WORLD HEALTH REGIONAL OFFICE FOR

ORGANIZATION SOUTH EAST ASIA

Fourteenth Session

Provisional Agenda item 8

IKWRITION PROBLEMS TN THE SOUTH-EAST ASIA REGION

Working Faper No.1

for the Technical Discussions Introduction

Nslnutrition and nutritional deficiency diseases are canrmon throughout South-East Asia, although their intensity my vary from country to country and even from one local area to another. Clinically evident cases of malnutrition, however, represent only a fraction of their real prevalence. Cases without frank manifestation, but of impairment of vital functions, such as of gro~rti~and development of children, resistance to infectious diseases, physical and mental fitness, longevity, etc., are often missed, with the result that the magnitude of the problem is hardly realized. Even the absence of gross malnutri- tion is no guarantee of nutritional safety, and only properly conducted long- tern studies can assist in determining the role played by minor qualitative and quantitative nutritional deficiencies in reducing the biological potential of = population.

Numerous nutritional and dietary surveys have been carried out and have indicated that in most instances the wnifestations of malnutri- tion in this regLon are more or less similar in the various countries and can be attributed to the same determinants, viz. inadequate food production, low purchasing power and defective dietary habits of the population.

Protein deficiency and vitamin A deficiency represent the most common nutritional disorders. The prevalence of iron deficiency anaemia is high in most of the countries of the Region, as is calcium deficiency. Thiamine deficiency and the consequent prevalence of beriberi differ as between countries and areas; riboflavin deficiency often occurs but is not very well defined; pellagra is found in some areas, and endemic goitre is an important public health problem in certain localities. Rickets, vitamin C deficiency and scurvy are of minor importance in the South- East Asia Region, although cases have been reported. Lathyrism, endemic dropsy and fluorosis occur substantially in a Tew restricted ilrfas..

1. Proteins

Protein t'eficiency is one of the major nutritional disorders in South-East Asia. It most commonly affects infants and small children. Conditions such as nutritional o,dz~~-.andkwashiorkor are canrmon in India and Indonesia; they are less often seen in Burma, Thailand and Ceylon, although clinical records suggest they are not rare. Usually protein deficiency is combined with the deficiency of other essential nutrients, thus aggravating the condition of the child. 111 a recent survey in South India on 4 536 children under five years of age, extreme retardation of growth has been demonstrated, not so severe in the early period of infancy, but more and more apparent as the child is weaned gradually to mixed feeding. Clinical examination showed that kwashiorkor was present among children in all the areas surveyed, and there occurred at the same time symptoms of other nutritional disorders such as vitamin A and riboflavin deficiency. Again, haemoglobin and Lotal serum proteins in the children of the area surveyed were lower than is normal in healthy children in well-to-do comnities. Although the prevalence of kwashorkor observed in this sample did not exceed 1$, it could be concluded, from the size of the population, that the probable number of frank cases of kwashiorkor in the area might exceed 120 000 at any given time. Among the contributory factors economic poverty was minly stressed, but dietary habits and social customs, infections and infestations also played a role.

In addition to clinicalmnifestations in the form of nutritional oedema or kwashiorkor, retardation of growth is an important feature of protein deficiency. Available data indicate that this is prevalent throughout the Region, in both infants and school-children, Infants of six months and over are the more severely affected.

Darbyl s and Mclaren' s report on lndonesial indicates that protein deficiency or protein plus calorie deficiency is responsible for growth retardation of children after six months of age. It is significant that the small mrasmic child is more often seen in Indonesia than in any other part of the world, even in Africa and Central America, where protein deflciency is also endemic; this my reflect a more severe inadequacy of total calories. The probable reason is that the mother does not recognize the importance of appropriate food for babies or considers the particular food as unsuitable or hermf'ul to the child.

Similar, although less serious, is the situation in Bum, where, according to Bengoa (unpublished WHO report), calorie protein mlnutri- tion '%eo Myet" is more common than kwashiorkor alone.

DBta on the growth and development of school-children are available for most of the countries in this region, and the general conclusion is that poor diet, particularly lack of protein, is responsible for the retarded growth of children. It is not possiblc to dcfine precisely the magnitude of this problem, as information on '!normalt' growth and developnent is limited,and consequently the findings cannot be evaluated in relation to a standard. However, comparisons between the growth and development of children of var$ous socio-econanic groups in the same countries indicate growth retardation of the cnildren of the poorer econdc groups.

In Ceylon, according to a survey done by Clcments and ~ocobo~~tha available records on growth of pre-school and school-children in the area surveyed suggest that the heights and weights of these children correspondedto the heights and weights of well-developed children two to three years,younger based on the height-weight tables recently prepared in Ceylon. The conclusion was that at least 20% of the children examined require additional calories and proteins.

