Title Page
 Table of Contents
 List of Tables
 List of Figures
 The human scene
 The human diet
 Improving food supplies and population...
 Custom and food
 Malnutrition in childhood
 Nutrition education
 Combating malnutrition
 Appendix I. Recommended daily dietary...
 Appendix II. Information required...
 Appendix III. Weight for age...
 Appendix IV. A planned demonstration...
 Appendix V. Specimen recipes for...
 Appendix VI. Approximate quantities...
 Appendix VII. Packed meals for...
 Appendix VIII. Nutrition rehabilitation...
 Appendix IX. Home-feeding kit
 Appendix X. Preparation of artificial...
 Appendix XI. The Mulanda proje...

Title: Child nutrition in developing countries
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00087173/00001
 Material Information
Title: Child nutrition in developing countries a handbook for fieldworkers
Physical Description: v, 200 p. : illus. ; 24 cm.
Language: English
Creator: Jelliffe, Derrick Brian
United States -- Office of the War on Hunger
Publisher: U.S. Office of the the War on Hunger for sale by the Supt. of Docs., U.S. Govt. Print. Off.
Place of Publication: Washington
Publication Date: 1969
Edition: Rev.
Subject: Children -- Nutrition   ( lcsh )
Children -- Nutrition -- Developing countries   ( lcsh )
Child Nutrition Physiology   ( mesh )
Developing Countries   ( mesh )
Tropical Climate   ( mesh )
Genre: non-fiction   ( marcgt )
Statement of Responsibility: by Derrick B. Jelliffe.
 Record Information
Bibliographic ID: UF00087173
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 00051412
lccn - 73604655

Table of Contents
        Cover 1
        Cover 2
    Title Page
        Page i
        Page ii
    Table of Contents
        Page iii
    List of Tables
        Page iv
    List of Figures
        Page iv
        Page v
        Page vi
        Page 1
        Page 2
        Page 3
        Page 4
    The human scene
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
    The human diet
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
        Page 25
        Page 26
        Page 27
        Page 28
        Page 29
        Page 30
        Page 31
        Page 32
        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
        Page 38
        Page 39
        Page 40
        Page 41
        Page 42
    Improving food supplies and population pressure
        Page 43
        Page 44
        Page 45
        Page 46
        Page 47
        Page 48
        Page 49
        Page 50
        Page 51
        Page 52
        Page 53
        Page 54
        Page 55
        Page 56
        Page 57
        Page 58
        Page 59
        Page 60
    Custom and food
        Page 61
        Page 62
        Page 63
        Page 64
        Page 65
        Page 66
        Page 67
        Page 68
        Page 69
        Page 70
    Malnutrition in childhood
        Page 71
        Page 72
        Page 73
        Page 74
        Page 75
        Page 76
        Page 77
        Page 78
        Page 79
        Page 80
        Page 81
        Page 82
        Page 83
        Page 84
        Page 85
        Page 86
        Page 87
        Page 88
        Page 89
        Page 90
        Page 91
        Page 92
        Page 93
        Page 94
    Nutrition education
        Page 95
        Page 96
        Page 97
        Page 98
        Page 99
        Page 100
        Page 101
        Page 102
        Page 103
        Page 104
        Page 105
        Page 106
        Page 107
        Page 108
        Page 109
        Page 110
        Page 111
        Page 112
        Page 113
        Page 114
    Combating malnutrition
        Page 115
        Page 116
        Page 117
        Page 118
        Page 119
        Page 120
        Page 121
        Page 122
        Page 123
        Page 124
        Page 125
        Page 126
        Page 127
        Page 128
        Page 129
        Page 130
        Page 131
        Page 132
        Page 133
        Page 134
        Page 135
        Page 136
        Page 137
        Page 138
        Page 139
        Page 140
        Page 141
        Page 142
        Page 143
        Page 144
        Page 145
        Page 146
        Page 147
        Page 148
        Page 149
        Page 150
        Page 151
        Page 152
        Page 153
        Page 154
        Page 155
        Page 156
        Page 157
        Page 158
        Page 159
        Page 160
        Page 161
        Page 162
        Page 163
        Page 164
        Page 165
        Page 166
        Page 167
        Page 168
        Page 169
        Page 170
    Appendix I. Recommended daily dietary allowances
        Page 171
    Appendix II. Information required concerning feeding young children
        Page 172
    Appendix III. Weight for age table
        Page 173
    Appendix IV. A planned demonstration for use in East Africa
        Page 174
        Page 175
    Appendix V. Specimen recipes for weaning foods
        Page 176
        Page 177
        Page 178
        Page 179
        Page 180
        Page 181
    Appendix VI. Approximate quantities for school meals
        Page 182
        Page 183
    Appendix VII. Packed meals for school children
        Page 184
        Page 185
    Appendix VIII. Nutrition rehabilitation unit
        Page 186
        Page 187
    Appendix IX. Home-feeding kit
        Page 188
    Appendix X. Preparation of artificial bottle feeds in the village home
        Page 189
        Page 190
    Appendix XI. The Mulanda project
        Page 191
        Page 192
        Page 193
        Page 194
        Page 195
        Page 196
        Page 197
        Page 198
        Page 199
        Page 200
Full Text




