixed with, foods rather earlier than has been suggested already available in the local dietary. for breast-fed babies. These foods may The food would usually be particu­ be commenced from about four months larly aimed at the problems of early onwards. childhood, especially the transitional or Use ol Commercially Processed weaning period. High Protein Foods. Socio-Cultural Considerations. A Much malnutrition in early child. processed food would have to be accept­ hood is due to the incorrect, or insuf- able in the local culture pattern with ficient, usage of foods already available regard to flavor, appearance, cooking locally in the village and thus can best properties and palatability. be tackled by means of nutrition edu- Also, in many places, it may be best cation. to have a high-protein food which is However, in an increasing number of capable of being used by the whole parts of the world especially in towns, family, but with special emphasis for people are already spending some of the young child.

138 Work in different parts of the world used for human food (e.g. cottonseed has also shown that the status of the presscake). It should also store well, product is extremely important. If pos- and be cheap and convenient to trans­ sible, the food should be introduced as port, both in bulk and at village-level. a high-protein food for use by all eco- Above all, the food should be eco­ nomic groups, and, to start with, it need nomically and commercially viable, so not be particularly inexpensive. It that manufacturers will be able to should sell through the supermarkets as make at least a modest profit. This may well as village stores. Ultimately, it will be helped by making the product a fain­ be possible to reduce the price of this ily food, thereby increasing the likeli­ food, which by this time should have hood of sales. established itself in the eyes of the vil- Commercially Processed Protein lager not as a "poor man's food," but Foods. These foods may be made of as a modern food eaten by the well-to- (a) animal protein, (b) vegetable pro­ do. teins, or (c) animal-vegetable protein Likewise, it is usually important to m have the product considered as a food, mixtures. not as a medicine. This can be best Animwi Protein. These will be for achieved if it is actually in the form of use as protein additives and include an existing local food (e.g. noodles re- dried skimmed milk, meat powder and inforced with fish flour in Chile) fish flour. Also with the extremely limited Dried skimmed milk has been widely kitchen facilities in the tropics and also available from UNICEF or from other with the very full and hard day's work agencies (p. 191). However, in only a anthat village mothers customarily have, very few tropical parts of the easy-to-prepare, preferably pre- world, such as East Africa, is dairying increas­ cooked, convenience food may be even ing sufficiently so that limited quanti­ more important than in the U.S.A., pro- ties of locally produced dried skimmed vided it is culturally acceptable. The milk are available in the markets and "dosage" required for each child shops already. should be clear, and easy for the mother Also, it is obvious that meat powder to understand and follow, will not be available very widely. How­ Economic Considerations.A high- ever, again in East Africa, a pilot meat protein food intended principally for powder project has been successfully young children should be cheap and, started in part of Kenya, using scrub if possible, based on ingredients grown cattle in remote rural areas which are locally and processed in the country or slaughtered in field abattoirs and region concerned. If possible, it should which would have no commercial value help the economic development and the as butcher's meat, if driven long dis­ employment situation in the country, tances to market. introducing a new crop or increasing Fish flour has been prepared corn­ an established crop not previously mercially in many parts of the world exploited. (p. 371), including certain developing Ideally, the food should be made in countries, notably Morocco and Chile. part from some source not at present The main difficulties are ensuring a

800-112 o-s----10 139 uniform product and also carrying out An interesting recent technological the process economically. Fish flour and development has been the dehydration fish protein concentrate have been used of tempeh, a well-tried traditional In­ as additives in infant feeding in varil- donesian soy preparation. ous parts of the world. Vegetable Protein Mixtures. It is Vegetable Proteins.A tremendous possible to prepare an all vegetable pro. amount of research is under way in tein infant food, composed of a hal­ different parts of the world into the anced mixture of two or more different better usage of sources of vegetable vegetable proteins. The classical exam. protein that have long formed part of pie is "Incaparina," developed by the the human diet, and also into the proc- Institute of Nutrition of Central Amer­ essing of relatively new sources, par- ica and Panama, and composed of ticularly the protein from oilseeds, in- whole corn flour, whole sorghum flour, cluding the presscake from the soybean, cottonseed flour, torula yeast, calcium cottonseed and groundnut. carbonate and vitamin A. This is sold Geneticists are breeding new varie- in a powder form, in economical and ties, and food technologists are devising convenient packets. It is easily cooked, and testing more appropriate process- and can be readily made up by moth­ ing with a view to improving the nu- ers into a porridge or gruel-like food, tritive value, lowering the cost, in- similar to the atole which is the cus­ creasing the safety, and producing an tomary preparation for young children end-result which is convenient and of in much of Central America. acceptable taste. Another vegetable protein mixture is Modern technology can now produce Indian Multi-Purpose Food, which is protein isolates from oilseeds; while made up of 3 parts of low fat ground­ the feasibility of reinforcing legume nut flour and 1 part of Bengal gram protein with synthetic methionine, their (Chick-pea) flour. limiting amino acid, has been demon- Animal-Vegetable Protein Mix­ strated. tures. A number of low-cost, high-pro. Various soybean preparations, tein infant foods are based on a mixture treated to increase their digestibility of animal and vegetable proteins. Thus, and reinforced with vitamins, have in Nigera, "Arlac" is available. It is been tried out on a large scale for the composed of groundnut flour, with 25 feeding of young children and school percent of dried skimmed milk. In children. The advantage of this treated Senegal, a mixture containing sorghum soybean is that it is high in protein and groundnut flours, sugar and dried (up to 40 percent) and is economical in skimmed milk is under trial. that up to the present it has been a by- A successful product is "Pronutro," product of the soy oil industry, which is produced in South Africa from Soy protein concentrate (75 per- dried skimmed milk, whole soy and cent) can now be prepared; while a groundnut flours, wheat germ, pow. new process can produce a digestible dered bone meal, iron, iodized salt, the full-fat flour, which, because of its high vitamin B complex and sugar. calorie content, promises to be very Development oj Protein Foods lor useful. Young Children. This is a seemingly

140 simple matter, but, in fact, it is highly thorities, international and bilateral complex. Much endeavor and thought agencies, and, above all else, commer­ has been given to this matter in differ- cial food manufacturers, with their ent parts of the world, under the guid- knowledge of marketing, advertising ance of various international agencies. and merchandising. Initially, nutritional testing of suit- Current schemes of "food aid" by able mixtures has to be carried out bi- Food for Peace and the World Food ochemically, followed by investigations Program are geared to stimulating local on experimental animals, and, ulti- interest in the development of high-pro. mately, by assessing effectiveness in tein foods for young children on a curing malnourished children and in commercial basis. producing normal growth in well infants. 2. Early Recognition of Less Se. An investigation has to be carried out vere Malnutrition and Supplemen. into the economic feasibility of using tary Feeding. the suggested ingredients, including their availability in the country, their The early recognition of mild and seasonal variation in price, and other moderate degrees of PCM of early child­ aspects, which require the knowledge of hood can best be accomplished by an agricultural economist, regular health supervision at monthly Acceptability trials have also to be intervals at Young Child Clinics carried out to see if the food is cultur- (p). 155). The practical operation of ally acceptable-that is, whether it will these clinics is given later. be used by mothers and will fit into The main objective method for the their traditional concepts of infant feed- early recognition of less severe PCM ing and methods of cooking. is by regular weighing at intervals to Finally, however, the success of a detect growth failure. Methods of eval. particular protein food for young chil- uating the adequacy of weight gain are dren depends on its commercial success. given earlier (p. 94), when the ira­ Again, this is a complicated matter to portance of plotting the weights on a assess beforehand, and depends on mar- weight graph on the Young Child Clinic keting research and ultimately on pro- card (1p.155) was stressed. longed trial. It cannot be undertaken Supplementary Feeding Programs. without the active participation of ex- These aim to close the gap between the perienced food manufacturers who food actually available and what is know the problems of the particular re- needed in terms of adequate nutrition. gion and, preferably, already have a At the same time, they are aimed addi­ sales network available there. tionally at teaching parents better It is apparent that the development nutritional habils and in calculating a of a low-cost, high-protein food for desire for a more mixed and varied young children can only be achieved diet. with the pooled knowledge of a variety Supplementary foods may be issued of experts, including the biochemist, the widely on an entirely preventive basis, pediatric nutritionist, the agriculturist, because a particular nutrient is known the food technologist, governmental au- to be commonly deficient in the com­

141 munity, or more usually be issued to However, in some areas, as has been selected individuals showing evidence noted, certain specific vitamin deficien­ of early malnutrition, especially chil- cies may be highly important, and in. dren with PCM. deed may reach the dimensions of The foods issued will obviously de- public health problems. Under these pend on the particular nutritional prob- circumstances, it may be desirable to lem, and may be imported on a free or issue appropriate vitamin supplements subsidized basis (e.g. dried skimmed to selected groups at risk. milk), or maybe locally produced (e.g. For example, in areas where vitamin "Incaparina"). A deficiency is a common cause of Supplementary feeding programs blindness in young children (p. 87), may be based on the issue of foods or naturally-occurring sources of vitamin supplements for mothers to take with A may be issued, especially red palm oil them to prepare for their children at or fish liver oil. If children are difficult home. Alternatively, the supplement to reach, it may be considered prac. may be taken as such on the spot, either ticable to give them vitamin A by at a Young Child Clinic or in the home, mouth or by intramuscular injection, or in the form of a meal which may be which will last for several months. prepared and fed at a variety of places, Likewise, where rickets is an impor. including schools (p. 184), nutrition tant childhood disease, it may be con­ rehabilitation anits (p. 186) or at sidered desirable to issue this vitamin special child feeding centers in the as a supplement to all children from 6 community. months to 2 years of age in the form of (a) CalorieSources. In situations of vitamin concentrate, or as naturally oc. famine or other natural or manmade curring vitamin D in fish liver oil. Once disasters, the distribution of food may again, a long.acting intramuscular in­ be required purely to avert starvation. jection of vitamin D way be an alterna. This will often largely be in the form tive approach. of calorific carbohydrate foods, as, for If infantile beriberi is a problem example, with the distribution of maize (p. 19), thiamine can be administered (corn) flour in areas of Africa during to pregnant and lactating mothers, exceptional drought conditions. These either in the form of the vitamin itself foods may also be accompanied by (20 mg/day) or as a naturally occur­ limited quantities of protein-rich sup. ring source, such as tiki tiki (fresh ex. plements, in which case it is important tract ofrice bran), or gram soup. to see that adequate shares of these An additional supplement that must should go to the more vulnerable seg- be mentioned is that of iron, which may ments of the community, especially be required by pregnant mothers in young children. (b) Vitamin Supplements. In tropi- some parts of the world where iron de­ cal regions, the mass issue of multi- ficiency anemia is common. This can vitamin tablets is to be avoided. These sometimes be usefully issued in the are not usually priorities and tend to form of inexpensive ferrous sulphate divert attention and finance from more tablets (one 0.1 g tablet per day during important nutrients, especially protein, the last three months of pregnancy).

142 It may be noted that in some circum- influence on the nutritional scene as far stances the supplement should be given as young children are concerned in as a medicine rather than as a food. In tropical developing regions in the last the Western world this was the case decade or so. It is, therefore, important with cod liver oil which was widely to understand its sources. advantages used to prevent rickets, as well as with and disadvantages, and best usage. medicinal iron to prevent iron deficien- Sources of DSM. The majority cy in pregnancy. In Indonesia, this has of the DSM used in tropical regions is been found to be an acceptable ap- derived from the U.S.A. where its pro. proach with the use of red palm oil in duction has, to some extent, the prevention been re­ of vitamin A deficiency. lated to the production of the butter and (c) Protein Supplements. These cream industry. It has been supplied may be issued free or at a subsidized by the U.S.A. in extremely large quan­ low cost through the health service, tities through CARE, Catholic Relief community development clubs or other Service, AID and UNICEF. channels. Although the various foods Much of the DSM reaching develop­ already mentioned (p. 112) may be in- ing countries has done so under the cluded in this category, such as soy aegis of UNICEF, who is responsible preparations and fish flour, in practice for its transport as far as the port or low-fat (dried skimmed) milk is widely border town in the particular country. used and an understanding of its opti. Thereafter, the storage and distribution inal use is highly important as is the is the responsibility of the Government use of more recently introduced CSMI concerned. Both of these often pose ex­ (p. 181). tremely difficult problems, owing to lack However, it seems certain that dried of storage space, insufficient staff to skimmed milk will be much less avail- supervise adequate distribution, and able in tropical countries in the near shortage of transport and fucl to carry future, and may then have to be re- this out. Nevertheless, UNICEF quite served for treatment of severe PCM rightly insists on a reasonable degree (p. 73). Under these circumstances, the of efficiency and accountability in this most appropriate alternative protein regard. supplement must be decided on for Packaging.The packaging of DSM moderate PCM, and a policy worked has changed over the years. Currently, out by health and nutrition authorities it is most usually available in large for issue and practical usage. reinforced cardboard boxes containing 1 54 lbs., with individual smaller Ultimately, boxes it is hoped that this may of 41/., lbs. each inside individual be a locally produced low-cost, high- plastic polythene bags. protein food. Until such are available, UNICEF dried skimmed milk is now it may be necessary to issue available reinforced with both vitamins A and vegetable protein sources, such as, for D (p. 21) to make good the fat soluble example, groundnuts, either whole or itamins that have been removed dur­ as flour, or various legumes. ing the manufacturing process. Dried Skimmed Milk (DSM) or Usage and Method of Issue. The Non-FatDried Milk (NFDM). The use correct use of DSM also poses a num­ of dried skimmed milk has had much ber of problems. Ideally, it might be

143 best for the reconstituted liquid milk improve the output of her breast milk, to be drunk by the child on the spot, rather than to attempt the hazardous thereby ensuring that it is not misused. addition of reconstituted liquid DSM This is, however, rarely possible owing, fed to the young child with all the prb­ amongst other things, to distances in- lems of infective diarrhea tat are likely volved and difficulties incident to chil- to occur. dren's attendance; also, uncertainty Priorities.In many tropical cir­ with regard to the child's appetite. This cumnstances, DSM can be best allocated method may occasionally be of value in according to the following priorities: some village circumstances, where sup- (i) Severe PCM (kwashiorkor and plementary feeding centers may be set marasmus) top priority with DSM re­ up. constituted as liquid and fed to the More usually DSM is issued in its child, preferably in hospital, when re­ powder form. Instructions may be given inforced with calories in the form of to reconstitute this as a liquid milk, but sugar and, if possible, vegetable oil there is no doubt that it is better to use (p. 129) ; this high-protein powder as an addi- (ii) Moderate PCM-with weight tive-that is, mixed with the child's for age between 80 to 60 percent of other foods. standard, or with failure to gain weight DSM has often been misused-for (p. 173) or with arm circumference example, sold to village stores or used measurements below 80 percent stand­ in parents' tea. Various methods have ard (p. 86), to be advised on the best been suggested to prevent this, such as high-protein diet, based on local foods, issuing it mixed with groundnut flour together with DSM issued as a powder or by adding a pinch of gentian violet for mixing in with diet for 1-3 months, powder to each 41/2 pound container, with follow-up and serial weighings (d) Selective Issue. Unless under fortnightly. famine or other very serious nutritional The criteria will obviously have to circumstances, DSM or other protein be adjusted to the commonness, or supplement should be issued to vulner- otherwise, of PCM in the area. Also, able groups on a selective basis. Its too with certain decreasing availability of universal use means that the issuing DSM in tropical countries in the com­ site becomes a food distribution point ing year, it is probable that more alone, with the staff's limited time taken stringent selection will be required. up with this alone and with too little Practical Use of DSM. A simple of its attention devoted to other im- method of reconstituting DSM with portant matters, especially to nutrition sugar and, if possible, oil is given else­ education, where for the treatment of severe PCM The selection of priority children to (p. 80). receive dried skimmed milk will de- When DSM is used for the supple. pend upon local circumstances and also mentary feed of moderate PCM, a upon the amount of DSM available. In mother should be advised to add five malnourished women with inadequate level teaspoons (each with a volume of lactation, it may be more suitable to 5-6 c.c.) to the child'sfeeds three times issue DSM to the woman herself to daily.

144 If this type of instruction is given, plementto take the placeof DSM, when, a full 1.1/2 lb. polythene bag of DSM as is probable in the near future, it is as issued by UNICEF at the moment, no longer available. will last the child for approximately 4 3. Prevention and Management weeks. However, it is often desirable to issue milk for a shorter period tha o Conditioning Infection this, as if large quantities are given out Infections of various sorts have great they may become contaminated or, nutritional consequence (p. 72), and, regrettably, be misused as, for exam- in trying to combat malnutrition in pie, sold or used in the adult's tea. It young children, it is of importance to may then be thought preferably to try to prevent or minimize the effects issue smaller quantities. This is best of bacterial, viral and parasitic infec­ done by arranging for the DSM to be tions. repackaged in suitable sized (often 1 This can be attempted in three ways, lb.) paper or preferably polythene bags all of which approaches are required: for issue to mothers. If the DSM is (a) specific prevention of infectious issued in paper bags or tins supplied diseases, (b) recognition and manage­ by the mothers the likelihood of it be- ment of common childhood illnesses, coming hard and lumpy, or contami- and (c) improved environmental nated is very considerable. Undoubt- sanitation. edly the best way to issue the DSM is Specift, 'revention, Infectious Dis. in polythene bags closed with an elastic eases. Many infectious of nutritional band, although, of course, the cost of importance may be prevented by means these has to be considered, of immunization, including measles, Dried skimmed milk is an extremely whooping cough and tuberculosis. valuable commodity in dealing with the (a) Infectious Diarrhea. Diarrhea problem of PCM in young children in in early childhood is most often due to developing tropical countries. It is the bacterial infection of the alimentary basis of economical treatment of severe canal. Its commonness can be reduced cases (p. 73), and is also an excellent by breast feeding in early infancy, by protein supplement for the rehabilita- cleanliness with regard to feeding uten­ tion of young children with moderate sils and food, and by the use of clean, PCM. It also has the advantage of at- boiled water for drinking. tracting mothers to attend Young Child Clinics and, hopefully, may draw the (b) Worms. Intestinal worms, espe. attention of a country's politicians and cially the roundworm and the hook­ administrators to the problem of pro- worm, also add their nutritional burden tein shortage. to the young child, especially if present It is, however, by no means a long- in large numbers. The prevention of term solution to the problem, and, it these parasites is largely concerned with must always be combined with nutri trying to ensure the disposal of feces lion education as to the best use of in well-constructed latrines. local foods, and must always be paral. (c) Malaria. In areas where malaria leled by attempts within the country is highly prevalent, it is justifiable to itself to produce a suitableproteinsup. try to issue antimalarials to young chil.