In Thailand the findings are similar. School-children from north hast and central Thailand and non-selected groups of school-children in Bangkok were about one to two years behind the growth rate of the boys frm the higher economic strata of Bangkok. htrition in Indonesia: Assignment Report on Assistance to Institute of Nutrition, Djakarta, by W.J. Darby and D.S. Mc Laren - SEA/NU~/~ 2~eporton Nutrition in Ceylon, by F.W. Chnts and Mrs D.L. Bocobo - ~m/57/12/9206 2. Vitamin A

Vitamin A deficiency is connnon in all countries of South East Asia, but particularly so in India, Indonesia and Burm3. In Indonesia it represents a serious problem in infancy and is very often combined with protein deficiency; xerophthalmia and keratomalacia, which are the clinical signs of lack of vltomin A, are comon and nrt: Pmng the moot important causes of blindness in that country. In India, the clinical signs of vltamln A deficiency, including night blindness, are also comn and are found among school-children in several States, tls prevalence var- between 5% and 12%. A study in South India or. children under five years of age showed that avitaminosis A predominated among thc deficiency signs in that area.

In Burma two WHO nutrition experts, Raahakrishna ~aoland ~ostmtls~, found a high prevalence of conjunctival xerosis (21%) and Bitot spots in about 146, which indicate that vitamin A deficiency was quite comn among the school-children examined.

Findings in Ceylon were similar: ocular symptoms of vitamin A deficiency are comon in pre-school children.

In Thailand, although there are areas where the consumption of leafy vegetables is higher end no clinical signs of vitamin A deficiency were found (~amalin~aswami3)there are other areas, c.g. Dusit District, where the incidence of ocular symptoms of vitamin A deficiency were as high as 9.546 for school-children. Blindness due to a lack of vitamin A also occurs.

In most of the countries of South East Asia, rice represents the main staple food of the population. Thus thiamine deficiency is liable to occur; in fact, South East Asia and the "Far. East" were for long known as areas where beriberi occurred endemically. Current records,harever, on the prevalence of beriberi in the South East Asia Region are not complete. According to Earby's and McLaren's report, refcrrcd to above, beriberi has practically disappecscd from Indones a since the Second World War, amd in India, according to JJr fitward although rice is consuned by more than half the total population, beriberi is endemic only in certain restricted areas, mostly in WasStzte, and in a few circum- scribed areas in Bengal and Assam.

The situation is, harever, different in Burma. The number of beri- beri cases has seemed to be increasing since the Second World War, because of the introduction of small mills for polishing rice. Gross symptoms of thiamine deficiency, e.g. cardiac manifestations, peripheral neuritis and ataxic gait, are often seen in expectant and nursing mthers and, from time to time, in patients attending polyclinics. Complaints caused by minor thiamine deficiency, such as nervousness, constipation, loss of appetite, indigestion, fatigue, palpitation of the heart and paraesthcsia of the legs, are frequently met wlth.

'Nutrition Survey in Bum Report, by M.V. Radhakrishna Rao - SEA-52-347 2~inalReport on Nutrition in B-, by S. Postmus - SEA/NU~/~ 3~umm3eryReport on Nutritional Situation in Thailand, by V. R-lingaswamC - .SEA/Nut/2 Rev.1 4"Nutrition in Indla", by V.N. Patwardhan, published by the Indian Journal of Mfdical Sciences, Bombay, 1952 InfOrDt3ti0II on the prevalence of beriberi in Ceylon is scanty.

In Thailand, beriberi seems to occur quite often. Reports of the Vital Statistics Division attribute 1 500 - 2 000 deaths to beriberi each year. The infantile ber;.beri death rate ranges between 1.8 2nd 21.7, and among the total population the incidence of beribcri was found to avernge between 1 and 4$. The highest reported prevalence in any one area was l2$. A recent survey covering 2 355 pregnant women revealed that approxim;ltcly 1@ had beriberi. This percentage would be even higher in nursing mothers, since by custom the nursing mother receives a diet of rice and salt only, according to statements of most of the clinics recently visited in different parts of Thailand.

4. Riboflavin

Riboflavin deficiency is also a comon vitamin deficiency in this region,judging from the prevalence of such clinical symptoms as engular stomatitis adnasolabial seborrhoa. These clinical signs of ariboflavinosis have been regularly found mngst school-children.

In India the prevalence of angular stomatitis in different States varies between 2% (Uttar ~rdesh)to 18% (Bihar). in Burma it goes up to 24$, in Thailand, to 23%; in Ceylon the rate is much lower, about 2%. Although clinical signs of riboflavin deficiency are less dramatic than acutc cases of keratomalacia or beriberi, for e::ample, the adequate supply of riboflavin to the human body is of paramount importance for many vital functions, including physical grarth.

5. Anaemias Nutritional anaemias seem to be very comon in all countries of South East Asia. Hospital records and field investigations tend to support the vlew that iron deficiency anaemia is the moot connuon. In India, nutritional surveys in school-children indicate that haemglobin levels are, generally, low. Severe eascs of anaemia occur in pregnancy. According to thc reports from the Institute of Obstetrics and Gynaecology in Madras, anccmia is the most common complication in pregnancy, Bnd only 346 of the pregnant women observed in that clinic had haemoglobin in tho amount of 9.5 gz$ or highcrino less then 16 of .ll r~t~rrwldeaths has been attributed to anaemias. Other obstetric clinics in India record similar findings, e.g.,in Luchar the prcvalcncc of nnaemias in pregnant women is as high as 80&.

