David L. Pelletier

Epidemiologic evidence for a potentiating effect of malnutrition on child mortality.

OBJECTIVES Despite broad agreement that severe malnutrition contributes to child mortality in developing countries and that malnutrition has a physiologically synergistic relationship with morbidity, evidence of an epidemiologic synergism has been lacking. Also, the literature provides conflicting evidence concerning the existence of elevated mortality among children with mild to moderate malnutrition. A review of published population-based studies of anthropometry-mortality relationships was undertaken to clarify these relationships. METHODS Six studies with the relevant data were reanalyzed to test for synergism and elevated mortality in mild to moderate malnutrition. RESULTS The results demonstrate that mortality increases exponentially with declining weight for age. This effect is consistent across studies and there is no apparent threshold effect on mortality. The primary difference across studies is in baseline levels of mortality, which determine the quantitative impact of malnutrition on mortality in a population. CONCLUSIONS These results indicate that mild to moderate malnutrition is associated with elevated mortality and that there is an epidemiologic synergism between malnutrition and morbidity. This previously undemonstrated finding has significant implications for child survival policies and research.

Maternal and child undernutrition: effective action at national level

80% of the worlds undernourished children live in just 20 countries. Intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal (MDG) and greatly increase the chances of achieving goals for child and maternal mortality (MDGs 4 and 5). Despite isolated successes in specific countries or for interventions--eg, iodised salt and vitamin A supplementation--most countries with high rates of undernutrition are failing to reach undernourished mothers and children with effective interventions supported by appropriate policies. This paper reports on an assessment of actions addressing undernutrition in the countries with the highest burden of undernutrition, drawing on systematic reviews and best-practice reports. Seven key challenges for addressing undernutrition at national level are defined and reported on: getting nutrition on the list of priorities, and keeping it there; doing the right things; not doing the wrong things; acting at scale; reaching those in need; data-based decisionmaking; and building strategic and operational capacity. Interventions with proven effectiveness that are selected by countries should be rapidly implemented at scale. The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its adverse effects. Programme efforts, as well as monitoring and assessment, should focus on this segment of the continuum of care. Nutrition resources should not be used to support actions unlikely to be effective in the context of country or local realities. Nutrition resources should not be used to support actions that have not been proven to have a direct effect on undernutrition, such as stand-alone growth monitoring or school feeding programmes. In addition to health and nutrition interventions, economic and social policies addressing poverty, trade, and agriculture that have been associated with rapid improvements in nutritional status should be implemented. There is a reservoir of important experience and expertise in individual countries about how to build commitment, develop and monitor nutrition programmes, move toward acting at scale, reform or phase-out ineffective programmes, and other challenges. This resource needs to be formalised, shared, and used as the basis for setting priorities in problem-solving research for nutrition.

The Relationship Between Child Anthropometry and Mortality in Developing Countries: Implications for Policy, Programs and Future Research

The prevention of child mortality is a commonly stated health goal in developing countries and the target of much international assistance in the health sector. Over the past decade the primary strategy for accelerating the reduction in child mortality has been the dissemination of simple, low-cost technologies, such as immunization, oral rehydration therapy and antibiotics, that target specific diseases (Huffmann and Steel 1994). This is done despite the knowledge that malnutrition and disease have a synergistic relationship (Scrimshaw et al. 1968) and that the optimal strategy may involve a combination of health and nutrition interventions. In the 1970s, for instance, it was estimated that malnutrition (notably protein-energy malnutrition--PEM) was the underlying or contributing cause of death for roughly half of all deaths to children aged 1-4 years in several Latin American countries (Puffer and Serrano 1973). Apart from this early study, however, there has been little effort to quantify the contribution of malnutrition to child mortality in other regions of the world in ways which are meaningful to policy. This paper reviews the results of 28 community-based, prospective studies, in 12 Asian and Sub-Saharan African countries, which examined the relationship between anthropometric indicators of malnutrition and child mortality. One purpose is to estimate the contribution of malnutrition to child mortality--distinguishing the effects of severe malnutrition from mild-to-moderate malnutrition--and to examine a number of related issues relevant to policy, programs and research in this area. The accumulated results are consistent in showing that the risk of mortality is inversely related to anthropometric indicators of nutritional status and that there is elevated risk even in the mild-to-moderate range of malnutrition. This latter result contradicts the findings from an earlier, landmark study which suggested that mild-to-moderate malnutrition was not associated with an increased risk of mortality (Chen et al. 1980). The present results indicate that somewhere between 20% and 75% of child deaths are statistically attributable to anthropometric deficits, with most estimates falling in the range 25-50%. When taking account of the relative proportions of severe versus mild-to-moderate malnutrition in the population, the results show further than 16-80% of all nutrition-related deaths are associated with mild-to-moderate malnutrition rather than severe malnutrition. In most studies 46-80% of all nutrition-related deaths are in the mild-to-moderate category.(ABSTRACT TRUNCATED AT 400 WORDS)