145 Table 7. SUMMARY OF IMMUNIZATION PROCEDURES FOR YOUNG CHILDREN IN RELATION TO NUTRITIONAL ING INFECTIONS CONDITION. AND OTHER IMPORTANT INFECTIONS

Disease Storage Vaccine Main Transport Dose Afethod Lowest Interval (1) NUTRITIONAL CONDITIONING INFECTIONS Whooping "Triple Lower part of Cough, Teta- Cold Boxes 0.5 cc on 3 Intramuscular Vaccine." refrigerator, with in- I mo...... 1-3 months. nus, and Diph- gel bags occasions. jection (outer (or) large side Tuberculosistheria. of thigh)...... thermos. " Once ...... B.C.G. Intradermal Birth...... ­ (Protect from injection. Measles ...... Live Vaccine ... light). inje ttio us Once ...... or intradermal.. 9 months ..... -

(2) OTHER IMPORTANT INFECTIONS Smallpox ...... Calf Lymph ... " Once ...... Multiple Poliomyelitis pressure Birth ...... - .... Oral ...... ,, " 3 drops orally By mouth ...... I month... 1-3 months. on 3 occasions. dren during the special danger period quires prolonged experience and medi. from 6 months to 2 years. cal training, some of the relevant com­ There is the obvious risk that by so moner childhood infections mentioned doing there may be an interference can be detected quite easily. with the development of natural im- The'"recognition, based on certain munity, but this method has the advan-. elementary symptoms and signs, and tage that it postpones the child's main their simple management are given in struggle for co-existence with the Tables 8 and 9. If the management of malarial parasite until after the age of these conditions is to form part of the greatest nutritional strain, particular program, appropriate in. The use of antimalarials during this structions will have to be given to field period is especially worthwhile if there workers prior to going overseas, later is some other indication, as, for ex. reinforced by practical demonstration ample, if the child is already showing and supervised experience in the coun. some degree of PCM, as judged by fail- try in which the program is being ure to gain weight (p. 72). The best developed. drug to use will vary with different Training should include how to carry communities, depending upon the drug out a head-to-foot examination of chil­ sensitivity of the local species of dren and the recognition of the follow­ malarial parasite. "Daraprim" (pyri- ing physical signs-anemia (moderate methamine) 1/2 tablet (12 mg) once and severe), conjunctivitis, dehydra­ weekly is often suitable, especially as it tion (depressed fontanelle, inelastic is relatively tasteless. Chloroquine 1/2 skin, sunken eyes), edema, ear dis­ tablet (75 mg) once weekly may be charge, fever, hair changes (light col­ used instead. ored, sparse, straight, silky), measles Alternatively, some workers advise spleenrash, rapidenlargementrespiration, and thescabieswvhooprash,of the issue of one tablet (25 mg) of gwhoop "Daraprim" monthly, to be taken when whooping cough. attending the Young Child Clinic. Improved Environmental Sanitation. Much improvement in infectious Recognition and Management of Com- disease of nutritional consequence mon Childhood Illnesses. A major part could be expected as a resul of i­ of the prevention of the nutritional infections proved hygiene in the village, leading ill-consequences of childhood in e to clean food, clean water and a clean is their recognition at an early stage, home. and their correct management and In most countries, one or more gov­ treatment before they have become too ernmental agency is concerned with advanced. village improvement, often the Commu­ The importance of a good diet during nity Development Department. Plainly, and following infections requires stress, advice is required as to the regional especially as in some communities it is policy and as to methods found to be customary to limit food intake drasti- suitable in the area. These are usually cally during childhood illness, available in booklet form, and will in­ While obviously the recognition of clude improvements to: the early stages of some conditions re- (a) The homestead, both in con.

147 struction of the walls, roof and win- disposal, mosquito breeding, rats, dows, and in interior furnishings, such flies) ; as corner cupboards, mosquito nets, (d) The water supply (e.g. pro. and so forth; tected spring, storage pots, home-made (b) The outbuildings, especially the filter) ; kitchen (stove, food storage), the bath (e) The market place; place, the latrine, and so forth; (f) The roads; (c) The compound (e.g. rubbish (g) The community center. Table 8.-RECOGNITION AND SIMPLE MANAGEMENT OF EARLY CASES OF

SOME COMMON CHILDHOOD ILLNESSES I

Condition Recognition Managemnu

Fever Penicillin course, or Pneumonia Cough Sulfadimidine course Rapid breathing Fever Measles Cough Red eyes Fine rash Sulfadimidine course Protein supplement (e.g. DSM) Whooping Cough Cough (with whoop) Advice on feeding Fever

Loose watery stools Large quantities(Table of su 9)ar-saline Diarrhea Dehydration (sunken eyes and by mouth and fontanelle, inelastic skin) Do not stop milk feeds Clinical Malaria Fever No rash or rapid breathing Chloroquine course

Roundworm Worm passed in stool or vomited Pipraine

Do not wash out stomach Kerosene swallowing Penicillin Hospital Accidents Cover with clean cloth Burn or scald Penicillin Hospital

Weakness Iron course Anemia Pale "red" of eyes Chloroquine course (conjunctiva) 'reat hookworm

Scabies Itchy rash between fingers and Application of benzyl benzoate elsewhere emulsion or tetmasal soap for family

Conjunctivities Red eyes with discharge Apply tetracycline ointment three times d.-ily

Soak discharge from outer end of Ear discharge ear canal with thin stick or ap­ plicator twice daily. Instill boric and spirit ear drops

I To be considered if neither health service nor microscope available nearby, and if included in training. Failure to respond indicates need for further adivce.

148 Table 9.-BASIC DRUG DOSAGE FOR TROPICAL VILLAGE CHILDREN

Drug Dosage

Single dose-l.2 million units benethamine peni. Penicillin cour-se cillin by intramuscular injection. (or) Daily dose-400,000 units of procaine penicillin for 5 days by intramuscular injection. Sulphathiazole course 1-2 tablets 6 hourly for 5 days (I tablet= 0.5 gin) Sugar-saline for dehydration I (Y teaspoon EXTRA to milk feeds: salt, 6 teaspoons sugar to 20 fluid 10 lb. weight-40 fluid ounces/day ounces boiled water) 20 lb. weight-60 " " ,, 30 lb. weight-80 " " is Chloroquine course %-I tablet daily for three days (I tablet= 150 rag) Piperazine Single dose 2-4 gm by mouth I Demonstrate to mother how to feed child with a few spoonsful at a time between feedings. Arrange for mother to commence to give sugar-saline for 1 hour or so under supervision. 4. Improved Treatment of Severe foods that the mother Malnutrition is to give at home must be prepared in the wards. She In countries where severe malnutri- must be shown how to prepare both the tion in the preschool child is common, specially cooked dishes and how to im­ it is obvious that adequate treatment prove the average family diet. While in facilities for these severely afflicted the hospital the mother should not only children should be a priority. This is see them prepared but hell) to prepare necessary not only on humanitarian them herself-"If Ido it,Iknow." grounds, but, in addition, because it is It may be possible for the mother to important to demonstrate a convincing help to grow the foods that have been ability to cure, if it is hoped to be able used to cure her child in the hospital. If to persuade parents with nutrition edu- it is desirable to introduce new strains cation aimed at prevention. The educa- of such crops as legumes into the area, tional aspect of efficient treatment can. she should be given the seeds to not be overestimated, take home with her. The purpose of a hos- Methods. Treatment of severe PCM is pital garden is to make this kind of outlined elsewhere (p. 79). It is es- nutrition education realistic. sentially based on the feeding of a Sites. Treatment of severe cases is best high-protein, high-calorie diet, given in undertaken in the hospital ward, but the form of approximately calculated may have to be carried out in the out­ quantities of a milk formula (p. 80), patient clinics attached to hospitals, followed by the introduction of high- health centers or mobile units, or in protein foods from the local diet. "nutrition rehabilitation units," or The in after-care of PCM by correct the home itself. feeding at home is just as important as The Field Worker and Treatment. the cure of the disease itself. Vigorous Adequate curative services imply that health education is therefore essential, the politicians and administrators of a and for this to he effective, the same country must be awore that the problem

149 of childhood malnutrition exists and the cooking of food and feeding of the they will, therefore, be willing to divert children. some of the limited finances to these If Nutrition Rehabilitation Units are services. This awareness is not always built of cheap materials, employ limited present, so that suitable modest build- junior staff and helpers from the vii­ ings, food supplements and, above all, lage, and use basic kitchen equipment appropriately trained staff may not be and economical local foods, they may available in sufficient quantities. contribute significantly to the low-cost Under different circumstances in treatment of malnutrition and also to various parts of the world, the worker nutrition education in the community. may find himself treating children with Such units should not cater to more PCM, or, if health services are nearby, than a small number of children, prob­ in assisting in treatment carried out in ably not more than 20 in all, and, when­ them. ever possible, they should be under su­ Nutrition Rehabilitation Units. The pervision by health staff, because of the concept of th- Nutrition Rehabilita- risk of intercurrent infection in these tion as anUnit approach has been to bothdeveloped treatment recently and y ung childre .I oepaei a be possible for a field worker to initiate to nutrition education. Such units may or to supervise the development of a be practicable and helpful in some parts Nutrition Rehabilitation Unit. of the world. For aeNrin RWhenever feasible, the units should For a Nutrition Rehabilitation U nit, al o i c r r te th r sp ts f nu a building is required, preferably of also incateot a spectsoeu cheap, easily available local materials trition education and village improve. and often contructed by "self-help" or ment, such as a demonstration garden, community development endeavor, in an improved kitchen, and so forth. which young children suffering from malnutrition may be rehabilitated by 5. Increased Village.Level Food means of nutritious diets based on local Production foods for the nost part prepared and Much malnutrition in childhood cooked by the mothers themselves with could be prevented by increased village­ customary cooking methods. This, it is level food production, storage and pres­ felt, has the double advwntage of return- ervation. This can be put into effect ing the child to a near normal nutri- through school gardens, cooperative ef­ tional state and, even more importantly, ts, siho gardense orarms, acts as a profound educational experi- forts, and in home gardens or farms, ence for the mother herself, often in cooperation with various types Various forms of Nutrition Rehabii- of Youth Clubs. tation Units have been developed in The Home Garden and Its Potential. different parts of the world. In some, The home garden forms a natural and mothers stay in residence with their important segment of an agricultural children for several weeks at a time subsistence economy, as from it can be (Appendix VIII). In others, children obtained the supplementary nutrients, are left during the daytime only, with notably the vitamins and iron, that are one or two of the mothers in charge of usually lacking in the staple diet. M5 Gardens adjacent to the house often Major topics will include: have a rich fertile soil, and a consid- (a) Soil Fertility.Much can be done erable variety of plants can be grown to augment agricultural productivity conveniently near the kitchen with little by increasing the soil fertility, either labor. They are often semi-wild and are with appropriate chemical fertilizer, or, easy to propagate. more logically, by ensuring rotation These mixed gardens are particularly of crops and fallow periods, and with suited for such leafy vegetables as va- the use of organic manure in the form rieties of tropical spinach, for such of animal dung, compost, or green "fruit vegetables" as tomatoes, egg- manure. In particular, a knowledge of plants, okras, and red peppers, and for the best local method of preparing a such fruit and leaf vegetables as gourds compost heap is often of real practical and pumpkins, value. So-called "permanent crops" can also (b) Seed Selection. In some coun­ give a continuing yield for years, includ- tries, the agricultural extension services ing various fruit trees, such as citrus, are in the process of trying to popular­ the papaya, and the banana, as well as ize new varieties of seeds, which may the coconut, the red oil palm and the have a higher yield, or be disease or pineapple, pest resistant. The field worker may A principal aim should always be to assist in trying to introduce "starter" use local plants, which are resistant supplies of these new varieties of seeds to disease and adapted to the soil and and to demonstrate their value. climate, rather than imported plants, (c) Soil Erosion. The prevention of such as the cabbage or cauliflower, soil erosion may be achieved in some which are also often less nutritious, cases by relatively simple means, in­ Increased yields of locally suitable cluding ridging, crop rotation, hedg­ legumes should also be an important ing, and so forth. objective, both in gardens and parzicu- (d) Maintenance o/ Crops. The larly between field crops. The aim yield of a particular crop is related to should be to ensure adequate year. how well it is maintained, that is how round supplies, particularly for the diet it is irrigated, weeded, and kept free of of the young child, pests and diseases. Increasing Agricultural Productivity. (e) Storage. As noted several times This is a very wide subject and the (p. 45), an extremely high wastage of field worker, can, of course, in no crops occurs after storage due to the way be expected to be an expert or au- depredations of rats, molds, and insects. thority. However, there are certain Sometimes indigenous storage gra­ areas of great importance on which in- naries may be improved simply. Rat formation can be sought from agricul. proofing may be assisted by ensuring tural extension workers in the country, that they are tightly closed with no concerning the best practical advice for holes, and preferably raised on legs. the village circumstances. Some prac- Molds are less likely to be widespread tical reference books are suggested at if the grain or legume is dry before the end of the chapter. storing; while insects may be kept at

151 bay by mixing in suitable insecticides ing, using a simply constructed poultry that are nontoxic to man. pen, with advice on feeding and disease (f) Marketing. New ideas concern- prevention. ing marketing may be possible, and (c) Fishponds. Fish culture repre. advice on "farm arithmetic" concern- sents one of the best ways to make ani­ ing, for example, yields and accounts mal protein available to populations may be welcome in some places. living inland. This may exploit existing Cash Crops. Although there is little water areas, such as ponds or flooded doubt that in many countries cash crops rice fields, but in many areas is carried are over-emphasized at the expense of out in specially dug fish ponds, prefer. food crops, at the same time is is im- ably using marginal, agriculturally un­ portant to have an outline knowledge productive land. of the cultivation of the area's cash In countries where fish ponds are crops which may include cotton, coffee, being developed, advice on the best local cocoa, tea, and so forth. methods of construction, stocking, feed. By appreciating the basic problems ing and cropping will be available from and by knowing the usually straightfor- the fisheries authorities. ward advice given by agricultural ex- (d) Various small animals, includ. tension workers to increase the yield of ing rabbits and guinea pigs. cash crops (e.g. by spraying cotton Applied Nutrition Programs. Various with appropriate insecticide), it is governments in different parts of the likely that assistance and ideas concern- world have undertaken Applied Nu. ing other matters may more likely be trition Programs, with the assistance of followed. FAO, WHO, and UNICEF. Animal ProteinProduction.Methods They are a practical approach to the may be available, but not appreciated increased production of better quality by villages, for the improvement of ex- foods at the village level, thus ensuring isting livestock, as, for example, by im- that families, especially young children, munization of cattle. enjoy a more varied and nutritious diet In addition, in some areas it may be than previously. sound animal husbandry policy to in- Activities center on gardens at troduce and popularize new sources of schools, in the homes, or those run co­ animal protein or improved methods of operatively by the community, and aim production. These may include: at the improved production of vege­ (a) Pigrearing.If culturally accept- tables (especially legumes), fruits, and able, swine can be an economical and animal protein, in the shape of poultry efficient way of producing animal (and eggs), small animals and fish. protein. Programs are intended to interest (b) Poultry.Chickens are often kept and to be of educational value for vari­ in the tropics on "free range". While ous groups, including those in author­ not often possible for the peasant ity, school children and the villagers farmer to be able to afford to introduce themselves. They are also combined the "deep litter system", especially on a with nutrition education activities in­ large enough scale to make a profit, it tended to encourage and ensure greater is frequently practicable to increase the consumption of the foods produced, egg yield with "restricted range" rear. especially by young children. 152 In addition, Applied Nutrition Pro- from a small cultivation, or the school grams include training activities for fees to be paid with a limited income. those involved, such as courses and in- Methods. These will have to be cheap, bervice training for technical personnel, culturally and religiously acceptable school teachers, club leaders and to both parents, without serious side. voluntary workers, effects, and involve little change in customary sexual behavior. At present, 6. Child Spacing the plastic intro-uterine device (IUD), most Plainly the problem posed inby urencwidelythe in one suitable.of its various forms, seems population explosion varies in urgency rdette. in different countries, depending on the TrendSetters. Experience has shown availability of arable land and on the that the first group to indicate a prac­ efficiency of food production. However,thwelo-oubnliadlhugtical interest in family planning is often of recent years in the developing parts the well-to-do urban elite, and, although of rceni yeasthedevlopig prts this affects the main problem not at all, of the world as a whole, despite some in- thir importane as tren-se t fo lh crease in total food production, the food their importance as trend-setters for the production per head has declined. Also particular community or country is as a rule, high human fertility charac- likely to influence future developments. terizes the developing countries. The Sites for Family Planning Activities. result is that the rapid growth of popu. The question of introducing family lation is constantly outstripping eco- planning services has to be approached nomic growth, and, because of this, with great care and diplomacy in rela­ is always ahead of the development tion to existing cultural, religious and of social services and employment political attitudes by the authorities and opportunities. by the people themselves. While these services often commence Rising Expectations. Unless birth at separate clinics frequently run by rates in many developing countries can voluntary organizations in towns, it is be reduced, standards of living of those most desirable to include them as a part populations which depend on economic of maternal and child health services, development, food production and such as pre-natal and Young Child available social services, cannot begin Clinics. to rise in the way intended by national The practicability of suggesting planners and hoped for by the common family planning will obviously depend man. on local circumstances. However, the Family Decision. The decision to try field worker should be aware of the to limit family size and space pregnan- arguments for and against family plan­ cies has to be made by both the parents ning, espeially those relating to child themselves. They are not likely to ap- nutritin. Whether anythingfurther is peciate the national or world problem, feasible will have to be decided by the and even if they do, they are not likely supervisors of the particularproject. to be motivated by this knowledge. It may, for example, be possible to At the family level, much more per- talk unobtrusively about problems of suasive are the obvious problems posed an over-large family and to know where by too many mouths to be fed on food to refer those interested, if, indeed,