In one study on a group of school-children in Burma it was shown that the average haemoglobin level was below 10 gr$; in another, that onaemia was present in 38% of the children exmined. Anaemia in pregnancy is also common in Burma. According to a recent study by the Nutrition Institute in Rangoon, out of a sample of 500 prcgpant und nursing women, 60.4% suffered from anaemia. In Thailand, the haemglobin determinetion in school-children has shown that values below 12 gr$ are comn. In a study of a sample of .adult population the averagc haemglobin level was only 10 gr$.

No accurate figures on the prevalence of iron deficiency anaemias in Indonesia are available, but according to m earlier report of ~ur~essland to the above-mentioned reports of Dzsby md McLaren, anaemia , is quite ~idespread~

In Ceylon anaemia in pregnancy is common. Most of the pregnant wonrn for whom figures are o.v.voilable have hacmoglobin values between 35 - 5@. 6. Goitre

Iodine deficiency, with the consequent zppeuance of endemic goitre, represents a public health problem in India,pri1mrily in the Himalayan and sub-Himalayan regions. In thc heavily affcted areas the prevalence of goitre is as high as 86,but there are large areas in the Himalayan belt where the affected persons exceed 36of the total population.

The seme high occurrence of goitre ks bccn reported from northern Thailand. For instance, in some areas of Chiengmi Province, about 50$ of the population are affected. In other parts of Thailand the prevalence is less, i.e.,about l5$ in Udorn Province and 2 lower percentage still in the south.

Northern Bm, too, has a higher prevnlcncc of goitre than the rest of the country, but rcliable data me not available.

There is little information on the prevalence of goitre In Indonesia adCeylon. There is evidence of a high incidence of goitre in the Pamn District of Afghanistan.

7. Other Nutritional Deficiencies Other nutritional deficiencies in this region, as mentioned earlier, are pellrgra, scurvy and rickets - indications of zn inadequate supply of nicotinic acid, vitmin C,e.~d vitanin D :.nd c .lcium respectively.Hmver, their appearance is limitcd to certain areas only.

In India, pellagra occurs sporadically throughout the country, more particularly in parts of Wcs State. Scurvy seems to be rare, ~vcnthough the intake oi' vitamin C mong the 2oorer Indian familles is not high. It is a general belief that rickets occurs rarely in India, perhaps because of the degrec of sunlight throughout thc year. Its occurrenci:, however, has bccn reported from timc to time from several parts of India, in one particular region, thc Knngra Valley, where the reported incidence is as high as 5@, it is c public health problem.

l~eporton Indonesia, by R.C. Burgess - SEA/NU~/~ Mild signs of rickets (spat rickets) have been reported from Burmn - up to 28.9% in school-children, which is quitc c high figure.

Occasional mild cases of rickets are also found in Ceylon.

8. Conclusions

The above information, although not based on studies of representative samples of the population in different countries, gives evidence that protein malnutrition and vitmin/mineral deficiency diseascs play a prc- dominant role in the nutritional patholorn of South East Asia.

The imnrdiate cause of such conditions - viz, lack of proteins, particularly proteins of animal origin, accompanied by deficient intake of vitamin A, thiamine, riboflavin, iron and calcium - is well known. Unfortunately, awareness of the ccusal factors is just a starting point in the long and. complicatcd road to a solutioi~. !Phe foodstuffs rich in protective nutrients are not produced in adequcte 2mounts in this region, and where they are produced, their cost is beyond the purchasing parer of the average member of the population. Therc is an urgent need for providing more food, particularly protective food, in sufficient ~uoounts for the whole population at prices within rcoch of the lower income groups.

There is no doubt that bad dietary habits also play a role in nutritional pathology in these countries, as evidenced by the appearance of beriberi in nursing mothers in Thail'uld; uttcntion should be given to thc nutritional education of the population. Poor sanitary conditions, especially heavy intcstincl pamsitism, create cm additional negative factor. Furthermore, thc special needs of the more vulnerable groups such as pregnant and. nursing mothers, infants and toddlers, need direct and special attention. In these groups it not zlways be possible to supply enough protective foods from local sources, and recourse my have to be had to obtaining them elsewhere. Skim milk is uscful for such a purpose but is available only in limited quantities; other sources of protein must be sought nrld provided. The possibility of introducing morc protein-rich foods of vegetable origin, marketable ?t low cost, should receive serious consideration.

.Such efforts will be successful only if m-de on a national scale and supportcd by a sound food production policy and related active progrcmhes. Nutritionists md food technologists can contribute substantially to this solution, but the participation of agriculturists, economists and politicians is equally essential.