A Methodology for Estimating the Contribution of Malnutrition to Child Mortality in Developing Countries

According to conventional methods of classifying cause of death, approximately 70% of child deaths (0-4 y) worldwide are due to a small number of priority infectious diseases which, in turn, receive the vast majority of donor and national resources in the health sector. Despite the long-recognized synergism between malnutrition and infection in the causation of child mortality, malnutrition does not appear as a major cause of death in health statistics from developing countries. Part of the reason for this has been the difficulty of estimating the percent of deaths due to malnutrition, because the conventional methods of classifying cause of death do not recognize the potentiating effect of malnutrition on the disease. The purpose of this paper is to develop and test a simple methodology to estimate the percent of child deaths in a given country or community that is due to malnutritions potentiating effects on prevailing infectious diseases. The cornerstone of the methodology is knowledge of the strength of the association between malnutrition and mortality in developing countries, as measured in eight prospective studies. These studies reveal remarkable consistency in relative risk across different grades of malnutrition. The mean and SE of relative risk for severe malnutrition is 8.4 +/- 2.1, for moderate malnutrition it is 4.6 +/- 0.9, and for mild malnutrition it is 2.5 +/- 0.3. When applied to survey data from Ethiopia, Malawi, Guatemala and India for illustrative purposes, this methodology indicates that 42-57% of all child deaths in these samples (6-59 mo) are due to malnutritions potentiating effects on infectious disease, of which 76-89% is attributable to mild-to-moderate malnutrition. This methodology is recommended for use in a variety of policy and planning applications.

Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative

Undernutrition is the single largest contributor to the global burden of disease and can be addressed through a number of highly efficacious interventions. Undernutrition generally has not received commensurate attention in policy agendas at global and national levels, however, and implementing these efficacious interventions at a national scale has proven difficult. This paper reports on the findings from studies in Bangladesh, Bolivia, Guatemala, Peru and Vietnam which sought to identify the challenges in the policy process and ways to overcome them, notably with respect to commitment, agenda setting, policy formulation and implementation. Data were collected through participant observation, documents and interviews. Data collection, analysis and synthesis were guided by published conceptual frameworks for understanding malnutrition, commitment, agenda setting and implementation capacities. The experiences in these countries provide several insights for future efforts: (a) high-level political attention to nutrition can be generated in a number of ways, but the generation of political commitment and system commitment requires sustained efforts from policy entrepreneurs and champions; (b) mid-level actors from ministries and external partners had great difficulty translating political windows of opportunity for nutrition into concrete operational plans, due to capacity constraints, differing professional views of undernutrition and disagreements over interventions, ownership, roles and responsibilities; and (c) the pace and quality of implementation was severely constrained in most cases by weaknesses in human and organizational capacities from national to frontline levels. These findings deepen our understanding of the factors that can influence commitment, agenda setting, policy formulation and implementation. They also confirm and extend upon the growing recognition that the heavy investment to identify efficacious nutrition interventions is unlikely to reduce the burden of undernutrition unless or until these systemic capacity constraints are addressed, with an emphasis initially on strategic and management capacities.

The Nutrition Policy Process: The Role of Strategic Capacity in Advancing National Nutrition Agendas:

Undernutrition is the single largest contributor to the burden of disease in developing countries and has documented effects on social and economic development, yet progress in reducing undernutrition remains slow. This paper identifies the range of factors that have influenced the nutrition agenda in developing countries, in order to inform the implementation of three major global initiatives related to undernutrition. Data sources include interviews with nutrition practitioners at the national and international level, written accounts from six African countries, and observations of the policy process in five countries. Data were thematically coded to identify recurrent factors that facilitated or inhibited progress in addressing undernutrition. The data reveal the following: First, societal conditions and catalytic events pose a variety of challenges and opportunities to enlarge and shape the nutrition agenda. Some countries have been successful in using such opportunities, while others have been less successful and there have been some unintended consequences. Second, disagreements over interventions and strategies are an almost universal feature of the nutrition policy process, occur primarily among mid-level actors rather than among politicians or senior administrators, and are primarily the product of structural factors such as organizational mandates, interests, and differences in professional perspectives. Third, many of these structural factors can be molded, aligned, and/or circumvented through strategic action on the part of the mid-level actors to strengthen movement on the nutrition agenda. This evidence that strategic action can redirect and/or overcome the effects of structural factors has important implications for future efforts to advance the nutrition agenda.