153 such a clinic is available. Simple de- major part of village improvement vices, such as the condom, and creams, schemes, often initiated in a limited such as spermicidal preparations, art area, and adapted to the availability of usually available in the local shops in existing health and extension services. towns. These do not require a doctor's Aims. Six main methods of combat. prescription, as "the pill" does, or ing childhood malnutrition have al. skilled personnel to insert, as the IUD ready been suggested with nutrition does. Often the most important first education, running through all of these step is simply to point out to parents activities: (a) improved feeding of the advantages of using these locally young children, (b) early recognition available supplies, of less severe malnutrition and supple. Finally, it should be pointed out that mentary feeding, (c) prevention and for the individual family, infant lives management of conditioning infec­ saved through improved nutrition, im- tions, (d) improvement of treatment munization and healthier environments for malnourished children, (e) in. make it desirable to space future preg- creased village-level food production, nancies. The same number of children and (f) child spacing. will survive to enter school as before Some or all of these methods can be family planning and the other health incorporated in a P.P.P. The aspects to advances were introduced. The advan- be included or emphasized in a specific tage is reduced wastage of human re- program will depend on the area's prob­ sources as maternal, infant and child lems and needs, on existing services deaths. and other circumstances. 7. Programs Reaching the Preschool Child. The problem essentially is how to reach a The concept of the Preschool Pro- significant percentage of the preschool tection Program (P.P.P.) was intro- age population, and their parents, both duced in 1963, when the wide range of in remote rural areas and in urban activities that could be included was slums, with a program designed to im­ outlined, ranging from health super- prove the health, welfare, and standard vision of young children to such im- of living of families, with special refer­ portant over-all aspects as raising the ence to the nutrition of young children. economic level of communities and the In the rural circumstances often improving of agricultural production found, this implies in practice taking ofwith the due population, regard to especially the nutritional young needs chil- thefound, program t ipeto the village,i pate eitherti by dren. means of mobile services, or, prefera­ In the future, it is envisaged bly by having field workers living in In tei ftur,isenviage tht rralareas. many nutrition projects organized by rural are field workers, including Peace Corps It is apparent that when field work­ Volunteers, will in effect, be Preschool ers are living near to villages or devel­ Protection Programs 1 developed as a oping areas of towns, they will be in an excellent situation to try to initiate, de­ I Medical aspects of these programs have veo , r asi t n a P es h l Pr e ­ Protec­ been termed "Young Child Health Services" velop, or assist in a Preschool oy "Under-Fives Health Services." tion Program, together with the village

154 people themselves and, if possible, with more Y.C.C.'s may have to be devel. national coworkers. oped by the field worker to serve the Sites of Activity. A P.P.P. may in- area. Sometimes one may be adequate, clude activities in several, or all, of the but if dwellings are widely scattered or following places-a health center, a if the area covered is large, Y.C.C.'s nutrition rehabilitation unit, a day care may have to be held at several locations center, a Young Child Clinic, a hospital, on different days of the week, in the village extension activities, religious form of mobile clinics serving nearby meetings, clubs, formal and informal settlements. meeting places (such as markets), Site. The physical structure of homes, and, very likely on the worker's these clinics is unimportant, provided doorstep, or at any other opportunity. they are adjacent to the people con. It is possible that the area of opera- cerned, acceptable to them and rela­ tion will be far away from the main tively weatherproof, as regards rain and services, so that, while ensuring liaison tropical sun. They can, therefore, be and contact for technical supervision, carried out in the open air, under a advice, consultation, and referral, a tree, in a school house, in a hut lent by P.P.P. may have to be planned to be the village or anywhere else. carried out entirely by national and Functions. Wherever they may be, foreign nonhealth trained staff, together their function will be a combination with the villagers themselves, of prevention and curative work, in­ (a) Young Child Clinics. The basis cluding, therefore, examination (par­ of much practical work directed at ticularly weighing), early treatment, combating malnutrition in young chil- supplementary feeding, inununization, dren is by means of health supervision, prevention of important infectious which permits preventive measures to diseases and, above all else, nutrition be put into practice, as with nutrition education. In all cases, it is of the education and immunization, infectious greatest importance to ensure, however, diseases to be recognized and treated, that the preventive aspects of the clinic and malnutrition to be detected at an should always be the main priority, early stage by examination and regular constantly before the eyes of the or­ weighing, so that appropriate measures ganizers of the clinic as their principal can be taken. aim and concern. Health supervision is based on the Sequence and "Lines of Flow." regular observation of young children, Young Child Clinics should be orga­ usually at monthly intervals. nized to run in a certain sequence from Sometimes this can be carried out, one "station" to the next, often in the at least in part, by home visiting. More following order: (a) registration, (b) usually, health supervision entails at- weighing, (c) nutrition education by tendance of the mother and child at group discussion-demonstration, (d) some form of Young Child Clinic examination and counseling, (e) im­ (Y.C.C.). munization (if feasible), (f) issue of Dopending on the distribution of food supplement and/or medicine (if houses in the particular region, one or required.)

800-112 o-e---11 155 If facilities exist for simple labora- can be available if children attend a dis. tory tests, as may occasionally be the tant hospital or health center. case, a separate "station" should be set Cards may be lost, but, if their up for this purpose. inpeu tanLC is understood by mothers in Registration. Many different sys. relation to continuing care of their chil­ tems of records can be used. It is usu- dren, they are often kept conscien­ ally helpful to have a book kept at the tiously. clinic in which the names of those at- These cards also have considerable tending can be recorded on each oc- educationnl value, as regards health and casion, together with a briel note of any nutrition, especially the weight records, procedure, advice or decision on man. which sometimes unsophisticated moth. agement (e.g. home visiting required). ers seem able to appreciate.

At the same time, experieace has sug. .Veighing. Weighing, especially gested that a Young Child Clinic card, serially is the most important method often kept by the mother, can form the of detecting early protein-Calorie mal­ best record of weight, immunization, nutrition of early childhood (p. 84), antimalarial drugs, diet, nutrition and and also can be valuable nutrition edu. illness. cation for the mother, provided she is One type of Y.C.C. card is used in kept informed. Uganda. On the front page, social iden- The scales employed must be sturdy, tification data are recorded, while space inexpensive, easily transportable, and is available for recording information usalyfoo.rkmoa4tioheniaccurate to within the limits required, ue concerning immunizations and the issue usually to 0.1 kg or 4 oz. When in use, of antimalarial drugs. the machine must be checked twice daily through the complete range of The inner pages are divided into weights envisaged by the use of objects three columns for recording the date, of known weight available for this pur­ the weight and a blank column for brief pose. The scales should be corrected in notes on feeding, results of examination, the light of.the tests, or, less satisfac. and advice given. torily, allowance made in the results. When unfolded the card contains a Beam, or lever, balance scales are graph, on which the child's weight can preferable, as they are less likely to be be plotted. Three curves are marked on inaccurate if carefully looked after. this-the "standard" (100 percent), Their accuracy depends, however, on and 80 percent and 60 percent of this the integrity of their knife-edge balanc. standard. Children's weights may be ing part or fulcrum. compared with these levels and appro- Beam balance scales are usually of priate action taken. Also serial meas- the familiar type supplied by UNICEF urements can be made to see if growth for young children, measuring up to is occurring satisfactorily or not (p. 16 kg (35 lb) with increments of 100 g 85). (approximately 4 oz or the platform In some circumstances, these cards type for adults or older children. Both can be issued to mothers in a plastic are rather heavy to transport and can container and can act as permanent, become mechanically inaccurate after readily available health records, which jolting on a rough road journey. The

156 use of a locking device or wedging the 112). A model garden and house adja. moving parts before journeys is advis- cent to the clinic can be valuable visual able. They must be used on a firm, non- aids. tilted surface, and checked before use. Examination and Counselling. Technique. Young children should Children attending the Y.C.C. should be weighed nude. If bells or heavy be examined nude for certain basic, charms are worn, as in some rural com- predefined signs of malnutrition and munities, they should be removed, if relevant infections. permissible and practicable. Otherwise The history taken from the mother due allowance should be made for their should inquire principally into the weight. child's diet. If the interview mainly em­ With careful attention to technique, phasizes illness, the preventive objective relatively passive infants can be of the clinic may be lost sight of. weighed on most scales. The problem is Counselling to individual mothers more difficult with larger, more active concerning their children's health, diet 1-4 years olds. With apprehensive and need for supplementary food, im­ young children in rural tropical sur- munization or medicine is an impor­ roundings, it may sometimes be best to tant educational aspect of the clinic, use an adult platform beam-balance which overlaps to other waiting scale to weigh the mother alone, and mothers, who will be listening. then weigh her carrying her child. The Immunization. This will depend advantage of this method is that the on the immunization activities in the child is calmed by the mother, so that particular program, and on the meth­ time is saved and accurate recordings ods used. can be made. The disadvantage is that Details of equipment cannot be given two weights have to be recorded and here, but will include appropriate subtracted, so that the risk of clerical syringes, needles, cooling apparatus for error is increased, the vaccines, and so forth. A synopsis The accurate weighing of young chil- of commonly used technics is given dren is by no means easy, and should earlier (Table: 7). only be carried out by a trained person Food Supplements and Medical under supervision, using carefully Treatment. Supplies of food supple. checked scales. ments should be available for issue to Standards of Reference. Weight selected children who require them. measurements can best be compared This may take the form of dried with locally prepared standards (p. 84), skimmed milk or other protein supple. if such exist. More usually, general ment, or source of some other nutrient, standards of reference have to be used such as iron (as ferrous sulphate), thi­ (e.g. the Harvard Standards for young amine, red palm oil, fish liver oil, and children, as shown in Appendix Ill. so forth. Nutrition Education. The Y.C.C. The quantity and method of distribu. is an excellent site for nutrition educa- tion must be planned beforehand and tion, especially using well planned can often be made easier by prepackag. group discussion demonstrations (p. ing suitable quantities.

157 Food supplements may be appreci. (b) Planning a P.P.P. ated more if a nominal charge is made. Also the sale of small, cheap, sub. Selection of Area. The selection sidized saucepans and a teaspoon may of the area within a country for a par. be most helpful in the preparation and ticular P.P.P. will best be decided upon feeding of semisolid foods designed by national authorities and govern. especially for young children, mental technical services, together with The drugs available for simple treat- the organizers and planners of the pro. ment will depend on local problems and gram. In practice, the area selected will needs, and on the program policy, depend on many factors, including the The following is a simple and eco. nutritional needs and problems, and the nomical basic list of drugs, which backing, cooperation and enthusiasm may be suitable in some circumstances: of local leaders. Eye In/ections: small tubes of sul- Community Diagnosis. The pro. facetamide (10%) and tetracycline gram should always be based on the (1%) eye ointments, maximum use of available information Skin Disease: gentian violet (1%) concerning the locality, including: the aqueous solution; benzyl benzoat types of malnutrition most prevalent; emulsion; benzoic acid ointment, the causation of malnutrition in the dis­ Ear Infections: boric and spirit ear trict; the local pattern of infant feed. drops. ing; existing foods and their cost and Various Infections: (including pneu. availability; methods of food produc. monia) benethamine (long-acting) tion, preparation and preservation, penicillin (1.2 million units); sulfadi- cooking practices; and the existing midine tablets; small quantity chloram. services, formal and informal, in the phenicol capsules. district which are already trying to Malaria: chloroquine tablets, dara. work towards village improvement and, prim tablets. more specifically, the betterment of the Intestinal Worms: Piperazine tab. nutrition of young children. These may lets, bephenium packets (or tetra. include government extension agen. chlorethylene) cies, village clubs, religious groups, and Miscellaneous: dressings, bandages, so forth. Relevant aspects of the local and so forth. culture pattern (p. 61), including social Paper is needed to wrap up the tab. organization and community leader­ lets. Squares of newspaper can be pre- ship, are also obviously important; as pared beforehand, or small inexpensive is the pattern of housing, e.g. whether envelopes purchased. A packet of wood- in villages or in more scattered home. en tongue depressors should be avail. steads or settlements. able for dispensing ointment, together In addition with a supply of small biottles and Inadtotoifrtonbaneto information obtained boxes, by prior inquiry and from the available If any drugs are to be issued, the literature, it is important, if practicable, dosage schedule and method of admin. for the field worker to carry out a sur­ istration will have to be learned (p. vey of the community to be covered by 146). the P.P.P.

158 The scope of the survey will vary Analysis of the data obtained, to­ with local circumstances and details gether with information already avail­ should- be carefully worked out previ. able, will enable a tentative community ously in consultation with technical ex- diagnosis to be made. This will help to perts. In particular, advice will be identify problems and their causation, needed on the type of forms to be used, and will suggest priority aims for the the data to be collected, and methods of program and methods most likely to be coding results. Statistical guidance as useful. to the selection of a random sample of In addition to assisting in program the population will also be required. planning, baseline data will have been This type of preliminary inquiry obtained which can later be used for should be carried out by the field evaluation. worker and national colleagues, to. Priority Aims and Methods. gether with the local leaders. It should While general improvement of village be preceded by the definition of a se- life is the over-all aim, more limited lected area as the "intensive area" of specific technical goals will have to be the project, which should be mapped, defined for the particular project in especially to show the boundaries and relation to the nutritional problems of the position of dwellings, young children. If acceptable to the particular com- These aims should be related to the munity, collection of data should then actual causes of childhood malnutrition be made by home visiting of all dwell- in the area, to the felt needs of the ings in the intensive area, or, if the community, and, to some extent, to number is too great, by visiting only objectives which can be achieved those that have been statistically se. convincingly. lected at random. These priority aims need to be care­ The data to be collected must be care. fully defined and understood by every­ fully defined and will vary from pro- one working in the project. gram to program. The following types Thus, in some Southeast Asian of information will often be required: villages, priority aims may be related Basic census data-family de- to the prevention of vitamin A defi­ tails (including geneology, age, sex, ciency, by distribution of red palm oil marital status, educational levels), to children in clinics and by home amount of land and its use, type of visiting, by the popularization of the house (construction, roof, rooms and production of carotene containing foods their use and accommodation, kitchen) in home gardens, by trying to incor­ water supply, and so forth. porate more practical nutrition educa­ Incidence of Malnutrition-chil- tion in schools, and so forth. dren with signs of malnutrition, meas- The type of service for the particular urements of young children (weight community also has to be decided on, and arm circumference) compared as well as the methods to be used. with standards. The program may for example, be Conditions responsible for mat. initiated by the development of a Young nutrition--pattern of infant feeding, Child Clinic, with an associated dem­ and so forth. onstration vegetable garden and a