A Handbook for Fiei


Director, Caribbean Food & N
University of the West Inc

Visiting Professor of Tropi
Tulane Medical School, IS

Formerly Professor of Pediatrics
Makerere Medical School, Ka

he writing and publication of this handboo

Office of War on Hun,
Agency for International De
U.S. Department of S1
Washington, D.C.

For sale by the Superintendent of Documents, U.S. Go
Washington, D.C. 20402 Price $2
Stock Number 044-001-00029-
Catalog Number S 18.8:C43




.P., F.A.P.H.A., F.A.A.P.

itrition Institute
ies, Jamaica

cal Medicine
ew Orleans

and Child Health
npala, Uganda.

k has been financed by the


'ernment Printing Office


The author is most 1
and guidance:

Acknowledgment is m
Mr. William Seruma
Makerere Medical S
and to the following

The Food and Agrict
The World Health 01
To UNICEF for Figs
To the Kenya Inform
To Dr. I. Schneidema
To Miss P. Pollard

First Printing 1968-1
velopment, U.S. Del
Service Publication I
Revised 1969-As a I
Agency for Internat
French Edition 1969-
T-1-;-. 1 AM;. CPn


Fateful to the following colleagues for ad


ode to:
iga of the Department of Medical Illustratj
school, Kampala, for drawing the illustral
; for the kind use of photographs.

lture Organization for Figs. 2 and 3
organization for Figs. 6 and 7
.10 and 11
.ation Service for Fig. 4
in for Figs. 13 and 14

Financed by the Agency for International
)artment of State, and issued as Public H4
N;o. 1822
publication of the Office of War on Hui
:ional Development, U.S. Department of i
-Translated and published by the Regi
ter. Paris. Aaencv for International Devw


Introduction . . .
Chapter I The Human Scene
chapter II The Human Diet . .
apter III Improving Food Supplies
tapter IV Custom and Food . .
chapterr V Malnutrition in Childhood
mapter VI Nutrition Education . .
tpter VII Combating Malnutrition .

I Recommended Daily Dietma
II Information Required Con
Children ......
III Weight for Age Table .
IV A Planned Demonstration I
V Specimen Recipes for Wean
VI Approximate Quantities for
VII Packed Meals for School Cl
VIII Nutrition Rehabilitation Ui
IX Home Feeding Kit . .
X Preparation of Artificial Bo
Home . . . .
XI The Mulanda Project .

. .... . . .. . .

. . . . . i
. . . . . 5
. . . . 13
. . . . . 43
. . . . 61
. . . . 71
. . . . . 95
. . . . 115

Allowances .... 171
ring Feeding Young
. . . . 172
. . . . 173
r Use in East Africa 174
Lg Fo6ds ...... 176
school Meals . . 182
idren ......... 184
t . . . 186
. . . . 188
le Feeds in the Village
. . . . 189
. . . . 191

. . . . . 195

List of Tables
Table No. Page
1 Average Eruption Time of First Teeth ........................ 85
2 Inadequate Weight Gains During the First Two Years of Life.... 86
3 Approximate Protein Content and Amino Acid Deficiency of Main
Categories of Vegetable Foods Used in Multimixes .............. 129
4 Villiage-Level Multimixes .................................... 130
5 Simplified Use of Cow's Milk and Its Preparations in the Feeding
of Babies Up to Three Months of Age ........................ 136
6 Simplified Use of Cow's Milk and Its Preparations in the Feeding
of Infants Over Three Months of Age ......................... 136
7 Summary of Immunization Procedures for Young Children in Re-
lation to Nutritional Conditioning Infections and Other Important
Infections ........................ ....................... 146
8 Recognition and Simple Management of Early Cases of Some
Common Childhood Illnesses ............................... 148
9 Basic Drug Dosage for Tropical Village Children ................ 149

List of Figures
FRONTISPIECE-Kwashiorkor in two-year old East African child.
1 High infant and 1-4 year mortality rates in Peru, Guatemala and
Mexico compared with the U.S.A ............. 8
2 Traditional raised rice granary (Madagascar) ........ 46
3 Traditional granaries (Togo, West Africa) ......... 47
4 Sun-dried strips of beef (North Kenya) .......... 48
5 Sun-dried, smoked fish on sticks (Uganda) .......... 49
6 Traditional market (Mali, West Africa), showing mixed beans in
foreground .... ............... ..... 50
7 Traditional floating market on canals (Bangkok, Thailand) 51