The food-first bias and nutrition policy: lessons from Ethiopia

This paper presents results of the 1992 National Rural Nutrition Survey in Ethiopia that challenge the appropriateness of the centrality of food security as a dominant element of nutrition policy and planning. While the focus of this work is on protein-energy malnutrition in Ethiopia, the implications extend to other countries, and some of the same principles apply to micronutrient deficiencies. After a description of the design of the Ethiopian national nutrition surveillance system, results are presented for rural Ethiopia in terms of 1) the prevalence of stunting, wasting, and underweight by age; 2) changes in prevalence of stunting and underweight between February 1983 and March 1992; 3) prevalence of stunting and wasting by region; 4) distribution of stunted children by economic group and size of cultivated land; 5) prevalence of stunting and wasting in selected household economic groups by age group; 6) prevalence of stunting and wasting among children 24-59 months of age by size of cultivated area among cereal growers; 7) height-for-age z-scores across regions and cultivated areas; 8) weight-for-age z-scores; and 9) prevalence of stunting and medial age of introducing complementary foods. The most relevant findings of the study are that 1) stunting is far more common than wasting; 2) chronic malnutrition occurs at high rates among infants aged 6-11 months despite a typical rate of low birth rate, and the presence of stunting does not increase markedly after 24 months; 3) high rates of chronic malnutrition are ubiquitous, with some of the highest in food surplus areas; 4) the prevalence of chronic malnutrition has increased since 1983; 5) household food security is not uniformly associated with child nutritional status; and 6) cultivated area and child nutritional status are not significantly associated among children 6-23 months old.

Values, public policy, and community food security

Values and beliefs regarding communityfood security were investigated among participants in2–3 day participatory planning events related to thelocal food system in six rural counties from oneregion of upstate New York. The results of Qmethodology reveal three distinct viewpoints: a) theSocial Justice viewpoint, which is primarily concernedwith hunger and the potential harm caused by welfarereform; b) the Pragmatist viewpoint, which values thecontributions agriculture makes to local communitiesand is not concerned about environmental or socialexternalities of the dominant food system; and c) theVisionary viewpoint, which also values agriculture inthe community but is very concerned aboutenvironmental and social externalities. After theplanning events, the Pragmatist viewpoint experiencedan 88% increase in members and the other twoviewpoints became less salient. Various categories ofprofessionals (e.g., nutrition, social welfare,agriculture, environmental) tend to express theviewpoints associated with their professions and/orthe client groups they serve. Despite thesedifferences among participants, the planning events inall six counties resulted in a wide range of goals andobjectives centered on a theme of re-localizing avariety of food system activities. These results arediscussed in relation to the desirability ofdeveloping an explicit philosophy of food andagriculture and the ideal processes required to doso.

Community food security: Salience and participation at community level

Community food security (CFS) is an incipient movement based on the re-localization of many food system activities in response to values concerning the social, health, economic, and environmental consequences of the globalizing food system. This study examines the salience of these values based on the action agendas and accomplishments emerging from community planning events in six rural counties of New York, and the nature and type of participation and local support. The study finds a high level of agreement between CFS values as articulated by national leaders in this incipient movement and the action agendas. Further evidence of the salience of these themes is seen in the levels and types of activities and accomplishments taking place 8--12 months after the planning events. However, these follow-through activities appear to have been impeded by a variety of government regulations, uneven levels of support from community organizations and agencies, and a policy environment of fiscal austerity, narrow outcome-oriented accountability, and allocation of agency staff toward special-purpose grants and contracts. Many of these constraints are likely to exist in other communities and are beyond the scope of what community volunteers and practitioners can be expected to address on their own.

Trends in Body Mass Index in Developing Countries

Iron-deficiency anaemia is highly prevalent among women of reproductive age in South-East Asia. In this study, the haemoglobin levels of 2,813 women living in inner-city Mumbai, India, were measured as part of a reproductive health study. Women were recruited over a two-year period at three health facilities providing pregnancy and post-partum services. Five reproductive groups were studied, and the haemoglobin values differed significantly among the groups. Infertile women and women without living children had the highest haemoglobin values (p <.01). However, a least-squares regression analysis of factors affecting haemoglobin status accounted for only 16% of the variability observed. The study concludes that nutritional interventions that focus on reducing fertility or iron supplementation during pregnancy are beneficial, but many women remain iron deficient. Action is needed to improve nutritional status before pregnancy—a policy that is feasible given the current interest in adolescent sexual and reproductive health programmes.The purpose of this study was to examine the extent to which adult body mass index (BMI) has changed in developing countries over the past several decades. The analysis is based on a compilation and analysis of mean BMI in 1,432 published samples from developing countries measured between 1957 and 1994. A hierarchical multiple-regression model is applied to these data, controlling for country and study as random covariates and modelling age, sex, socio-economic status, and year as fixed effects. The results reveal a statistically significant increase in mean BMI between 1957 and 1994 in all major regions of the developing world. The size of the increase was 1.4 kg/m2 over the 37-year period, with a 95% confidence interval of 0.4 to 2.4 kg/m2. Mean BMI appears to have increased in all major regions of the developing world, although the size of the increase varies across regions. Using assumptions about the statistical distribution of BMI within populations and cut-off points recommended by the World Health...