159 nutrition rehabilitation unit. However, a pair of field workers might work with many combinations of the Lx different two nationals--one of whom might be approaches to combating childhood a junior member of the health service malnutrition are possible (p. 119), and (e.g., a health assistant), and the other the most suitable components for the a hational volunteer. area have to be selected. Apart from officiz. personnel in a Both the aims and the methods sug- project, there are always to be found gested will have to be tentative and people in villages who show special in. flexible, and the plan of campaign de- terest and initiative. They are of ale vised must have built into it methods gieatest importance to the development of evaluating what is being dooe of a P.P.P. Not only can their help be (p. 114). As a result of this feedback, enlisted in the organization and run. modification and adjustment of future i.'*g of various activities, including developments must be possible, espe. YoLng Child Clinics, but they are also cially in light of the worker's experience invaluable in stimulating local interest of the real needs and fields of oppor- in the commun'ty, as with the forming tunity in the village itself, of clubs, and by initiating self-help ac­ Team Structure and Organiza- tivities, such as the construction of a tion. The scope and methods used in a simple building made of local materials particular program will also be related for a clinic or a nutrition rehabilitation to the structure and organization of the unit. team concerned. Also, the training of suitable people This will vary from place to place, who work closely in the village with the and is likely to evolve as experience of field worker means that there will be child nutrition programs staffed by an extra network of peop~le, both in. nonhealth trained personnel accu- formed about the methods and objec­ mulates. tives of the project and also capable of Teams may be of varied size-from carrying out at least some aspects of the a single field worker to a coordinated work. In particular, if the area covered group of twenty or more. is somewhat spread out, it may be feasi­ Thus, a large team for a P.P.P. might able to have one or two villagers trained consist of 20-40 generalist nonhealth practically and helping in outlying trained field Norkers, with 1-2 tech- parts of the area, not only while t6e nical supervisors, one of whom could field worker is there, but also between best be a medical nutritionist-that is, visits. a physician, preferably with experience Technical supervision and advice in nutritional problems of tronical chil- should be available locally from the dren. The area of operation nught have government extension agents and rep­ the generalists located in pairs at the resentatives of the health service, and, center of an appropriate zone, each pair in some circumstances, from the super­ with a defined intensive area in which visor of the whole P.P.P. team, who they would work initially, would spend some of his time "on The national members of the team circuit." also would vary with the circumstances While the field worker is most defi­ in different countries. In a large team, nitely not a multipurpose expert, he

160 can and should aim at being a multi- ble, which will enable them to achieve a purpose extension worker, assisting healthier, better and more profitable life government and voluntary extension within the framework of their tradi­ services in carrying ideas to villages- tional village background. bridging the gaps between modern In other words, the field worker scientific knowledge and rural needs, should have a catalytic function between and also between governmental plans the villagers' felt needs and the often and rural suspicions. unappreciated potential that exists for Also, the field worker may, by en- improvement thr-ough inexpensive, thusiasm, hard work, and capacity to unelaboratc mutual help programs. get things done, help to invigorate ex- Training. In addition to training tension services, add prestige to the in the local language and knowledge of work of his national colleagues, and the cultural and historical background, assist in raising the status of village life, the technical content of the training of which seems so important if the drain generalist field workers in a P.P.P. will of population from rural areas to towns obviously have to be specifically tailor­ is to be halted, made for a particular program. A field worker can have special ad- The general content will cover infor­ vantages in relation to the development mation encompassed by the present pub­ of P.P.P. as a component of an overall lication. In addition, a limited number plan for improvement of rural life. He of special technical skills will be re­ may often be in intimate social contact quired-as, for example, the best meth­ with the people themselves, without the od of improving a local village kitchen, obvious geographic, economic and or the prevention of soil erosion, or the linguistic gaps that usually separate recognition and simple therapy of the tropical villagers from foreigners. main conditioning infections, or of im­ However, in addition, the field munizing children against whooping worker m eds the right psychologic ap- cough. Which of these are taught as proach to village people: priorities will depend upon the tenta­ • . . appreciating them and their way of life, tive program drawn up by the project their gifts and skills; not seeking to bring things to people so much as seeking to in- organizers. crense the people's ability to get them for Training Program.If practicable, themselves; passing on skills in a kindly and a humble manner, instead of condescendingly training program should be devised and patronizingly; giving the people a sense for the individual project. Part can be of belonging to something bigger than them- carried out in the U.S.A. (or country selves; focussing public attention on them and their progress; above all, being a living from which the field worker may be example of the new kind of life. coming), and part in the host country. If accepted by the people, the field In the U.S.A. The following will worker is ir an important position of have to be covered, as far as general trust, in which by lending a hand principles are concerned, together with rather than by offering advice, he may examples relevant to the particular be able to initiate the:.ecessary ferment project: of change from within by helping peo- (1) Basic nutrition (main facts con­ ple to realize that new ways are possi- cerning types of food, dietary re­

161 quirement and vulnerable groups); many visual aid3 (e.g. color slides, (2) Causation, prevention, treatment movies, and so forth) as possible should and recognition of early and late forms be employed. The main aims should be of major types of malnutrition, espe- to ensure that the background to the cially methods of detecting less severe problems of childhood malnutrition is PCM by serial weighing; outlined and the principles of a Pre. (3) Custom, diet and food produc. school Protection Program understood. tion; In the Host Country. By contrast, (4) Infectious diseases and their training in the host country should control (including immunization, rec- have a minimum of classroom lectures ognition and simple treatment of lim- and seminars, and should be mostly ited childhood illnesses, and village im- practical-in other words, training by provement of environmental sanitation doing, with the classroom, the corn­ by means of better water supply and ef- munity, and the textbook, real life. fective excreta disposal; The coverage will again include the (5) Food production at the village range of subjects mentioned earlier (p. level, including cultivation of legumes, 110), although t6is can best be under. dark green leafy vegetables, fruits, and taken by visits and inservice activities so forth, raising of poultry, develop- in the following places: ment of fish ponds; Health Services. To recognize the (6) Local dietary pattern including appearance of children with various cost, availability of foods and custom- forms and degrees of malnutrition, ary methods of infant feeding; with the clinical features of important (7) Principles of nutrition educa. infectious diseases and with the meth­ tion; ods employed in the treatment and (8) Methods of combating malnu- prevention of these, to become familiar trition, through health services, exten- with the running of the local health sion agencies, community development services, their staffing and methods. and by village self-help schemes. Markets and Shops. To see at (9) Community diagnosis and pro- firsthand the range of foods available gram evaluation, by analysis of data i n t an do ops a nd from censuses, and so forth, in local markets and small shops, and The type of training envisaged re- to note the cost of these and their quires a multidisciplinary approach availability. with teachers from different fields in- CultivationSites. To see the types volved. Wherever possible, it is very of foods grown, the methods of agri­ valuable to include instructors from the culture and animal husbandry, includ. host country and also American teach- ing irrigation, rotation of crops, fertil. ers with personal experience of the ization, storage, preservation, and so country in which the program is to forth. operate. Kitchens and Homes. To see local Inevitably, the technical training for methods of fed preparation, includ­ a P.P.P. organized within the U.S.A. ing type of stove, fuel, cooking pots, will be largely theoretic, although as types of measure used, and so forth;

162 to observe the family meal and the way (4) Immunization Procedures--de. food is served, apportioned, and eaten. pending upon range of immunizations Local Extension Services. To to be included (if any). know the local organizations and other (5) Issue of Food Supplements­ units which are involved in trying to how much per child, in what package, improve village life in general and in to be used in what way. particular food production and meth- (6) Weaning Foods-actualpracti­ ods of feeding young children and cal preparation, using quantities sug­ mothers, undertaken both in the head- gested, cooked in traditional kitchen. quarters of the various organizations (7) Methods o/I mproved FoodPro. concerned, but even more importantly duction-selected techniques depending by visiting and seeing what is going on on local priorities and using methods and how various ideas are working out advised by government extension serv­ in practice in rural circumstances; to ices (e.g. compost heap, spaced planting learn specifically the suggested practi. of beans in rows, use of insecticide in cal methods advised by extension serv- traditional granary, and so forth). ices to improve the village, food pro- (8) Methods of Village Improve. duction, recipes for infant foods, and ment--selected procedures suggested by so forth; to learn what assistance is government extension services and re­ available from government to vii- lated to local needs (e.g. safer "smoke. lagers, which they may not be aware of less" kitchen, protected spring, and so (e.g. credit schemes, assistance with foih). latrine construction, and so forth). (9) Nutrition Education-gr o u p Practice. Depending upon details discussion demonstrations, with visual of the program a variety of technical aids, on priority topics. procedures will need not only to be Again depending upon the program, knon i eory,but onycticdree- practical training needs to be carried known in theory, but practiced repeat- out using the services to be developed, edly in field circumstances using actual which may include one or more of the equipment. These may include some of following-a Young Child Clinic, home the following: visiting, a nutrition rehabilitation cen­ (1) Recognition of malnutrition- ter. The use of a pilot project or trial by signs, by weighing. area is desirable for training purposes. (2) Recording-usingYoung Child Only a short part of the training in Clinic card for weight graphing, record. the host country should be carried out ing immunizations and antimalarials in the capital. Certainly, here the field given, noting present infant diet and worker will be able to see how the prob­ appearance as regards health, nutrition lems are perceived in the capital. How­ and infection. ever, the major portion of the training andinfectinTre in the host country should take place (3) Basic Treatment-includingrec- in the area within which he will be ognition of clinical features of main in. working. Possibly this may be based on fections, details of basic treatment, and the district capital, but the visits and technique of intramuscular injections other activities suggested should take (if to be included), place in a similar area to that in which

163 the project will be working and with Ultimately, it will usually be feasible actual field situations. to widen the program as people's trust and understanding increase, and their (c) Deveopment oa P.P.P actual and felt needs become apparent. With a new program in an area, the Difficulties to be anticipated are re­ following phases often may develop: lated to the field worker's limited range Acceptance. To start with, in a of knowledge and experience, so that new program it is wise and most pro. it is unwise to try to extend either the ductive to do little, but to settle quietly ae c overy te orm or ts into the new surroundings, and to ob. area covered by the program, or its serve and be observed. It should, per- Readjustment. In some cases, the haps, be more a period of social adjust­ ment, of introductions, and of mutual program may develop differently from acclimatization by villagers and field what had been anticipated, while, in

worker than of technical activity. iddition, village interests and needs The villagers should be aware of the may call on technical skills that the main objectives of the program. How- field worker does not possess. ever, all too often they have various For more immediate technical advice, misoncepticons, so tl.at discussiorc, the local government extension agencies both arranged and informal, will or rural services should be consulted, usually be the next stage. if such are available. In addition, con­ Initial Action. It is always desir, tact with and advice from the team's InitalIt Ations alaystechnical adviser should be sought able to work with and through, a village t group or committee, on which it may be if the program appears to need possible to join with both the locally readjustment. influential and the energetic innovators In larger teams, regular meetings of always to be found in any community. the field workers and the national A suitable committee may already be counterparts at 3-6 monthly intervals in existence, or may develop, either are of great value. Encourhgements and through traditional or new channels, disappointments can be shared, ideas Group discussion and exchange of views pooled, and new skills that have been should not only guide the program's found to be needed can be learned and initial development, but the committee taken back to the village. should also be a sounding board to as- These meetings act as a continuing ses the successes and failures of future feedback and aid in the evaluation of activities. It can be the permanent nu- the program, leading to readjustment cleus for liaison between villagers and and modification of the original plan. field workers, permitting a two-way Evaluation. As with all public flow of information, health or social welfare programs, eval­ As a result of initial discussions and uation is essential in order to assess the observation, it will be possible to carry benefit or otherwise that has resulted. out a census and community diagnosis, With P.P.P. largely run by nonhealth followed by the initiation of some pait trained personnel, both foreign and of the overall program-for example, national, it is particularly important to perhaps, a Young Child Clinic, which be able to demonstrate and document is understandably likely to appeal. success to governments of these com­

164 munity-based programs carried out tions, such as various types of dubs. with limited funds in collaboration In this way, the field worker can also with village people. more readily gain insight and accept. Methods of evaluation should be con- ance in the village, as a result of the sidered during the planning of the par- national counterparts' local knowledge. ticular P.P.P., and incorporated into At the same time, the field worker's preliminary census and community presence at the grassroots level may diagnosis. add prestige to this type of work. Evaluation can be based on data As noted earlier, probably the main obtained at Young Child Clinics, and functions of the field worker should be preferably by subsequent repetitions of as a catalyst to assist people to use the original census carried out in the their own resources to help themselves, community by home visiting. In the and, also, to try to ensure that the pro­ course of these, changes will be noted gram, in some form, can continue to be by observation, as with the adoption run by national personnel after the end of ideas concerning food production of outside assistance. suggested by nutrition education (p. With this in mind, the main long­ 112), and by the use of questionnaires, range aims of this type of program as with the foods and recipes for in- should be to ensure its genuine accept­ fants (p. 176). Also, examination of ance, understanding and ultimate young children for clinical features and "take-over" by the rural people them­ by weighing will show whether the in- selves, to demonstrate the true value cidence of malnutrition has decreased of the village level approach to govern­ or not. ment authorities, and to try to develop Continuity. All programs de- a realistic and practical network of signed to help improve the nutrition, trained, enthusiastic personnel and vol­ health or development of village people unters in the village, who can carry must, except when dealing with emer- on and develop the program in the gency circumstances, be based on the future. need for continuity. What is left be­ hind at the end of a project in terms of AMONG SCHOOL-AGE long-range future continuation is more CHILDREN important than the short term improve­ ments, which may have been possible Although school-age children are during the field worker'o period in the still growing quite rapidly, they do not village. usually exhibit the severe degree of With this in mind, a P.P.P. aimed at malnutrition found so commonly in improving the nutrition of young chil- children in the early years of life, un­ dren in the community should always less serious food shortage or near be planned as a joint endeavor with famine exists. Nevertheless, many foreign field workers teamed with local school-age children in tropical coun­ personnel, either national volunteers or tries are far from well nourished, and junior technical staff, often from the their appearance has been described health service, working where possible elsewhere (p. 93). It must also be ap­ through permanent village organiza- preciated that, in many tropical coun­ 165 tries, only a percentage of school-age food and nutrition. In other words, children are actually attending school. school children, who themselves will be The health supervision of school chil. fathers and mothers of children in the dren may be undertaken by a school near future, must be regarded as a pri. health service, but, in tropical coun- ority target group for nutritional edu­ tries, this is usually rudimentary or cation. Also, under some circumstances, nonexistent, the new ideas learned at school may The nutrition of school children can filter back with the children to their be ascertained by "cross sectional sur- homes and influence the ideas of veys" (p. 116) ; while regular weighing parents. of children by school masters may be The principles and practice of nutri­ practicable in some parts of the world, tion, with a special reference to local and can detect poorly nourished chil- circumstances, must form an important dren who are not growing adequately. part of a child's schooling. It should be included, for example, in all science Maximum Benefit from Educa. courses, where the examples must be Lion. Attention should be given to the carefully geared to the local situation. problem of the nutrition of school chil- Ultimately, this may require a reoonsid­ dren for two reasons. Firstly, a coun- eration of the curriculum and of the try's development is to a very large ex- examinations. tent dependent on its trained personnel. For girls, the inclusion of domestic So that it is most important that all science, or home economics, and moth­ being educated, including children at ercraft must be regarded as an essen­ school, should derive as much advan- tial part of secondary education. tage as possible from their experience. The teachers themselves must be Too often Toochildren ftenchidrenleav leave thirtheir hmesawarehomes of the basic facts concerning nu­ with no breakfast to walk long distances tritionare of and the their icpfactimportance too eagreal life.nu­ to school, where they may then be too Undoubtedly, the most important places exhausted to benefit much from their inaoutry, her is ontnutrition ideas on nutrition lessons. n a country where are teacher-training Attention to the nutrition of school should be injected pays dividends not only in the colleges. children than improvement of the children's However, more important actual in nutrition and often suboptimal nutri- planned, formal education growth are the new ideas gained by pupils by tional status, but, more importantly, observation, and especially by practice. enables the pupils to benefit maximally It is for this reason that school gardens, from their schooling experience, and school meals, if, in fact, really nu­ Target Group for Nutrition Educa- tritionaily adequate, are of great value tion. Secondly, school children can be educationally. regarded as both accessible and "edu- School Gardens. A school garden oationally vulnerable." At school they has five main purposes--(a) to famil­ are by definition in the process of iarize children with local, and less learning new things and may be more often, exotic plants which can be cul. willing than their parents to listen to, tivated locally and could play a con­ and to absorb, fresh ideas concerning siderable role in supplementing the

166 customary staple diet, (b) to demon- However, as with other aspects of a strate simply, but convincingly, modern school farm or garden, problems of scientific methods of food production continuing attention during holidays (e.g., improved soil fertility, use of in- have to be overcome. It is wise to have secticides, and so forth), thus encour- some plants which are "semiperma. aging improvement of agricultural nent", such as papaya trees, or are self­ methods in the region, (c) to stress the seeding as with some types of tropical importance of garden crops in the bet- spinach, as these will last through the terment of nutrition, (d) to illustrate holiday period. Other crops can be cul­ instruction in science and nature tivated within the range of the school classes with living examples, and (e) calendar. to show pupils that the ideas they learn The produce of the garden should be at school have a practical application eaten by the children themselves, either in real life (as in the arithmetic in the school meal, or when taken home needed to calculate the quantity of seed to their parents. The nutrition educa. required and to keep a record of crop tion value will be enhanced if the pro­ yields, or by using insects collected in duce is of good quality. the garden for nature study classes). School gardens should not be used In brief, the school garden ought as a vegetable plot for the teacher, em­ to be thought of as "a method of teach- ploying the free labor of the children. ing, a living education" in applied sci- At the same time, the extra responsi. ence and practical agriculture, both in bilities and work required of the relation to the local natural scene teacher in initiating and carrying on a and to the nutrition of the particular school garden must be appreciated and community. encouraged. To be successful, the Planningthe Garden. In planning teachers need prior training in the run­ a school garden, a suitably adjacent site, ning of school gardens and should work its area, crops, and watering and so in cooperation with the pareiits. A forth, must be considered, together gardner is usually required for the with equipment, tools and seed. heavy work. The most appropriate plants to be School Meals. Various forms of grown will vary with the soil and rain- school meals may be practicable in dif­ fall of the region, but usually should be ferent communities. In some countries, local in origin, hardy and easily this may take the form of a breakfast propagated. The range commonly pos- and in others more suitably a lunch. sible has been given earlier. The meal or snack may be cooked at the Particular attention will have to be school, or sold at a cafeteria or canteen, given to including and demonstrating or can be brought from home as a cold­ methods of soil fertilization, rotation of packed meal. crops, prevention of insect and other (a) Organization. Problems of pre­ pests, and the propagation of plants paring meals at schools in tropical (including seed beds). countries may be very considerable, and The raising of small animals may pose an extra burden of work, at least also be practicable, including poultry, of a supervisory and administrative rabbits, guinea pigs, or fish ponds. nature, for the headmaster. A simple