List of Tables
Table No. Page
1 Average Eruption Time of First Teeth ........................ 85
2 Inadequate Weight Gains During the First Two Years of Life.... 86
3 Approximate Protein Content and Amino Acid Deficiency of Main
Categories of Vegetable Foods Used in Multimixes .............. 129
4 Villiage-Level Multimixes .................................... 130
5 Simplified Use of Cow's Milk and Its Preparations in the Feeding
of Babies Up to Three Months of Age ........................ 136
6 Simplified Use of Cow's Milk and Its Preparations in the Feeding
of Infants Over Three Months of Age ......................... 136
7 Summary of Immunization Procedures for Young Children in Re-
lation to Nutritional Conditioning Infections and Other Important
Infections ........................ ....................... 146
8 Recognition and Simple Management of Early Cases of Some
Common Childhood Illnesses ............................... 148
9 Basic Drug Dosage for Tropical Village Children ................ 149

List of Figures
FRONTISPIECE-Kwashiorkor in two-year old East African child.
1 High infant and 1-4 year mortality rates in Peru, Guatemala and
Mexico compared with the U.S.A ............. 8
2 Traditional raised rice granary (Madagascar) ........ 46
3 Traditional granaries (Togo, West Africa) ......... 47
4 Sun-dried strips of beef (North Kenya) .......... 48
5 Sun-dried, smoked fish on sticks (Uganda) .......... 49
6 Traditional market (Mali, West Africa), showing mixed beans in
foreground .... ............... ..... 50
7 Traditional floating market on canals (Bangkok, Thailand) 51


1.kwaLLUULxuL ilX VUaLVU1UaLu U1jlIUU, alLUwIUg CuUmU, misery, wasTea
muscles (with fat present) and growth failure ........
Late nutritional marasmus in two-year old child, showing very
wasted muscles and fat, and severe underweight (Guatemala) .
Clinical features of two main severe forms of PCM-Kwashiorkor

14 Nutritional conviction. Same chi
diet based on local foods . .
15 Straight forward understandable
obvious message. ("Breast-feed (
16 Plastic feeding cup, easier to kee

I after six weeks of high protein
. . . . . . 101
poster, with few words and one
mn't bottle feed") .... 109
clean than feeding bottle .. 137


This book is intended for the ma
with no technical training in the i
Volunteers, who are working in a
tropical countries. The aims of th<
remote from child nutrition, but
work has often involved them, dir
lems of malnutrition in children.
In addition, even health work
world may find themselves confus,
practices, by the types and severit
all, by the apparent lack of relev
plication, of methods that have se
and common-place back home.
The confused worker need not,
of the child population in tropic
has only recently been widely r
serious inquiry by modern scier
Apart from a few pioneers cryi]
problems of nutrition in young ch
at the end of World War II, and
last decade.
It is now abundantly clear t
diseases as yellow fever and cl
problems and blocks to progress
significance than childhood malnm
and socially, malnutrition not onl,
sickness, misery, and death, bui
may be irreversibly damaged physi
Understandably, initial medic,
vestigation of the clinical appears
of malnutrition, as well as to la
biochemistry, and into methods
is still inadequate in these fields


y different groups including those
alth field, including Peace Corps
variety of programs in developing
r projects are often at first sight
experience has shown that their
ctly or indirectly, with the prob-

*s being trained in the Western
I by differences in infant feeding
of malnutrition seen, and, above
nce, or, at best, difficulty of ap-
med so straightforward, obvious,

however, feel so badly. The plight
1 developing parts of the world
;ognized and made a matter of
ific medicine and public health.
g in the wilderness, attention to
dren in developing regions started
!as only gained momentum in the

at, while such classical tropical
)lera are very important health
in reality they are of much less
rition. Numerically, economically,
causes a higher rate of immediate
also leads to a population that
ally, mentally, and psychologically.
. emphasis was given to the in-
ice of children with various forms
oratory research into changes in
f treatment. Certainly, knowledge
md more research is required. At

appear to be increasingly realized and, m
greater action in the development of imagi
n the field is beginning to receive the price
)acking that it warrants.
The urgency of the situation has been
planningg levels in the United States, as
Fiction by President Lyndon B. Johnsol
ransmittal to Congress of the Food for I
March 31, 1965, and by the statement of
'ood for Peace, in a memorandum date
been firmly established that preschool
vulnerable to the effects of malnutrition
rreversible physical and mental retards
ire urged to give priority attention to the
'ul programs aimed at attacking malnutri
In the most recent directives outlining
he Agency for International Developm4
lorps, the need to give attention to the n
school children has been given high priority
It is hoped, then, that this handbook wil
o recognize the significance of the problem
children and to be able to gear their effort!
preventive and curative measures.