167 clean kitchen, cooking and eating uten- Within the limits of available finance, sils, water supply, secure thief-proof the school meal should aim at being a storage and fuel must be available; as practical experience in nutrition well as a cook and staff to help prepare education. the meals. As usual with any develop. Meals should, if possible, supply the ment in any part of the world, espe- nutrients likely to be lacking in the cially in poorer tropical regions, the home diet. However, extreme shortage limiting factor is money. of money may make only a largely (b) E x p e n s e and Collaborative carbohydrate dish possible. Schemes. Although most governments If dishes are to be cooked, they can would like to extend a school feeding usually be only of a simple type (Ap. program throughout the country, this pendix VI), often based on one-pot is rarely economically possible as an stew recipes. Again the "principle of exclusively governmental project. How- multimixes" (p. 129) can be very use. ever, school feeding may be practicable ful. A "quadrimix" of staple, legume, as a collaborative venture between the dark green leafy vegetable and a small government and the parents, possibly quantity of animal protein may be together with an outside agency. practicable. It may, for example, be possible for a (d) Feeding Utensils and Cleanli. school feeding program to be launched ness. At least plates and usually spoons, in which at least some part of the food or other cutlery, will be required for to be cooked may be supplied as food serving and eating the meals. Again, aid from outside sotuces (p. 143), this should be used as an opportunity where the parents pay a small, nominal for health education with regard to sum towards the salaries of the cook, cleanliness, by ensuring that pupils assistant and the fuel, while the govern, wash their hands before eating, and ment makes available a simple kitchen, also take turns at washing up the plates store and cooking utensils. Catering for after the food has been finished. larger numbers often reduces the cost The "dining room" may be extremely per individual, simple, although, in some circum. (c) Nutritional and Educational stances, a separate room with unelabo. Value. If the cooked meal is to be pre. rate tables and chairs may be feasible. pared at school, careful thought will Often the meal can be taken sitting on have to be given to the nutritional and mats, as at home, or on the grass under educational value of the menus used. the trees, which often are to be found The foods employed will, as far as pos- near many tropical schools. sible, have to be based on the often It is ideal if the food prepared at the intermitten supply and distribution of school be that which has been grown local resources and available crops, al. already by the pupils in the school though they may be enriched by the garden. In this way, education received addition of free or subsidized foods in formal lessons concerning natural made available from elsewhere, in par- history, human digestion and nutrition ticular such good sources of protein as can be demonstrated practically. dried skimmed milk, and soy, or (e) Cold Stacks. It is important to groundnut flour, try to ensure that "ill health" education

168 does not take place at schools, as can small nominal fee may have their chil. occur if the only foods available to dren included, but this often excludes childen are nonnutritious starchy or the less well-fed, poorer children who sugary snacks or carbonated drinks are plainly more in need. sold by street vendors near the school. (g) Use of Food Aid. Food aid from If it is the practice for children to overseas can be very useful temporarily. purchase either snacks or a meal from but has the obvious disadvantage that such vendors, it may well be possible a long-term supply cannot be guar­ to ensure that attractive, well-liked but anteed for future years. Its usc, there­ nutritious, foods are in fact on sale. fore, has to be based on the realization For example, in various parts of the that plans must be formulated to make world tasty preparations of legumes, increasing use of locally produced foods groundnuts, or beans may be both as the project develops. However, as popular and good sources of protein; well as the advantages of school meals mentioned, it while in other countries, the sale of that have already been mealiorograi wheat-soy flour may be hol e noed thtn bread rollsfeasble.should of be noted that a ineal p~rogram feasible, also has the advantage of increasing Uncommonly, it may be possible in t school attendance, decreasing the num­ to provide cold snacks b towns for schoolsor malsbroghtin oi he upis, s. er of dropouts and thereby helping in or meals brought in for the pupils, as. the fight against illiteracy. This argu. for example, milk and bread. it ment, however, is less valid in areas mayPed Lorenractcales Else , where the limited school accommoda­ may be more practicable and accept- tion is already overfilled. able to try to persuade parents to sup­ ply their children with a cold packed lunch. Again, this would have to be FURTHER READING based on the local dietary and can be V. F. K. AvivoB. and C. K. HELLINS, quite simple, while satisfying the child's Poultry-Keeping in the Tropics, Oxford Uni­ appetite and also being nutritionally versity Press, London, (1960) (G). H. DiJrPi, and M. DuPIN, Our Foods, A and educationally desirable. In parts of Handbook for Educationists in West Africa, lunch may be Les Editions Sociales Francaises, Paris, East Africa, a packed (1965) (G). brought to school wrapped in the tradi- American Public Health Association, plaintain leaf or carried in a "Some practical considerations of economy tional and efficiency in infant feeding," Food and covered handleless metal saucepan. tn- Nutrition and Maternal and Health Sec­ der these circumstances, it may be pos- tions, American Journal Public Health, 52. to persuade parents to 125, (1961) (G&T). sible not only G.J. GAMBLE, and A. F. GUTTMACHER, allow their children to bring food, but Family Planning: A Challenge to Health to develop a healthy rivalry as to Workers of Every Nation, Pathfinder Fund, also New York (1966) (G&T). who is going to bring the best meal T. M. GREENSIL, Healthy Soil, Book I, (Appendix VII). Rural Science for Tropical Schools, Evans Ifonly a limited number of school Brothers Ltd., London (1959) (G). T. M. GREENSILL, The Food Crops, Book meals can be prepared, then problems III, Rural Science for Tropical Schools, of selection obviously occur. Parents Evans Brothers Ltd., London (1959) (G)* T. M. GREENSILL, "The School Vegetable who are able and willing to pay this Garden," Book IV, Rural Science for Trop­ 169 ical Schools, Evans Brothers Ltd., London M. L. Scorr, School Feeding: Its Contri. (1959) (G). bution to Child Nutrition, -'\O Nutritional P. GYOcY, and A. BuRcEss, Protecting Studies, No. 10 (1953) (G&j). the Preschool Child, Tavistock Publications, G. J. A. TEIUA, Tropical Vegetables, Com. London (1965) (T). munication No. 4, Royal Tropical Institute, M. KING (Editor), Medical Care in De. Amsterdam, (1966) (G&T). veloping Countries, Oxford University Press, 0. 0. Ucunu, A Guide to PracticalRural Nairobi, Kenya (1966) (G&T). Science for Schools and Colleges, Mac. A. MONCRIEFF, Infant Feeding, Second millan Co., Ltd. (Nigeria), (1966) (G). Edition, Edward Arnold, London, (1963) (G&T). Agency for International Development, D. C. MORLEY, A medical service for Homemaking Round the World, U.S. Depart. children under five years of age in West ment of State (1963) (G&T). Africa, Trans. Roy. Soc. Trop. Med. Hyg. 57, R. 0. WILLIAMS, School Gardeningin the 79, (1963). Tropics, Longmans, London, (1963) (G). A. SAXTON, and G. SAXTON, "Family Planning": In Medical Care in Developing 'G=Recommended for the general reader. Regions, (Edited by M. King), Oxford T=Recommended for technically trained University Press, London, (1966) (G&T). health workers.

Current P.P.P. (1968)

Haiti: (Mothercraft Centers) Dr. W. Fougere Bureau de Nutrition P.O. 707 Port-au-Prince, Haiti Nigeria: (Ilesha "Under Five" Clinics) Dr. D. Morley Institute of Child Health Great Ormand Street London, England Thailand: (Village Ecology Improvement Scheme) Dr. P. Gyorgy Department of Pediatrics Philadelphia General Hospital Philadelphia, Pennsylvania U.S.A. Uganda: (Ankolc P.P.P.) (Lutete Scheme) M. Wanamugimu N.R.U. % Department of Pediatrics Makerere Medical School P.O. 7072 Kampala, Uganda

170 APPENDIX I FOOD AND NUTRITION BOARD, NATIONAL ACADEMY OF SCIENCES National Research Council Recommended Daily Dietary Ajiowances,a Revised 1968 Designed for the Maintenance of Good Nutritition of Practically All Healthy People in the U.S.A.

Ageb Weight Height Fat-Soluble Vitamins Water-Soluble Vitamins Ainerals (years) Protein Vita- Vita- Vita­ kcat (ir) min A min D rmin E Ascorbic Fola- Niacin Ribo- Thia- Vita- Vita- Co- Phos- Mog- phorus loline Iron n1.9ium Actirit (IU) Activity Acid cin, (mag florin min min B 6 min Bs cium From (kg) (b8) cm (in.) ° (g) (mg) (ing) Up to (I U) (1 ) (mg) (mg) equiv)d (mng) (mg) (mg) (jg) (g) (g)

Infants ------0-. 4 I 55 '22 kgXl20 kgX2.2 1,500 400 5 35 0.05 5 0.4 0.2 0.2 1.0 0.4 0.2 25 6 40 -3' 7 15 63 25 kgXllO kgX2.0, 1,500 400 5 35 0.05 7 0.5 0.4 0.3 1.5 0.5 0.4 40 10 60 33-1 9 20 72 28 kgX100 kgXl.8. 1,500 400 5 35 0.1 8 0.6 0.5 0.4 2.0 0.6 0.5 45 15 70 Children------1-2 12 26 81 32 1,100 25 2,000 400 10 40 0.1 8 0.6 0.6 0.5 2.0 0.7 0.7 55 15 100 2-3 14 31 91 36 1,250 25 2,000 400 10 40 0.2 8 0.7 0.6 0.6 2.5 0.8 0.8 60 15 150 3-4 16 35 100 39 1,400 30 2,500 400 10 40 0.2 9 0.8 0.7 0.7 3 0.8 0.8 70 10 200 4-6 19 42 110 43 1,00 30 2,500 400 10 40 0.2 11 0.9 0.8 0.9 4 0.8 0.8 80 10 200 6-8 23 51 121 48 2,000 35 3,500 400 15 40 0.2 13 1.1 1.0 1.0 4 0.9 0.9 100 10 250 8-10 28 62 131 52 2.200 40 3.500 400 15 40 0.3 15 1.2 1.1 1.2 5 1.0 1.0 110 10 250 10 300 Males ------1-12 35 77 140 55 2,500 45 4,5(A) 400 20 40 0.4 17 1.3 1.3 1.4 5 1.2 1.2 125 12-14 43 95 151 59 2.700 50 5,000 400 20 45 0.4 is 1.4 1.4 1.6 5 1.4 1.4 135 18 350 14-18 59 130 170 67 3,000 60 5,000 400 25 55 0.4 20 1.5 1.5 1.8 5 1.4 1.4 150 18 400 18-22 67 147 175 6?J 2,800 60 5,000 400 30 60 0.4 18 1.6 1.4 2.0 5 0.8 0.8 140 10 400 '-135 70 154 175 U. 2.800 65 5,000 ------30 60 0.4 18 1.7 1.4 2.0 5 0.8 0.8 140 10 350 35-55 70 154 173 68 2,600 65 5,000 ...... 30 60 0.4 17 1.7 1.3 2.0 5 0.8 0.8 125 10 350 55-75+ 70 154 171 67 2.400 65 5.000 ...... 30 60 0.4 14 1.7 1.2 2.0 6 0.8 0.8 110 10 350 Females ...... 10-12 35 77 142 56 2.250 50 4.500 400 20 40 0.4 15 1.3 1.1 1.4 5 1.2 1.2 110 18 300 12-14 44 97 154 61 2,300 50 5.000 400 20 45 0.4 15 1.4 1.2 1.6 5 1.3 1.3 11 18 350 14-16 52 114 157 62 2,400 55 5,000 400 25 50 0.4 16 1.4 1.2 1.8 5 1.3 1.3 1'20 is 350 10-18 54 119 160 63 2.300 55 5. 000 40 25 50 0.4 15 1.5 1.2 2.0 5 1.3 1.3 115 18 350 18-.2 5 128 163 64 2. 000 55 5,000 400 25 55 0.4 13 1.5 1.0 2.0 5 0.8 0.8 100 18 350 -2-35 5, 128 163 64 2.00 55 5.00 ...... 25 55 0.4 13 1.5 1.0 2 0 5 0.8 0.8 100 18 300 35-, 5 128 160 63 1,85(1 55 5, 000 ------25 55 0.4 13 1.5 1.0 2.0 5 0.8 0.8 90 is z00 55-75+ 58 12 157 62 1,700 55 5. 000...... 25 55 0.4 13 1.5 1.0 2.0 6 0.8 08 80 10 300 Pregnancy ------+200 65 6,o 400 30 60O 0.8 15 1.8 +0.1 2.5 8 +0.4 +0.4 125 18 450 Lactation ...... +1. Wt 75 8,000 400 30 60 0.5 20 2.0 +0.5 2.5 6 +0.5 +0.5 150 18 450

The allowance levels are. intended to cover individual variations ariong most normal The folacin allowances refer to dietary sources as determined by Lactobocilluscasei assay. persons as they live in the United States under usual environmental stresses. The recom- Pure forms of folacin may be effective in doses less than Y&of the RDA. mended allowances can be attained with a variety of common foods, providing other nu- 4 Niacin equivalents include dietary sources of the vitamin itself plus 1 mg equivalent for trients for which hunan requirenlnts have been less well dellned. See text for more-detailed each 60 ing of dietary tryptophan. discussion of allowances and of nutrients not tabulated. - Assumes protein equivalent to human milk. For proteins not 100 percent utilized factor b Entries on lines for age range 22-35 years represent the reference man and woman at should be Increased proportionately. age 2. All other entries represent allowances for the midpoint of tha specified age range. APPENDIX II Information Required Concerning Feeding Young Children (a) Obstetrical-prenatal maternal (g) Other protein foods (animal diet; and vegetable)-age introduced, type, (b) Neonatal-feeds in first days, quh, tity, method of feeding; laxatives, discarding of colostrum; (h) Method of stopping breast feed­ (c) Breast feeding-when started, ing (weaning)-age, abrupt or grad­ technics of nipple preparation, indige- ual, sent away or not, child prepared or nous tests of breast milk, duration of not, the ue of deterrent substances on complete and partial breast feeding, breast, "compensation" or not, apparent diet of the mother (normal, restricted, reasons for weaning; increased); (i) Food preparations for chil. (d) Animal milk-type, quantity, dren-special foods and their prepara. dilution, additions, feeding method tions; if none, which part of r lult (e.g., cup and spoon, bottle, local feed- dietary used, recipes, number of meals ing vessel, and so forth), milk prepara- daily, methods of child feeding; tions (e.g., yogurt, cheese) ; (j) Person responsible for feeding­ (e) Feeding orphans and twins--wet mothers r eoler feeing­ nurse, induced lactation, artificial feed- mother, grandmother, older sibling, and ing and method (e.g., bottle, feeding so f t cup, spoon); (k) Attention to sex of child---ref­ (f) Supplementary foods-age in- erential treatment of male or female troduced, type, quantity, method of child. feeding (e.g., spoon, finger, tongue);

172 APPENDIX 11 Weight for Age Table (Birth to 60 Months, Sexes Combined)1

Age Standard (months) 80 percent 60 per cent sb-oz kilos lb-oz kilos ib-oz kilos

0 7-8 3.4 5-14 2.7 4-6 2.0 3 12-8 5. 9-14 4.5 7-8 3.4 6 16-5 7.4 13-0 5.9 9-14 4.5 9 19-9 8.9 15-9 7.1 11-11 5.3 12 21-12 9.9 17-6 7.9 13-3 6.0 15 23-5 10.6 18-11 8.5 14-1 6.4 18 24-14 11.3 19-13 9.0 14-15 6.8 24 27-5 12.4 21-12 9.9 16-8 7.5 30 29-11 13.5 23-12 10.8 17-13 8.1 36 31-14 14.5 25-8 11.6 19-2 8.7 42 34-2 15.5 27-5 12.4 20-8 9.3 48 36-5 16.5 29-0 13.2 21-12 9.9 54 38-4 17.4 30-13 14.0 23-2 10.5 60 40-8 18.4 32-5 14.7 24-3 11.0

I From Harvard Standards-Stuart and Stevenson (1959).