recognized that, even with
it ought to be possible to
velop effective, economical,
vith the problem of malnu-
y the titles of recent Inter-
g Protein Requirements" in
'reschool Child" in Como,
tion; Major Deterrent to
Administrative Problems in
" Hamburg 1966.
n was described as follows:
,e means of improving the
en more acute. Evidence of
Lrly malnutrition is already
:h points to retardation of
child and the possibility of
lue to malnutrition in early
the future manpower and
i which it occurs, and adds
deleterious effects do, then,
ore important, the need for
native preventive programs
ority emphasis and financial

I recognized at the highest
exemplified by the call to
n on the occasion of the
Peace Annual Report dated
Mr. Frank Ellis, Director,
i March 24, 1965: "It has
aged children are most
(in some cases suffering
nation ; therefore, agencies
Establishment of meaning-
tion in this group."
g major activities of both
ent (AID) and the Peace
nutrition of infants and pre-

1 help nontechnical workers
mn of malnutrition in young
s toward locally appropriate

------2-i ~ -" _--~T~--

There is no doubt that tf
usefully as the "decade (
simple programs, so diffi
collaboratively by govern
cies, evaluated, suitably n
sions at the grassroots levi
where the majority of thi
In this decade of field
technical field workers, in
a most important role. T1
struggle against malnutrit
versal panaceas; but, hope
the detailed strategy to tl
finally to the ingenuity ani

Next ten years could be envisaged mos
field application," in which seemingly
lit to carry out in fact, are launched
nts and international and voluntary agen
dified, and carried to successful conclu
of the rural tropical villages and slums
world's children live.
application, there is no doubt that non
uding Peace Corps volunteers, can pla!
i book is intended to guide them in th
n. It does not, and cannot, suggest uni
illy, may indicate general tactics, leaving
planners of the specific programs, an
adaptability of the worker on the spot.
TlironT.w H TiTrTirymm

iiatrinl. smrriria sanA P~ninnhi~

Western world in the last 150 years, and
whose populations have not been di-
rectly involved in the development of
the system of thought and logic known
as "scientific rationalism." These coun-
tries are mostly located in the sub-
tropics and tropics, and they are now
making herculean efforts to modernize
and to raise their standard of living,
so that they are best termed "techni-
cally or economically developing."
It is also apparent that all preindus-
trial societies have their own well es-

Urbanization. In most developmg
countries, the majority of the popula-
tion-usually between 60 to 90 per-
cent-are scattered in rural areas,
dependent for the most part on subsist-
ence "garden-to-mouth" agriculture,
often in villages or homesteads to some
degree isolated by poor road communi-
cations. At the same time, partly as a
response to planned industrialization
and partly spontaneously, in all coun-
tries there is an increasing move to-
ward urban areas by men, sometimes

alone, seeking employment and the
excitement of the big city, but only too
often finding instead the disappoint-
ment and frustration of unemployment
and the demoralized life of the slum
dweller, with all the consequent nutri-
tional and social problems (p. 57).

Antiquated Agriculture and Inade-
quate Food Production. Old-fash-
ioned methods of agriculture are usual,
and although the tools and methods may
be time-hallowed by tradition and are
sometimes adapted to local circum-
stances, agricultural productivity is
low, under-mechanized, and usually
based on small uneconomic landhold-
ings (p. 44). Food production is, there-
fore, inefficient and highly dependent
on the weather; while the harvest is
exposed to much wastage by rodents,
insect pests, and molds during storage.
Likewise, the preservation, distribu-
tion and marketing of food is also likely
to be poorly organized and without
benefit of modern technology, thus
limiting the range of food distribution
from its area of production.

Poverty. The national earning capac.
ity of developing countries is usually
low and dependent on agricultural,
rather than industrial, production. It
is very frequently based on one or more
cash crops, such as coffee, rubber, cot-
ton, or cocoa, and subject to the price
fluctuations for these commodities on
world markets; or, as in the case of
rubber, for example, to the develop-
ment of modern synthetic substitutes.
Low per caput incomes plainly limit
the range of foods which families can
afford to produce, or to buy. Thus, ani-
mal protein foods which are, relatively
speaking, expensive to produce are little
iiA_ 'rThpv alan limit aA.iTplv t-h I.