173 APPENDIX IV

A Planned Demonstration for Use in East Africa'

The following example may be given 3. Avoid baby's swallowing "germ. of a planned group-discussion demon- si" by: (a) Breast feeding; (b) wash. stration organized for 6. particular ing hands; (c) boiling water; (d) group of people, the Baganda: cleaning feeding utensils. L "Germsi" attack bowel, producing Topic--Prevention and Manage. wf ;ry stools (resembling discharge ment of Diarrhea in Ymng from nose, in "cold"). Children 5. Baby loses much water and dies Aims-to discuss:B because body dries up. A. DiarrheaA. Darreaoftenftencaued caused byy swal. a B.s Home hydration needed in early lowed dirt and feces, containing cases. "germsi" (bacteria) 1. Don't stop milk feeds, especially B. Home hydration needed in early 2. Coax bby to take large amounts cases2.Ca'" totklagamus C. Recognition of dehydr'ation and of "sugar water" (prepared by adding need for urgent medical attention 1/2 teaspoon salt, 6 teaspoons sugar to I pint boiled water); small quantities Socio.economic Factors:none relevant given frequently (1 4hourly) with cup Cultural Attitudes: and spoon, 2-3 pints daily. "Blocks"-diarrhea locally consid- C. Signs of dehydration. ered due to obusoba (incorrect 1. Sunken eyes and fontanelle. behavior) (difficulty with bacteri. 11 Teaching Aid. al etiology; delay with treatment) Materials "Links"--none relevant A. for "germsi demon­ Presentation stration. 1. Magnifying glass, dirty water, and I. General. school microscope. A. Diarrhea. 2. Equipment for handwashing, 1. Dirt contains feces and bacteria utensil cleaning, and water boiling. ("germsi"). B. Equipment for preparation of 2. Baby can swallow "germsi" in: "sugar water" for home hydration. (a) Dirty water; (b) dirt on fingers; 1. Salt. (c) dirt on feeding utensih. 2. Sugar. 'Comment: probably needs two or three 3. Teaspoon. sessions. 4. Pint bottle.

174 5. Kettle. 2. Photo of dehydrated child and/ C. Equipment for dehydration dem- or patient in ward. onstration. 3. Hospital hycuaqon apparatus 1. Photo of drooping dry plant and (intravenous drip). dry pond (e.g. fontanelle). 4. Photo of child after rehydration.

175 APPENDIX V Specimen Recipes for Weaning Foods The specimen recipes given below are INDIA from various parts of the world. They are listed by country. InfantMeal 1 (for 2 servings) (Triple Some are given in precise weights Mix) (p. 130). in grams, and would in practice have to Black gram 1P. mungol------­ 50 g be translated into suitable simple local Semolina ------­ 50 g domestic measures (e.g. cups, or hand- Sugar ------­ 10 g fuls, or gourds, or bottlea). Others are Oiled skimmed milk------10 g already given in these household units. Water. Salt to taste. Some of the recipes are for a single child; others are designed either for 1. Wash the beans, put in saucepan several children, or for a family, in- with water and boil till almost soft. cluding a young child. 2. Sprinkle in the semolina sugar and continue cooking a little longer. BRAZIL 3. Stir in the DSM and mix well. 4. Serve to toddlers. 'Tutu' (Beans) (for 1 serving) 1 (Quadrimix) (p. 131). Kiehri1 (for approx. 8 servings)

Black Beans (P. vulgarsl------60 g (Double mix) (p. 130). Cassava flour------20 g Rice ------435 g 'Loura' leaf. Black gram (P. mungo) ------435 g Peppor and salt. Ghee ------30 g Beef ------30 g Salt ------9 g Fat Iforfrying)------.. 10 g Water 8-10 parts with pulse and rice. 1. Boil beans with 'louro' leaf and 1. Mix rice and pulse and wash once seasonings until soft. or twice to clean. 2. Add cassava flour and continue o ~c ocen 2. Ad cssaafour nd ontnue 2. Add water, and cook gently until cooking until it looks like brown por­ ridge, rice is soft and water absorbed. Keep 3. Fry the meat in fat or use roast lid on. meat and serve together. 3. Add ghzee and salt to taste.

176 Bengal gram--puffed rice mixture Rice, Cowpea and Milk 1 (for 3-4 (Double mix). servings) (Triple mix). Toasted Bengal gram (Cicer aried­ num,) which can be crushed into a fine Cowpea------bice ------200 g powder, and puffed rice are traditional Milk, 300 g (1/2 pint). foods. Water and salt as desired. Add 2 teaspoons of toasted Bengal 1 gram flour to 1 average cup of boiling . Soak cowpeas overnight and rub water and cook forof 5ricpffe minutes.an 1 Addonce 8 to 2.remove Cleanse testa the and rice eyes. thoroughly in teaspoons several waters and remove all stones. of milk. Stir well and feed to young 3. Cook the cowpeas in boiling salted infant. Older infants will take larger quanti- water. and higher proportions of Bengal ties and continue cooking till both are soft. gram (2:1). 5. Stir to mix well. 6. Serve to toddlers, with the milk to SIERRA LEONE drink.

Rice and Egg 2 (for 2-3 servings) LEBANON (Double mix).

Rice ------200 g Lentil soup (sharabatadis) (Double Egg ------g mix). Water, 1 pintapprox. Salt as desired. This may be served to young children way from about 6-9 months onwards. 1. Cook washed rice in usual until soft. 3cups lentils. 2. Break egg into rice, and beat in '/2 cup rice. until well mixed. 1/2cup samneh, or other shortening. 1 cup chopped onions. 3. Serve promptly to toddler. 11/2 teaspoon salt. Water. Rice and Groundnut I (for 5-6 serv­ ings) (Double mix). Soak lentils in cold water overnight. Wash and pick over. Cook with water Rice ------200 9 until soft. Pass the soup through a sieve Groundnut------200 g or food mill. Add water to desired con­ Water pint. Suit as desired. sistency. Fry onions in hot fat until brown and add to soup. Simmer for ten 1. Lightly roast shelled groundnuts minutes. Add salt. Serve thick and hot and remove skins, with squares of crisp fried bread. 2. Pound to a fine paste. To prepare in open kettle: Wash len­ 3. Cook washed rice in the usual tils. Pick them over. Boil until soft. way till soft. Pass through sieve or food mill. Add 4. Add groundnut paste and beat till fried onions and salt. Add more water creamy. if necessary, and simmer for ten 5. Serve promptly to toddler. minutes. 177 To either method, add cooked rice if in hot oil. Add salt to taste and mix to desired (one.half cup before cooking). a soft consistency with warm water. Wrap in leaves or greased tins and hot. PAKISTAN steam. Serve

Halwa-variation 1 (Double mix). GAMBIA Semolina ISuI . .------100 g Rice and spinach (for 1 or 2) Red lentils------100 ( Sugar. (Double mix). Fat ------15 i Watr.Ric* ------135 g Water. Water, pint------1// 1. Boil the lentils until soft and water Salt ------2 9 g absorbed. Spinach ------50 2. Melt fat, add semolina and sugar 1. Add rice to boiling salted water. and brown lightly. 2. Boil approximately ten minutes. 3. Add lentils to semolina, then add 3. Add chopped spinach. sufficient water, until the consistency of 4. Continue cooking (five minutes). stiff dough. 5. Serve to toddlers. 4. Mould the mixture into different shapes. TANZANIA If given with a little milk, this is con­ verted to a "triple mix." Banana-groundnut paste (Double mix). NIGERIA I ripe banana 1 handful groundnuts White beans and cray fish (Double Roast groundnuts and remove skin mix). Put pounded groundnuts and ripe

This recipe for the Yoruba dish, ole, banana in mortar and pound. When is given by the Institute of Child fine, smooth consistency, feed to child. Health, Ibadan. It has been modified by omitting the customary red peppers. GHANA If used with a carbohydrate staple, it would become a "triple mix." "Siwee" 1 (Double mix).

1/2 cigarette tin1/ white beans.no.Yam------1209g 1 anoon. Lightly roasted groundnuts------120 g Stablespoon dry crsh.Palm oil (clea15 g 2 tablespoons palm oil. Salt to taste. Salt Cold water. 1. Steam or roast the yam. Soak the beans in water, wash off 2. Remove skins from groundnuts. seed coats, and grind. Grind other in. 3. Pound the yam and groundnuts gredients separately. Heat the oil, beat till fine in a mortar. the ground beans, and all ingredients 4. Transfer to a mashing bowl.

178 5. Add salt and warmed palm oil. 1. Put water and salt into a saucepan 6. Mould and serve, and bring to boil. 2. Mix dough with a little cold water Oto 1 (Double mix). in a bowl

I3.10-- Strain into the boiling water. Eggs then's, 1)------50g 4. Stir until cooked and thickened. Palm oll 15 g 5. Remove from fire and cool Salt to taste, slightly. Water. 6. Break egg into basin and beat 1. Wash, peel and wash again slices welL of yam. 7. Stir into the akasa and stir till 2. Boil some water and salt in a pot. akasa is thick and creamy---serve to 3. Add yam and egg in shell for toddler. 15 minutes. 4. When yam is cooked, strain off UGANDA water. 5. Mash finely in a bowl. Add oil Maize Porridge (Double mix). and mix well. 6. Mould the Oto in a bowl and make Mali flour------120 g Dried skimmed milk ..------20 g hole in center. Sugar ------20 g 7. Remove shell from egg and put Water------1/1 pint (approx.) in hole in Oto. 8. Serve to toddler. 1. Combine maize flour and DSM in a saucepan. Sagbarigu 1 (millet soup) (Double 2. Mix with some of the water to a mix). smooth paste. 3. Add the remainder of the water Pennisetum flour------75 g and bring to boil. Powdered white fish------5 g Salt to tast. 4. Cook gently for 45 minutes with Tomato ------60 g constant stirring. Water. 5. Add sugar for flavor and salt if

1. Put some water on fire to boil. desired. 2. Add the seasoning. Etr Pastes (Triple mixes). 3. Add the powdered fish and simmer for some time. These recipes are based on method of 4. Add millet flour and stir well. cooking by steaming in small plantain 5. Simmer for another 30 minutes. leaf packets (ettu), used in one district 6. Serve hot. of Uganda.

Akasa and Egg The local staples are the plantain (matoke) and the potato ('umonde). Maize flour------125 g Vegetable protein sources are beans (made Into a dough) (Phaseolusvulgaris) and peanuts. Most Egg (hen's, 1)------50 g Sugar --- 101en 9 easily available animal proteins are Salt and water. eggs, fish and dried skimmed milk.

179 Basic Recipes for Ettu Pastes

Exact or Kitchen Measures Household Measures 12 oz matoke (weighed after peeling). 6 average "bananas" (fingers, pieces). 3 oz dry beans. 6 large spoons dry beans (English des. sert spoon), or 1 large handful. 5 tablespoons water, pinch salt. 10 large spoons water, pinch salt.

12 oz lumonde (weighed after peel- 11/2 medium sized roots lumonde. ing). 3 oz dry beans. 6 large spoons dry beans (English des. sert spoon), or 1 large handful. 5 tablespoons water, pinch salt. 10 large spoons water, pinch salt.

8 oz matoke or lumonde (weighed after 4 average "bananas" (fingers, pieces). peeling). 4 oz groundnuts (pounded) 8 large spoons groundnuts (English dessert spoon). 5 tablespoons water, pinch salt. 10 large spoons water, pinch salt. to ONE of these basic mixtures ONE of the following foods must be added: (a) 11/ oz. liquid egg. (a) 1 beaten egg. (b) 114 oz. DSM. (b) 5 heaped teaspoons DSM. (c) % oz. dried fish. (c) 1 side of a fresh or dried medium sized ngege (small fish).

Preparation and Cooking of Ettu Pastes

The following is the general method (3) Peel matoke or lumonde, wash for the preparation and cooking for ettu and cut into small pieces. pastes using matoke (plantain) or lu. (4) Wrap prepared matoke or lu­ monde (sweetpotato), dry beans and monde, beans and spoons of water in­ egg or DSM. side the banana leaves; tie carefully (1) Measure dry beans, wash and and put the ettu in the cooking pot with put to soak overnight in clean water, the food for the rest of the family. Steam This softens the skins and makes re- the ettu for about 2-21/2 hours. (Use moval easy. An alternative method of smoked banana leaves, luwombo, to skinning beans is to put them on to prevent the leaf's breaking or crack­ boil for about 45 minutes; put into cold ing). water and they skin easily. (5) Open the ettu and mash up the (2) Next day when starting to pre- cooked food very well. Measure the pare the child's food, remove outer skin DSM and sprinkle over the food and from the beans, again mix OR, beat up the egg and add

180 it to the cooked food, again mixing in Any of these mixtures makes enough well to make a soft mush. for a midday and evening feed for 1- to Method for ettu pastes using matoke 2-year-old child and preferably should or lumonde, pounded groundnuts and be given warm. After the first meal, the egg or DSM. ettu should be tied up and can then be As above substituting groundnuts for given a second time later in the day, the beans. The nuts may be roasted and either cold or after re-heating. skinned before pounding when possible. Dark green leafy vegetables can be Method for ettu paste using matoke incorporated in an), of these recipes, so or lumonde, beans or groundnuts and converting a "triple mix" to a "quadri­ fish (fresh or dried). The only differ- mix." ence in making this ettu paste is that fish is cooked in the etla. IThese recipes have been collected by Soak dried fish in clean water or wash Margaret L Cameron of tbe Human Nutri. fresh fish. Separate the fish meat from tion Unit, Nutritional Institute for Medical the bones and skin, and use about 1/2 a Research, Mill Hill, London, and are repro. medium sized ngege in the ettu. duced with permisaiea.

CSM (Corn-Soya-Milk)

CSM was developed by the U.S. in Board, National Academy of Sciences, recent years for distribution under the National Research Council. food aid program, as a food supple. CSM is a bland food which can be ment for children (particularly the used in many ways--as a beverage, a post-weaned young child). It can be porridge, il soul), in puddings, in baked used in school feeding and wherever goods, etc. It is easy to repre and there is need to improve the diet. CSM ' it has been pre-cooked, does not is a mixture of processed cornmeal require long cooking. To make a beve- (68'7), defatted soy flour (25,; ), non­ fat-dried milk (5/ ) plus vitamin and Ige, one part by volume of CSM is mineral supplements. mixed with six parts by volume of safe CSM is not intended to providle a water; while for a porridge the pro­ CSNIisinende nt to rovie a portion is one part CSM torthree parts complete diet for children, but to sup. lelilent thle (iet already used by lpro. water. The mixture is cooked slowly to viding additional amounts of nutrients, boiling, stirring constantly. and allowed particularly protein, vitamins andl to boil for one to two minutes. It can minerals. Eighty grams (about l/..1b.) be served flavored only wilh salt or supplies 2:1./ of the calories, 61'; of sugar and may be vaten hot or cold. the protein and between 41,; and 88'; Because of its blandness, it lends itself of the other nutrients (except vitamin to use in local recipes and to suit local C) of the Daily Recommended Dietary tastes. Recipes may be needed to con­ Allowance for children 1-3 years of age form to local custom and available as set up by the Food and Nutrition cooking equipment.

181 APPENDIX VI Approximate Guide for Uganda to Quantities of Foodstuff per Head for School Meals in Preparation of Triple Mixes (For mixed age range)

Quantity per head loodstuff Girls Boys

Plantain (before peeling) ...... l3bbs. per meal ...... 3-3/ lbs. per meal. Sweet potatoes (before peeling) ...... lj-2 lbs...... 2-3 lbs Staple: Rice ...... 3-6 oy...... 4-8 o s. " " Maize Flour (posho, thick) ...... 3-6 oza. " "..... 6-8 ozs. "' " Maize Flour (porridge) ...... 2-3 ozs. " "...... 2-3 ozs. " " Millet (thick) ...... 3-6 ozs. " " .... 6-8 ozs. " " Cassava (before peeling) I...... -- 2 lbs. " " ..... 2-3 lbs. lread 2...... 2-4 ozs. " " ...... 2-4 ozs. Sugar 2...... 1-3 ozs. daily ...... 1-3 ozs. daily. And Oil or Fat ...... oz. daily ...... % oz. daily. Protein: Milk (dried fatfree) ...... Y-1 oz. daily ...... %'-Ioz. daily. Meat with bone ...... 4 ozs. per meal ...... 4 ozs. per meal. Meat no bone ...... 3 ozs. " .. ... 3 ozs. " " fresh with bone ...... 4 ozs " "...... 4 ozs. " " Fish "' Fish fillet no bone ...... 3 ozs. " " .. ... 3 ozs. " Fish dried ...... 2 ozs. " ...... 2 ozs. " " Eggs ...... I egg ...... egg. Cheese ...... 12-2 ozs " " ...... -2 ozs. " " Beans ...... 3-4 ozs. " " .... 3-4 ozs. " " 'r,.q ...... 3-4 ozs. " "... 3-4 ozs. Nuts ...... 3-4 ozs " "... 3-4 ozs. " " l)ahl ...... 3-4 ozs. " " . . . 3-4 ozs. cc Vegetable: Vegetables green and yellow ...... 2-4 ozs. " "...... 2-4 ozs. " " Fruit: Fruit ...... 2-4 ozs. daily ...... 2-4 ozs. daily. Salt ...... ,- oz. daily ...... ,-Y oz. daily.

I Cassava is a poor food and should not be served too often. 2 Among items which can be used but are governed by availability and money are: tea, coffee, sugar, bread, margarine, jam and syrup. NOTES: Ingredients: 1) The above foodstuffs are divided into Matoke 3 lbs., before peeling. three nutritional groups and care should be Oil Y oz., for frying onions. taken when budgeting and planning the Beans, 2 ozs. menu to see that at least one food from Nuts, 2 ozs. each lood group is served at each meal. Vegetables including: If mo:e than one item is used horn mny Onions 4 oza., before preparing. one food group it is necessary to see that the Salt as necessary. total overall quantities are used-e.g. Supper 2) Oil. Double refined edible oil fortified Menu Secondary School (Boys) -Plantain, with Vitamin A is recommended particularly Beans, Groundnut and Vegetable Sauce. for schools and colleges serving a grain 182 staple food. The quantity listed above can 6) Milk (Dried Fat Free). Milk powder be increased if the budget permits. is nutritionally very valuable and is low in 3) Sugar is expensive, poor nutritionally cost (lb.=8 pints liquid fat free milk). and too much is bad for the teeth. The powder can 4) be added to the porridge Eggs have a high nutritional value and and sauces or sprinkled dry onto one easy the food. way of serving is to boil the eggs The quantity listed above can be increased hard and serve with a curried vegetable sauce if the budget permits. and a staple food. 7) Vegetables. Dark green and yellow 5) Cheese has a high nutritive value and vegetables are. nutritionally Ieat; onions can be cut into pieces or grated and added should be used for flavoring. to the sauces in the cooking, or it can be 8) Fruit of any variety should be served, eaten without cooking. and if possible once a day.