sibilities of investing in supplies and
equipment which are needed to increase
food production or to improve food
At the same time, the relative ex-
pense of a poor man's life deserves
emphasis. For example, he can only
afford to buy small uneconomical quan-
tities of any commodity at a time, in-
cluding purchased foods and, in some
tropical towns, water.
The national income of highly popu-
lated developing countries is often only
one twentieth of that of industrialized
countries, which means that there will
be an understandable competition be-
tween the various Ministries or De-
partments of Government concerned
with trying to develop the country for
the limited finance available, and espe-
cially for restricted foreign exchange.
This plainly means that all projects,
whether for more hospitals, or for bet-
ter communications, or for an increased
number of boreholes for water, have
to be judged, if possible, impartially.
Emphasis has to be given to those con-
sidered to be priorities for the coun-
try's development. Of such, those re-
lated to improving the nutrition of
young children are extremely impor-
tant in the long run.
Specifically, a low national income
means that little finance will be avail-
able for health or other social services.
Thus, in developing countries the per
caput annual health budget may be be-
tween U.S. $0.50-1.00, as compared
with $30-40 per head per annum in
Western industrialized countries.

Lack of Education. Educational prob-
lems will also loom large. There is
usually a high rate of illiteracy, espe-
cially among women. The number of
-~i..-~i ;- ;--:ll_j. -_j ~-~ -IL^3^

of school teachers is often a major ob-
stacle to the expansion of the educa-
tional system. The availability of all
types of technically trained personnel,
including those needed to man the
health or agricultural services, varies
in different parts of the world, but, in
general, will also be quite inadequate
in both number and quality.
There is no doubt that from the long-
term viewpoint, education is a major
key to the improvement of the health
and nutrition of a country. Educated
parents are likely to have an increasing
awareness of modern ideas of nutrition,
child rearing, and food production, and
to realize the economic limitations of
trying to rear and educate an over-
large family.

Defective Environmental Sanita-
tion. Standards of environmental
sanitation, including an easily available,
clean water supply and the disposal of
excreta and rubbish, are usually defec-
tive, with an increased incidence of in-
fections and parasites that are water-
borne, spread by flies, or due to fecal
contamination of the compound. These
will include diarrheal diseases and in-
testinal worms, both of much signifi-
cance nutritionally (p. 72).

Inadequate Medical Facilities.
Doctors are few-between 1 per 10,000
to 1 per 100,000 population-compared
with Western countries in which there
may be about 1 per 1,000 population.
In addition, there is usually a geo-
graphic maldistribution, with a high
proportion of the total in cities, and a
relatively small number in rural areas.
There is a similar scarcity of nursing
and other paramedical personnel, who
usually do most of the preventive and
lnrativ. h1A1h6 wnric in Ah;Q ta ,t

country. All too often hospital facilities,
including beds, are even scarcer for
children than for adults, and little at-
tention can be paid to the sheer numeri-
cal size of pediatric problems, espe-
cially malnutrition. Shortage of beds,
drugs, and equipment often mean that
health services can of necessity only
supply a rough and ready "first-aid"
type of treatment.

Nonwestern Culture Patterns. The
mass of the population has usually a
prescientific philosophy, with motives
and drives very different from those of
the Western world, and with unfamiliar,
but deep-rooted, classifications of dis-
ease, food, and all other aspects of life,
often much related to magic and ultra-
human forces. Women may often be
considered to have a low or subservient
status-a point of great importance in
relation to successful nutrition educa-
The local pattern of customs, atti-
tudes, and practices greatly influences,
both for better and for worse, the nutri-
tion, diet, and food production of a
community, and also modifies the way
in which preventive programs can best
be developed (p. 68). The scientific
mode of thought and logic usually has
neither influence nor long-standing his-
torical roots among the majority of the

Young Populations. The population
structure of most developing countries
differs greatly from, that seen in the
U.S.A. and in Western Europe. In gen-
eral, there are more children and young
adults, and fewer people reaching old
age. Thus, about 50 percent of the popu-
lation will be below 15 years, while 20
percent will be young children below the
p* 1 *.1 1

30 percent and 10 percent for corre-
sponding age-groups in Western coun-

Population Pressure and Food
Production. At the same time, and of
great consequence nutritionally, despite
high mortality in early childhood and
a low life expectancy at birth of 30 to
40 years, there is usually a population
increase of about 2-3 percent each year.
This is due to sustained high fertility
and the decreases in mortality that have
taken place in recent years, as a result
in part of the introduction and accept-
ance of some aspects of modern pre-
ventive and curative medicine, and in
some measure to a decrease in warfare
at the local level. The consequent popu-
lation pressure plainly has nutritional
significance (p. 55-56). In particular,
the high rate of population growth leads
to the continual outstripping of food
production by the number of mouths to
be fed.
The disproportion between numbers
of people and land available for food
production is notable in India, where
2.2 percent of the world's land area is
occupied by 14 percent of the world