183 APPENDIX VII

Packed Meals for Children to Carry to School

Foods are divide into three nu. this also avoids the meals becoming tritional groups and care should be tak- monotonous. en to st that at least one food from It is particularly important to pro­ each of the groups set out below is in- vide plenty of the borly building pro­ cltlh-4l ini the packed weal daily. As tein foods in tile packed meals daily different foods conta,6 '-.Ierent as these are necessary for growing ulll m of essential it.it I children. gool t) provil it variety f lombL--

Protein V egetabL/Fruit Staple Milk, Fresh Vcgetables,- Millet Milk, )ried Skim Green leaves Maize Chle'se Pumpkin leaves Rice Eggs Spinach Bread Meat Kale Sweetpotato Fish Cabbage Irish Potato Grans Bean leaves Matoke Groundnuts Cowr .'a leaves (Green Banana) Peas Carrots Yam ikBns Pumpkin Cassava Tomatoes Fat and Oil Fruit- Orange Lemon Mangoes Avocado Papaya Guava Tree Tomatoes Pineapple Bread Fruit Granadi~la/Passion Fruit Grapefruit Cape Gooseberry Lime and Salt

184 SUGGESTIONS FOR PAWKED 7. Bread ME.ALS Hard boilhed egg or piece of meat or ellvese 1. Roasted or steamed maize Cob "ronato Hard boiled egg 8. Bottle of pmrridge mado with maize Tomato or millet flour 2. Cold millet bread Sugar and milk Cold cooked dried fish and vegetalble ()range, bread fruit or banana, and stew so forth Mango 9. Bottle of milk 3. Cold roasted rweet potato Maize cot) Roasted groundnuts Tomiato Tomato of fresh fruit Non:: The food should be properly 4. Cold millet bread packed so Ihat it will survive t jour. Cold cooked beans with vegetablh, ney and will be casy for the cuihl to Slice of paw paw or other fruit carry. 5. Cold bailed potatoes The container must be of a iaterial Cold ground nut sauce with wege- mtrilhileailedstsdtfatethat can be easily cleaned or a hyg(niM tablesaterialiat which he disliowl (f after Barasols palm fruit drink use, e.g., siiple tlln with well ilting 6. drastedpalmssavatd lid; saucepan or basin with lid; polyt hyl. 6. Cold roasted cassava eno bag; clean paper or elean smoked Roasted groundnuts or steamd banana leaf, or fiber; ba­ Slice pineapple nana leaf which food has been cooked in and tied with banana or grass fiber.

185 APPENDIX VIII Nutrition Rehabilitation Unit

Nothing is quite so important in the their discharge from the wards. Out­ cart of children with kwashiorkor as patient mothers in small groups are etffective health education, yet few given health education talks, and are things are more dilicuht to provide on a shown how to prepare a lunch for their larget scale in a busy hospital. It was to ,hildren using the locally available fulfill this need that a nutrition rehabili- foods an(d the dried skimmed milk taliti unit was organized at Mulago powder that is issued to them in packets, Ilospital. It is the first of its kind in either plain or Calorie reinforced. They Africa, and, though it is set up in a are taught the importance of breast leachlng hospital and staffed by a spe- feeding, and the value of boiling water cialist )inlialrician,there senms no rea- and milk. There is an immunization son why similar on-s should not he program and antimalarial drugs are equally effective on a more modest prescril 'ed. scale in district hospitals, for it is here that the need is greatest. TIlE RESIDENTIAL CENTER BUILDINGS From the outpatient group, twenty mothers with their children are selected Tie buildings of the unit are simple. for admission to the residential center There is a "residential center" consist- for from four to six weeks. Great em­ ing of a dormitory and a kitchen where phasis is placed on this period of mothers can prepare their own meals, residence so that a mother can actually There is an out-patient hall and several see her child getting better without giv­ minor hut very important educational ing anything more than the correct strutures in the grounds nearby, such food. In this way she becomes con­ as a simple rural kitchen. The unit is vinced that the disease is due to faulty housed in single story buildings some feeding alone. A mother learns that the way from the hospital itself. At M,,mlago training she is given is to help her to some of these are of mud-wattle and teach her neighbours the dietary prin­ whitewash, but there is no reason why ciples involved in the prevention and the whole of this type of unit should cure of kwashiorkor. The program in not be of the cheap local pattern. the unit is mother-oriented ratherthan child-oriented and mothers are taught general homecraft as well as good At Mulago, all children with kwas- nutrition. hiorkor come to the unit; mild cases 'dtt residence probably has another are sent ,iraight from the outpatient de- effect. Mothers are in the unit long partment, severe cases come to it after enough for them to form a community

186 and, if the general attitude of this con- On the grounds around the unit ther munity is that kwashiorkor is a nutri- are several demonstrations of how tional disease, then new mothers are fLmilies vanl improve their own home.s likely to be converted to this way of and divts. There is a lowal patern hut thinking by those who have already with its cooking facilities inorporating been convinced. It is likely that a use- various improvoel.ielts that are within fiul part of tie unit's teaching is done tht means of the family. Thus, there is for it automatically in this way. Work- a rais'Il fireplace to keep pols of hoiling ing in pairs. two mothers from the resi- water aiway fron small children. The, dential center, a more experienced and hut has a high slitdf to keeplthe family's a less experienced one, are selected to paraflin bottle out of tile children's teach the outpatient mothers. They reach; therei is also an improved local show them how to prepare meals in the pattern lailer, and tabls, and so forth. simple denonstration kitchen near the In the hut are two large local pattent outpatient hall and, by working in pots with lids. It mw of these a nlother pairs in this way, not only do both (!talt keep boiled water, an1 in tle other teach the outpatients, but the senior unboiled water. Outside tit, hut is a mother teaches the junior one how to proper soak pit, a drying stand, and a teach. In this way a pair of mothers complst heap. h'levre, is also a vegetable needs less supervision from tile staff garden, ain improved chicken oo ) oil than they would otherwis. the deeI litter system and sone ral.]it On their discharge from the unit hut-hi4s. Mothers are also taught sowing mother and child are taken home by a and anythinig else that is likely to make, member of the staff. A meeting is ar- them nore effective wives aid mothers. ranged at which are present the mother The work of this unit can he ex­ and her child, who is now much better, pressed in another way. Baganda the father, some neighbors and any mothers variously attribute omu.sana­ chiefs or local authorities who can be obwosi, tihe; disease recognized as persuaded to attend. The mother and kwashiorkor, to the sun, to tile seeds staff member demonstrate the child to of a certain plant entering a child's this group, and the mother tells them body, to air entering him if I, is not the dietary principles that she has properly covered at night, and to ieat learned. from his mother's womb. The unit ainis to send mothers back to their villages Some important details. This is the convinced that all these notions are essence of what the unit does, but there wrong, and vigorous protagonists of are many other points which contribute the idea that incorrect feeding is the to success. Fathers, for instance, are major causeffnusana-obwosi. If they considered very important. Every week ar ralsy o nvinc.d, they there is a "Fathers Day" at the unit hred, convinc they wirinitaw when fathers visit, particularly the hoped, convince their andhriens fathers of children who have been ad- spread correct knowledge through the mitted with their mothers. They are community. Properly instilled, the shown the work of the unit and how knowledge imparted by the unit in the they can assist their wives when they minds of a fw mothers can multiply return home. many times.

806-112 o-0----18 187 APPENDIX IX

Home-Feeding Kit

This kit is designed for the feeding (2) Take out the tin of soap and at home by foster parents of babies who wash your hands. have to be artificially reared. Because (3) Take out the cup and spoon and of the difficulty of cleaning a feeding put them on the lid. bottlo and teat, with the consequent (4) Put water into the container up grave danger of infecting the baby with to the mark and boil it. diarrhea, the feed is mixed and given (5) Pour some of the boiling water in a special aluminum cup which is over the cup and spoon and then throw easier to keep clean, it away. Components of Kit: (6) Pour boiling water into the cn (1) Container (aluminum pan with up to the mark. lid). (7) When the water is cool enough (2) A tin containing soap. for you to be able to hold the cup com­ (3) A spoon. fortably, mix in - spoonfuls of milk (4) The feeding cup. and feed the child. (5) A tin of milk. (8) When you have finished, wash Directionsfor Use: the cup and spoon in soap and water (1) Open the container and put the before putting it away back in the con­ lid down beside it. tainer.

188 APPENDIX X

Preparation of Artificial Bottle Feeds in the Village Home

Artificial feeds are almost impossible with reconstituted milk, fix on teat and to make ,ipcleanly in many poorer feed infant. tropical homes. 8. Immediately after feed, wash in. If artificial feeding has to be re,orted side and outsidu of bottle, teats, cup to, a cup and spoon, or feeding cup (p. and spoon with clean cold water, using 137) should be used. The simplified, bottle brush. but still very complicated, procedure in 9. Store bottle, teats, cup and spoon preparing bottle feeds outlined below is in tin or cardboard box (preferably in­ difficult and unlikely to be followed, side saucepan) until next feed. Requirements: 1 tin full cream milk Stirilization with Sodium powder (or evaporated milk, and so Hypochlorite' forth), 1 tin household sugar, 1 wide- The Bottle necked plastic feeding bottle, 2-3 rub- 1. Immediately after feed, wash in­ ber teats, 1 teaspoon (5-6 cc volume), side and outside of bottle, teats, cup and 1 cup (7 fl. oz. volume), 1 saucepan spoon with clean cold water. with cover, 1 large tin or cardboard 2. Fill covered aluminum saucepan box with cover, for storing feeding or other suitable container with 2 pints utensils, clean cold water, and add 3 teaspoon­ fuls 1% hypochlorite solution, or chlor­ Sterilization by Boiling 2 The Bottle ide of lime powder. 1. Before feed, place bottle, teat, cup 3. Totally inimerse bottle, teats, cup and spoon in cold water in saucepan, and spoon until next feed (3-4 hours), heat, boil for about 5 minutes, and allow ensuring that bottle is filled with to cool. solution. 2. Wash hands. The Feed 3. Remove cup and spoon from sauea. o1. saucepan. Before preparing feed, wash 4, Add required quantity of dried hands. cup and spoon from milk and sugar (p. 136) to cup with 2. Remove spoon. 'Sodium hypochlorite solution can be 5. Boil water in kettle or separate bought ready prepared (e.g., as with "Mil­ saucepan. ton Antiseptic" or other brands), or can in the home using chloride 6. Mix required quantity (p. 136) of be made cheaply warm boiled water to dried powdered of lime ("Calx. chlorinata"). wThe amount of chloride of lime required milk, stirring in well with spoon to is very small, add the tip of a knifeful to avoid lumps. about 2 pints of water. The chloride of lime 7. Remove bottle front saucepan, fill should be kept in a small tightly sealed tin. 189 hypochlorite solution. Drain, but do not chlorite solution. Drain, but do not rinse, rinse. 3. Boil water. 7. Pour reconstituted milk into bottle 4. Add required quantity of full and fix on teat. cream powdered milk and sugar to cup 8. Immediately after feed, wash bot­ (p. 136). tie, teat, cup and spoon in clean cold 5. Mix. Add required quantity of water and immerse again in hypochorite warm boiled water into dried milk in solution. the cup using spoon. 9. Prepare fresh hypochlorite solu­ 6. Remove bottle and teat from hypo. tion each morning.

190 APPENDIX Xl THE MULANDA PROJECT'

utilizing the [An attempt to combat protein Calorie malnutrition in Eastern Uganda by resources of a district hospital, a district farm institute, and a primary school] By P. S.E. G. HARLAND, M.B., B. CH. (Formerly Medical Research Council Infantile Malnutrition Unit, Kampala) be. After nine months' experience of the cowpea (Vigna sinensis) was of re­ looking after the children's ward at ing grown less and less because bad weather and Tororo Hospital, it became apparent peated failures due to of eating pro. that treating the acute cases was not insect pests. The custom as plantain contributing to the main problem of tein dificient staples such amongst the reducing the number of malnourished and cassava was spreading Jopadhola and children in the area. We often had to previously millet-eating tribes in the W. readmit children for the same acute Teso (the two main were told by local symptoms only a few weeks after they Budama area.) We and milk pre­ had been successfully treated. Sick people that groundnuts the homes were children were brought to hospital on viously consumed in the point of death and others were not now being sold for cash. we decided that brought at all. It was therefore neces. In view of these facts health education, it sary to make the local people aware that before undertaking people to the symptoms of malnutrition were cur- was necessary to encourage of protein able in hospital and the disease could increase their production then put our be prevented by the parents themselves, foods so that they could There was no After visiting some of the homes of teaching into practice. people what foods these children we could see that the point in teaching you could also show them parents were often unable to put health to eat unless prepare them. education into practice because protein how to grow and admitted to the ward foods were not available to them. Al. Children were usually the mother, though UNICEF dried skim milk was with an "attendant" sister. While the child distributed in the District Child Wel- father or elder we gave the attendant fare Clinics, many people lived far was in the ward about the reason for the away and often supplies and transport information how we intended to cure were lacking. The local popular legume child's illness, protein him, and how by producing the at home and giving them to Dr. P. S. E.G.Harland is foods 'This paper by hewould prevent the illness from from the Journal of Tropical child reproduced form as it repre­ Pediatrics in an abridged This was done through a a P.P.P. stemming from curative recurring. sents the District health services, program incorporating 191 Hospital, District Farm Institute, ana eat enough of the diet. As we had few a Primary School trained staff, the attendants were re- sponsible for feeding the children. Treatment of Severe Caes of When we had explained the reason, the Protein-Calorie Malnutrition in mothers were very good at cajoling Hospital their children into taking the full amount of food and preventing them Set erely ill children were admitted from filling themselves with staples be. to a 36 bedded ward staffed by two tenmas usin bu ok registered staff nurses, three locally tween meals, Questions about hook­ trained nursing assistants supervised worm anemia, diarrhea, thaerculosis by a ward sister and a medical officer. and other diseases were deanswered. We treated these children with "rein-. forced milk"-dried skim milk rein- given the normal ward diet 3, that is, .foredwith edible oil and sugar to pro- maize porridge, meat and bean sauce, vide sufficient Calories to ensure ef- groundnut soup and an egg each day, ficient utilization of protein. Two and supplemented with one-half ounces of this milk were mixed as a powder intoreinforced the porridge. milk given per lb body weight over 24 hours When possible we also gave them green as a continuous drip through a naso- vegetables, cowpea tops, and dodo gastric polythene tube (internal diam- (Amaranthus) and purees made from eter I mm), ifthe child refused oral beans grown in the hospital garden feeding. If the child accepted the diet which adjoined the ward as described orally it was given in 5 feeds during later. These included cowpeas, black die day. gram (Phaseolus mungo), soybean (Glycine max), gram gram (Phaseolus Health Education to the Attend- aureus), and pigeon pea (Cajanus ca. ants of Children Admitted to Jan). rTe beans were cooked by a lo­ the Ward cal method in which they are boiled in an alkaline solution prepared from When a child was admirld, the medi- ash, for only 45 minutes instead of the cal officer discussed his case with the 4 hours required with plain water. attendant, with the participation of the attendants of the other children. He HOSPITAL GARDEN was told that his child was ill because he had not had enough of the correct As their children improved, the at­ food; that we would cure the child by tendants were asked to help cultivate giving him a special diet. The recover the hospital garden adjoining the ward. ing children and tlhe testimony of other The purpose of this was (1) To try out attendants (who were usually well-in- a variety of legumes and other vegeta­ doctrinated by this time) were used to bles to see which were accetable to demonstrate this. We did not give rou- local people and would yield good tine injections of penicillin and unless amounts of vegetable protein, (2) To we explained the reason for this the show the attendants how to cultivate attendants complained that their chil. these crops efficiently. By actually par­ dren were being neglected. We also em- ticipating in the cultivation they could phasized tie need for the children to learn the techniques and value of row