High Burden of Childhood Dis-
ease. The child population is not only
a very large one, but also has a high
incidence of illness. A visit at any out-
patient clinic in a tropical country will
show at once that about half of those
attending are young children, and this
impression is confirmed by the fact that
more than 50 percent of the total mor-
tality at all ages occurs in early child-
The high death rate in early
childhood is also shown by the infant
mortality rate-that is, the deaths of

children occurring in the first year of
their life. Rates in developing countries
of the world may be as high as ten times
those found in industrialized Western
countries. Less obvious, and usually
unappreciated, is the fact that the death
rate of children in the 1-4 year age
group-a relatively healthy period in
Western countries-may be 40 times as
high as those in the U.S.A., largely
due to malnutrition and to associated
infections and parasites (Figure 1).
In general terms, this will mean that
approximately half the children born
die before they reach their fifth

1 year infant mortality
100 1-4 years




FIGURE 1.-High infant and 1-4 year
mortality rates in Peru, Guatemala,
and Mexico compared with the U.S.A.

Pattern of Childhood Disease. De-
spite some differences from one part
of the world to another, the general
pattern of disease and ill-health in early
childhood is broadly similar from re-
gion to region in developing countries.
The "Big Three" childhood ailments
are usually malnutrition, diarrheal di-
sease, and pneumonia. Following
behind these come the remainder of

the "Top-Ten"--tuberculosis, malaria,
certain infectious fevers of childhood
(notably measles and whooping
cough), intestinal worms, accidents,
and infections of the newborn. Char-
acteristically, young children in tropi-
cal regions are rarely found to be
suffering from one disease alone, but
from several at one time, each adding
to the total cumulative burden of mis-
ery and ill-health.
None of the diseases mentioned is
"tropical" in the old-fashioned sense-
that is, found exclusively in hot tropi-
cal regions. Kwashiorkor, one of the
severe forms of protein-calorie malnu-
trition (p. 75), was common in Europe
at one time, as was well documented
in the Irish Potato Famine of the early
19th century. Malaria can be a scourge
in Arctic regions in the summer, and
deaths from intestinal roundworm in-
fections were once well known in
What seems a difference in place is
rather a difference in time and devel-
opment. Urbanizing areas of nine-
teenth century Europe during the In-
dustrial Revolution had a very high
infant mortality rate due to summer
diarrhea, malnutrition (including
"flour-feeding illness," actually a form
of kwashiorkor) (p. 76), and many
infectious diseases, -all occurring among
grim social and hygienic circumstances.
The so-called "tropical" pediatrics of
20th century city slums found in some
developing countries present a strik-
ingly similar picture.
Moreover, that the tropics, in a cli-
matic sense, are not primarily impli-
cated is shown by the fact that com-
parable nutritional and health problems
are seen in less well-developed com-
munities in cold or temperate regions,
including, for example, parts of rural

Chile, and among some groups of Eski-
mos; by the usual good health of the
children of the well-to-do, both indige-
nous and foreign, living in tropical re-
gions; and by the recurrence of similar
child health problems, when environ-
mental factors, especially nutrition
deteriorate as was the case in Holland
in the last months of World War II.
Wars, famines and other natural and
man-made disasters always have their
main nutritional ill-consequences
among the vulnerable groups--the
young children and pregnant and lac-
tating women.

Preventabilty of Problems. The
common illnesses mentioned are all
potentially preventable, including the
various forms of childhood malnutri-
tion. Cure alone is economically un-
sound and illogical, and will in no way
prevent the child or others in his family
from contracting similar diseases on re-
turn to the home environment. It is this
preventive approach which has to domi-
nate all realistic child nutrition pro-
grams in developing countries.

Molding Factors. Four groups of
factors appear to mold the pattern of
childhood disease in different parts of
the world. These are: the economic,
hygienic, and educational levels of de-
velopment in the community; genetic
characteristics; the cultural pattern;
and geographic and climatic factors.
That certain important diseases are ex-
clusively "tropical" in distribution is
not to be denied-for example, some
parasitic infections, such as African
Sleeping Sickness. Also, all human
groups are subject to different inherited
diseases. However, there is no doubt
that most disease in present-day "tropi-
cal pediatrics," including malnutrition,

is principally the result of poverty, tech-
nical backwardness, inadequate sup-
plies of nutritious foods, lack of
education, and defective hygiene, asso-
ciated in varying degree with the effect
of certain local customs and practices.