192 planting, proper time of sowing, fer- of them did. Normally farmers attend. tilizer and insecticides, (3) To use the ing these courses were "good farmers" produce of the garden ':o feed the chil- whose children were often well fed. By dren in the ward. The attendants were enabling the fathers of children with shown the method of preparation and malnutrition to attend the courses, we could see the improvement in their hoped to extend benefits of the Institute children who were being fed on the to people who would not normally at. foods that they themselves had helped tend courses, but who were in the to grow, (4) To give the seeds from greatest need of such education. In re­ the successful kinds of plants to the turn, the hocpital medical officer lec. attendants on discharge from the ward, tured to farmers attending the courses for planting in their own gardens at on nutrition, and another member of home. the team gave demonstrations on food In addition to the other types of preparation. People attending the legumes mentioned, we also grew and courses-chiefs and teachers as well as disseminated sunflower seeds (to be farmers--were taken to the hospital to eaten parched), tomato, maize, and see the treatment of malnutrition in lettuce. practice irn the hope that being leaders of their communities they would con­ THE FARM INSTITUTE tribute to the solution of the problem of The function of the Tororo District in their home villages. As a result to Farm Institute is to offer courses de- these visits, we were often invited chiefs signed to introduce local farmers to village meetings arranged by the efficient agricultural methods. The at which lectures and demonstrations farmers participate in demonstrations were given. to of ox ploughing, soil improvement by Believing that it was important rotation of crops and the use of fer- bring the problem of infant malnutri­ tilizer, the proper cultivation o. cotton, tion to the attention of important local millet, and maize, beekeeping and so people, a function was arranged at the on. In addit;on there are courses for Institute to which the ssenkulu (cere­ farmers' wives on child welfare and monial head) of Bukedi Chiefs and nutrition. Particularly valuable are the politiciais and councillors in local gov­ demonstrations on the care and breed- ernment were invited. The program showing ing of small animals--rabbits, guinea consisted of a farm walk, the pigs, pigeons, chickens, quails, and of a homemade 8 mm film about the at which turkeys, and also the care of cattle with work of the project and a meal foods emphasis on improving milk produc- 20 different locally grown protein value tion. were served and the nutritive Once a fortnight a group of hospital explained. attendants was taken to the Institute by WORK IN THE ambulance where they were taken on an educational farm walk by a member of the Institute staff. They were also As we wished to influence people in shown how to join the residential the villages more directly, we obtained courses run by the Institute, and many the co-operation of the staff of the pri­ 193 mary school at Mulanda, a village 15 peas, and elephant grass. The labor was miles from Tororo. The 300 children provided by the children themselves attending the school were aged from 8 during their gardening period (2 hours to 18 years and their homes were in per week.) Seed, fertilizer and insecti. nearby villages in an area of W. Bu- cide were donated by local busines­ dama where the soil is infertile and mal- men. nutrition common. The school children The children were also taken to the themselves did not show signs of mal- Institute for farm walks and visited the nutrition which is mainly a disease of hospital, and the Principal and other the preschool age group. In any case members of the staff spoke to them only the healthy children are sent to about agriculture and nutrition. schooL The school garden has not been a We tried to awaken the children's great success. The soybeans matured interest in the prevention of malnutri- during the holidays and were not bar­ tion, in the hope that they would per- vested. However, two sacks of sorghum suade people in their villages to send were harvested, milled locally and used sick children to the hospital earlier. Also in the school meals. In spite of this dis­ we asked them to cultivate a school pro- couraging start, the staff of the school tein garden whose produce could be are contintring with the garden and with used to supplement the school diet and a rabbit project. which would provide a source of seed for children to take home. FOLLOWUP We began by talking at length to the Five months after leaving Tororo we children, asking questions about local revisited the area and were happy to beliefs and answering their own ques- find that the hospital garden was flour­ tions about health and the causes of ishing. Visiting the homes of children disease. With the help of the Institute treated for kwashiorkor the previous and the local agricultural assistant, year, we found that a second planting of three acres of the school garden were pigeon peas and sunflower seeds with ploughed, divided into plots and sown enthusiasm was being undertaken. This with soybeans, maize, sorghum, cow- is a completely new food in this area.

194 INDEX Acerola, 19 Banana, 34 Aflatoxin, 30-31,52 Beriberi, infantile, 19 Agriculture age incidence, 88 labor force in tropical countries, 43- causation, 19, 27, 88 44, clinical appearance, 88 productivity, 151-152 prevention, 89 Alcoholic drinks treatment, 88-89 nutritional value, 38-39 Biltong, 46 Amasi, 37 Blood (as food), 35 Amino acids, 16, 17, 34, 37, 54 Bottle feeding, see Artificial feeding Anemia Breadfruit, 185 age incidence, 91 Breast feeding causation, 21, 79, 91 advantages, 56, 111, 119, 126 clinical appearance, 91-92 duration, 72-73, 111, 120, 124-125 In school-age children, 93 in prevention of infantile scurvy, 89 prevention, 9 1-93 means of encouraging, 123-124 treatment, 92 principles, 124-125 Animal husbandry reflex",, 122-123 breeding, 45, 52 Breast milk problems, 67 composition, 35-36 Applied nutrition programs, 152 desirability, 35-36, 119, 126 Arlac, 140 effect of mother's diet on, 35-36 Arrowroot, 27 Burghul, 28 Artificial feeding dangers of, 36, 58, 89, 111, 119-120, Caffeine drinks, 39 125,137 Calcium methods, 84, 137-138, 189-190 functions, 21 number, timing, and volume of feed. recommended daily allowance, 21, 171 ings, 135, 137 needs, 21 type ofmilk used, 133-135 sources, 21 Ascorbic acid, see V!..min C Calories .atole, 140 definition, 13 Audiovisual aids (in nutrition educa- "naked calories," 15 ton), 107-110 needs, 14 Auditory aids (in nutrition education), sources, 14-15 110 Carbohydrates Avitamin3sis A as protein sparers, 17 causation, 86-87, 120 as staple food, 15 clinical appearance, 87 definition and function, 14 effects of, 19, 87 energy provided by, 14 prevention, 87-88 foods containing carbohydrates, 15 treatment, 80, 87 Carotene, we Vitamin A Avocado pear (as food for young chil- Cash crops, 47, 152 dres), V Cashew nut, 31

195 Cassava, 26 Dates Cereal-legume mixtures, 16 nutritional value, 34 Cereals Deficiencies calcium content, 21 See, Anemia preparation, 16 Avitaminosis A protein t;. tent, 16 Beriberi See also, Corn Calcium Millet Goiter Rice Kwashiorkor Wheat Marasmus Chapati , 28, 132 Pellagra Charqui,46 Protein-calorie malnutrition Chick-pea, 16, 30, 140 Riboflavin Childhood disease, 8-9 Rickets See also, Infectious diseases Scurvy Child-spacing Dental caries, 15, 21 and malnutrition, 55, 66, 72, 81 Developing countries (definition), 5 methods, 56, 153 Dal, 17 sites for services, 153-154 Diarrhea (infectious), 138, 145 Chlorine, 22 Dietary assessment methods, 40-41 Clarified butter, see Chee Dietary excesses, 24 Climate Dietary imbalance, 24 as factor in food production, 45 Diets for pregnant women, 111, 125 Coconut, 31 Commercially processed protein foods Edema, 76 acceptability, 138 Education, 6-7 animal protein foods, 139 See also, Nutrition education animal-vegetable protein mixtures, Eggs, 15 140 as "cash crop," 37, 47 economics of, 139 as food for young children, 37 vegetable protein foods, 140 nutritional value, 16,37 Cooperatives, 48 preparation, 37 Corn (maize) taboos against consumption, 64 as cultural super-food, 62 Environmental sanitation, 7 nutritional characteristics, 16, 19 preparation, 27-28 Family planning, see Child-spacing Cottonseed, 32, 52, 140 Fat (subcutaneous), 13, 15 Credit systems, 48 Fats Cultural classifications of foods animal, 15 body-image foods, 64 calorie content, 15 cultural super-foods, 62, 71 function of, 15 physiological group foods, 64 "naked fats," 38 prestige foods, 63 nutritional value, 15 sympathetic magic foods, 64 vegetable, 15, 38 Culture patterns, 7, 35, 61-70, 97 Field workers and child nutrition, 61, 64, 66-67 and treatment of PCM, 149 and disease, 66, 117 Fish,as information37-38 collectors, 116-117 child rearing practices, 64 flour, 37,139, 143 family structure, 6668, 97 liver oil, 90-91,142, 143 ideas about illness, 66, 68 nutritional value, 49 See also, Cultural classifications of ponds, 49,152 foods preparation, 25, 54

196 Flavorin Infant function, 23 foods, 26-34, 40, 86-93, 124-141, nutritional value, 23 168-169

source., 23 See also, Artificial feeding types., 23 Breast feeding Fluorine Supplemental foods deposits in bones and teeth, 21 Weaning foods functions, 21 growth curves, 74-75 Fluorosia, 22 illnesses, see Infectious diseases Food aid programs, 58-69, 141-145, malnutrition, see Malnutrition, 154-165 nutrient requirements, 171 Food for Peace, see food aid programs treatment of, 145-150, 157, 186-187 Food marketing, 46-48 weight tables, 173 Food preparation, 24,66,73 Infectious diseases and meal pattern, 73 and malnutrition, 72 arrowroot, 27 and sociocultural factors, 9, 117 breadfruit, 26 prevention, 81, 145-147 cassava, 24, 26 Iodine cereals, 27,28 deficiency, see Goiter nutritional aspects, 25 distribution, 21 papaya, 24 functions, 21 plantain, 26 sources, 21 soybean, 31 Iron Food preservation, 46, 151 absorption, 21 Food production, 6, 67, 115, 150-153 deficiency, see Anemia and special rites. 67 dosage in treatment of anemia, 92 blocks to increased food production, functions, 20 65 policies needed, 150-153 needs, 1621, 142 viltage-level, 150-153 sorces, Food protection, 45-46 Food values (calculation of), 38-39 Jaggery, 15,38 Fcte, Jerkey, 46 Fruit, 33-34 definition, 33 Ket ap, 1 nutritional value, 33 Khanam, 23 role in tropical diet, 39, 54 Kidney bean, Fugi 39 Kim clhee, 46 30 Kishkeh, 28,36 Gardens Kwashiorkor, 9, 10 home, 150-151 age incidence, 75 school, 166-167 causation, 76 Ghee, 15 clinical appearance, 76-79 Glycogen, 14 definition, 75-76 Goiter, 21 effects of, 76-79, 117 Gossypol, 32 prevention, 81 Groundnut, 15,140 treatment, 17, 79-81, 142-143 Group dIscussion-demonstrations, 112 Growth curves, 74-75 Lactation failure, 120-121 d1i, 17,23,47 Induced, 120 INCAPARINA, 140,142 Lactating women's diet&, 111, 125 Incentives for farmet, 48 lactos% 15

197 Legumes production (commercial), 139 importance of, 29 toned, 52 major varieties, 29-81 village milk products, 86 preparation, 29 Millet protein content, 16 calcium content, 21 storage qualities, 29 preparation, 28 uses in child nutrition, 29, 129 storage qualities, 28 vitamin content, 30 varieties, 28 Lyaine, 16, 28 Mineral salts, 20, 22 Mis, 17,23,31,47 Malnutrition (in children) Multimixes, 129-131, 168 assessment, 71-73 double mixes, 130 in the preschool child, 73-75 quadrimixes, 131 In school-age children, 93-94, 165 triple mixes, 130-131, 182-183 means of combatting, 115-171 Multipurpose food, 140-141 protein-calorie malnutrition (PCM), 75-81 New food sources, 54 vitamin deficiencies, 86-93 Niacin, 19 Mango, nutritional value, 34 deficiency, see Pellagra Marasmus sources, 19 age incidence, 82 Night blindness, 87 causation, 82 See also,Avitaminosis A clinical appearance, 82-83 Nutrients (basic), definition, 82 needs, 18 prevention, 84, 117 recommended allowances, 13-14 treatment, 83 types, 13,14 Maternal depletion Nutrition education, 80-81,95-114, 166 definition, 36 causes of failure, 98 effect on infant, 36 components, 98-102 Matoke, 62 media, 102 Meal patterns, 66-67, 73 purpose, 96 Meat sites, 103-107,149 as food for young children, 35 target groups, 103-105 nutritioual value, 35 teaching aids, 107-110, 168 preparation, 35 topics, 110-112 production, 35 Nutrition rehabilitation units, 150, 186­ role in diet of tropical people, 34-35 187 Mechanization (agricultural), 43-44 Nuts, 31 Medical facilities, 7 Methionine, 16, 29 Oils (vegetable), 38 Milk Oilseeds, 15,31 acid forms, 129 animal milks, 16, 35-36,40, 133 Papaya breast milk, 20, 35, 119 as food for young children, 34,87 condensed, 36, 134 nutritional value, 18,19,34 commercial milk products, 36 Paw paw, see Papaya composition of various types, 35-37 Peanut, see Groundnut cow's milk, 36, 119,129, 133 Pellagra dried powdered, 36, 133 causation, 19,28 dried skimmed, 36, 80, 120, 134, clinical appearance, 93 143-145 Plankton as food, 54 evaporated, 36, 134 Plantain, formulas, 80, 133-136, 189 as cultural super-food, 62 full-cream powdered, 133 nutritional value, 16

198 Population, Re control, see Child-spacing, as cultural super-food, 62 incr3 se, 54-55 as food forchildren, 17,27 pressue, 8, 55-5 overmliled, 19,27,54,88-69 Poultry preparation, 27 cultural attitudes toward, 53 thiamine content, 27 raising, 53,152 Rickets Preschool child causation, 20,90 malnutrition, 73-93,116-165 clinical appearance, 20, 90 protection programs, 3, 154-165. prevention, 91 186-187 treatment, 90-91 Pronutro, 140 Root crops, 16, 25-27, 63 Protein Amino acid content, 16, 27-28, 34, Sago, 27 35,37 Salt, 22 animal, 16, 34-38, 52-54, 58, 60, 73, School meals, 167-169, 182-185 81, 97, 111, 112, 127, 129, 131 School-age children 182 growth and nutritional assessment, 93, composition, 16 166 function, 17 nutrition education for, 94 leaf, 54 nutritional needs, 93 microbial, 54 See also, Malnutrition need, 14,34 Scurvy, infantile 89 vegetable, 16-17, 25-27, 29-34, 49- age incidence, 52, 54, 58-60, 81, 97, 129-132, causation, 21, 89, 120 89 140-141., 182 clinical appearance, 21, Protein-calorie malnutrition, 73-86, prevention, 89 141-145 treatmem, 89-90 causation, 76,82 Seaweeds, 39 clinical appearance, 76-79, 82-83, Seeds 84 new varieties, 45 definition, 75 selection, 151 mild.mo4erate, 84-86,141-145 Sodium, 22 prevention, 81, 84, 86, 111, 150-169 Soil, 45 129-130 treatment, 79-81, 83-84, 86, 149- Soybean, 16, 31, 52, 58, 150 preparations, 140 husbandry Protein gap, 17 Stock breeding, see Animal Protection Protein mixtures Storage, see Food see Fat animal-vegetable protein mixtures, SuLcutaneous fat, 140-141 Sucrose, 15 cereal legume mixtures, 17, 29-31, Sugar 38 130-131 nutritional value, 15, multixes, 130-131 Super-foods, see Cultural clasifications vewen".le protein mixtures, 17, 29- of foods 33,130,140 Supplemental foods Protein supplements, 112,125, 129-132, cereal-legume mixtures, see Protein 141-145 mixtures commercially processed foods, 38, Red palm oil, 88 138-141 Restrictive dietary practices, 64-65 introduction of, 112, 124-127, 157 See alo Cultural patterns recipes, 176-181 Riboflavin, 19 See also Protein supplements deficiency, 19,93 See also Vitamin supplements murees, 16,19 'See also Weaning foods

199 Supplementary feeding programs 141- in skimmed milk, 86,154 140, 155 sources, 1,, 18,142 Surveys Vitamin B complm:, 17,19, eosectonal, 116-117 Vitamin C, 15 longitudinal, 117 deficiency, sew Scurvy, infantile Sweetpotato, 26 dosage for treatment of infantile Saurvy, 89 Tare, 26 functions, 20 Teaching aids (in nutrition education) in breast milk, 89 audiovisual aids, 107-108 in cow's milk, 137,158 auditory aids, 110 sources, 16,19-20 visual aids, 108-110 Vitamin D, 21 Temp&h, 24,31,140 deficiency, see Rickets Thiamine, 18 dosage for treatment of rickets, 90-91 deficiency, see Beriberi functions, 20 dosage for treatment of infantile ben. recommended daily allowance, 20, ben, 8849 24,90-91 functioiq 19 sources, 15, 20,142 in breast milk, 88 Vitamin supplements, 19,142-143 in relation to carbohydrate calories, 19 Water needs, 14, 19 bodily requirements for, 22 sources, 19, 88-89, 142 calcium content, 21 synthetic, 54 danger@ of, 22 Three-plank protein bridge, 131 Weaning foods, see also Protein supple. Thyroxine, 21 ments and supplemental foods Tiki-tiki, 88-89, 142 definition, 125 (fn.) Tortillas,17, 28, 132 preparation, 129-132 Trytophan, 28 quantiies, 131 Tubers, 16. recipes, 176-181 types, 36,87, 112, 125-132 UNICEF, 139, 143, 145, 191 introduction of, 124-128 Urbanization and nutrition, 5-6, 57-58 Weaning practices, 72-75,125-126 Weight asiessment Vegetable protein mixtures, see Protein methods, 84-86,93, 156 mixtures problems involved, 84-85 Vegetables, 32-33 tables, 173 dark green leafy, 16, 18,33, 129-130 Wheat nutritional value, 32-33 as cultural super-food, 62 role in tropical diet, 54 preparation, 28 Visual aids, 108-110 World Food Program, see Food aid pro­ Vitamins, 17 grams Vitamin A, 13, 18-19 availability in developing countries, Yams, 26 1 Yeast, 54 decdency, see Avitaminosls A Yogurt, 36 fucltilons, 18-19 Young Child Clinics, 155-165, 186-187, irfant requirements, 171 191-192

200 GOENI MKIN OFFuICErn:19es 0-30s-112