Size of Problems. Some of the dis-
ease problems mentioned above may be
very large, and this is especially the
case with childhood malnutrition. Thus,
in Kampala, Uganda, 10 percent of all
children admitted to the main hospital
are suffering from the severe form of
protein-calorie malnutrition known as
"kwashiorkor" (p. 76); while surveys
in the surrounding countryside show at
least half of the children under school
age are suffering from lesser degrees
of this form of malnutrition. In 1958, a
countrywide survey in Haiti showed 7
percent of 1-3 year olds to have
Only too often the full dimensions
and the late consequences of the prob-
lem of childhood malnutrition are not
appreciated by the administrators and
leaders in some parts of the world. The
size of the problem, its direct and in-
direct influence on child mortality, and
its late effects on physical and mental
development have only recently been
appreciated by the medical world. They
are particularly unpalatable and diffi-
cult for hard pressed politicians in de-
veloping countries to accept and face,
confronted as they are with a wide
range of formidable social and eco-
nomic problems to be dealt with with
limited resources.

Need to Appreciate Background.
It is vital for all those working in the
field of nutrition to appreciate the back-

ground realities in developing regions
and the general pattern of childhood
disease. Many bacterial and parasitic
infections are more easily acquired and
have more serious effects in malnour-
ished children. At the same time, much
malnutrition results not only from lack
of the correct foods, but also the addi-
tional burden placed on the child by
intercurrent (conditioning) infections
It is in these difficult circumstances
that all those working to improve the
nutrition of tropical children find them-
selves enmeshed. Much plainly depends
on relatively long-term measures to im-
prove, modify, or expand the economy,
the educational system, food produc-
tion, and the social structure of the
particular country.
Important as these long-term objec-
tives obviously are, they cannot be
considered here, and the present book
is concerned with discussing the causes
and recognition of malnutrition in
childhood, and with possible measures
to improve the nutrition of children
available to those working in the field.

The Challenge. The challenge is how
to make the benefits of modern scien-
tific knowledge available simply, eco-
nomically, effectively, acceptably, and
persuasively to enable tropical villagers
to improve their own standard of health
and living, and, in particular, to advise
and motivate parents to improve the
nutrition of their young children. This
accomplishment plainly requires prac-
tical and tactful adaptation, with the
ultimate aim being always to secure
the maximum return in human welfare
from minimum expenditure in money
and trained personnel.


R. E. BROWN, Medical Problems of the
Developing Countries, Science, 153, 271
(1966) (G&T).
D. B. JELLFFE, Paediatric Practice in
Tropical Regions, Lancet, ii, 229 (1965)


M. Kimn (Editor), Medical Care in De-
veloping Countries, Oxford University Press,
Nairobi (1966) (G&T).
1G=Recommended for the general reader.
T=Recommended for the technically trained
health worker.

chapter 4


ALL OVER THE WORLD different human
groups have evolved their own diets,
based on an immense variety of dishes
made out of innumerable mixtures of
different foodstuffs. While not appreci-
ated by the people concerned, a satis-
factory diet in any part of the world has
to contain adequate quantities of spe-
cific nutrients to supply energy, to
maintain body repair, and to keep the
body working normally. In addition, in
childhood and pregnancy the diet must
be sufficient to cover the extra needs
of rapid growth.
The foods making up a diet, after
having been eaten, are digested and
absorbed from the alimentary canal.
Within the body, the nutrients are used
for one or more of the activities already
mentioned. If excessive quantities of
nutrients are taken, they may in some
cases be passed out of the body in the
urine, as with vitamin C, or may be
stored in the body, as with vitamin A in
the liver, and with too great an intake
of calories, as subcutaneous fat.


Diets are made up of six basic groups
of nutrients-carbohydrates, fats, pro-
teins, minerals, vitamins, and water,
together with substances added for
flavoring. The body has different needs
for these nutrients in health depending
upon size, sex, age, degree of activity,
and climate.

Nutrient Allowances. Analysis of
diets of well-fed, healthy people, and
laboratory investigations on experi-
mental animals and human volunteers
have led to the suggestion of certain
recommended daily nutrient allow
ances (Appendix I).
These figures are only approximate
as there is variation even between
healthy individuals, and it is quite pos-
sible that communities in various parts
of the world may have adapted them-
selves over long years to higher or
lower levels of intake of certain nu-
trients. The figures given are also aimed

at a safe level and may, therefore, some-
times be too high.
In any case, it will not be possible
for the nonnutritionist to calculate die-
tary intakes, and, for practical pur-
poses, it is more useful to plan diets to
insure intakes of certain groups of foods
known to be rich in different nutrients.

Needs for Growth. The nutritional
needs of young healthy children are
particularly great, as would be expected
from their rapid rate of growth. In par-
ticular, the requirements for protein,
calories, and iron are much greater pro-
portionally in young children than in
adults. Thus, a 150-pound man needs
about 70 grams of protein per day,
while a child of one tenth of this weight
(e.g. 15 pounds) needs 21 grams of
protein, which is almost one third of the
adult's requirements.
Pregnant and lactating women also
have a very high dietary need for the
growth of the fetus and uterus, and
because of the nutritional drain of the
human milk produced.

Needs During Infections. As well
as physiological variations in normal
healthy individuals, many bacterial and
parasitic infections can affect the body's
nutrient requirements. For example, in
diarrhea in young children the rapid
passage of food through the intestines
prevents its full absorption. The pres-
ence of numbers of roundworms in the
small bowel may lead to food being
taken up by these large parasites rather
than by the child. Likewise, any fever
leads to an increase in the body's needs
for protein, as well as resulting in poor
appetite and sometimes in vomiting.

Inter-Relationship of Nutrients.

are related to one another. For example,
the requirement for the vitamin thia-
mine, increases with the intake of car-
bohydrates. It is this inter-relationship
which has led to the concept of the
"balanced diet." In other words, not
only are certain quantities of the differ-
ent nutrients required, but for best
usage they should be taken together in
certain approximate relative propor-


Full details of the functions of vari-
ous nutrients, and their sources in vari-
ous foods can be found in standard
textbooks on nutrition--some of which
are listed at the end of the chapter. The
present section, therefore, only sunm-
marizes certain points, especially those
that are felt to be relevant to problems
of childhood malnutrition in develop-
ing tropical countries.

Carbohydrates. The group of nu-
trients known as carbohydrates consists
principally of starches, sugars, and
various indigestible substances, such as
cellulose. Carbohydrates are the body's
main source of energy and heat, and
every gram of carbohydrate absorbed
into the body provides four units of
energy (Calories).
Digestible carbohydrates are broken
down by enzymes in the intestinal canal
into simple sugars, which are then ab-
sorbed into the bloodstream and are
used directly as a source of energy; or
are stored in the muscles and liver
as so-called animal starch (glycogen),
which is subsequently reconverted into
sugar to deal with the body's require-
ments for energy. An excessive intake of

In developing countries in the trop- uver, Uanu DULLr, tAUo 1uuial UM IrL-
ics, predominantly carbohydrate foods soluble vitamins A and D.
are usually the main source of Calo- Vegetable fats are found in the
- ;. tin kP ,];at -;th thA or.nrinn nf groundnut, the soybean, the olive, the

or pastoralist communities. By con-
trast, in industrialized countries, Cal-
ories are less exclusively derived from
*arbohydrate foods, as the fat intake
is higher.
In many tropical regions, the diet
may consist to a very large extent of
one or more mainly carbohydrate
foods, the staples. However, it is im-
portant to realize that these predomi-

of various plants, including sesame,
mustard, and cotton. These oils are of-
ten extracted by traditional means and
used for cooking. Commercially, some
are grown in extensive plantations and
the oil used for a variety of purposes,
including the manufacture of marga-
rine and soap.
In most developing regions, fats are
costly and not widely available, and

so form a very minor ingredient in the
diet. Thus, in India only 13 percent of
the total Calories of the adult diet are
derived from fat, as opposed to 43 per-
cent in the U.S.A.

Proteins. The complex substances
known as proteins are essential consti-
tuents of all plant and animal cells.
Protein molecules are made up of var-
ied combinations of components called
amino acids. Over twenty of these
amino acids are required by the body,
but only eight are "essential" that is,
they cannot be manufactured by the hu-
man body from other ingredients, so
that they have to be present in the
food eaten.
The value of a particular food pro-
tein in the diet is determined by its
amino acid composition (compared
with the proteins of egg or breast milk
as standards), its known biologic effects
in experimental animals, the digestibil-
ity of the particular food, and the asso-
ciated calorie content of the diet, which
may have a "protein-sparing" effect
Animal Protein. Proteins may be de-
rived from animal or vegetable sources.
Animal proteins are found in meat, fish
(including shellfish), eggs, milk( and
some of its products, especially cheese,
yogurt, and buttermilk), and to a minor
extent from other sources, including in-
sects, snails, and so forth. Foods of ani-
mal origin not only are rich, concen-
trated sources of protein, but also all
contain the complete range of the eight
essential amino acids.
Vegetable Protein. While almost all
vegetable foods contain some quantity
of protein, the content varies considera-
bly. The richest in protein, usually con-
taining about 20 percent, are the leg-
.1 1- .L 1

the best protein source is the soybean
(up to 40 percent), although caution
has to be exercised in preparing this
food owing to its indigestibility (p. 31).
The next best plant sources of pro-
tein are the cereal grains. While there
is great variation between different
types of cereals and many different
strains exists, as a group they contain
about 10 percent protein.
Plant sources of protein that are often
overlooked are dark green leafy vegeta-
bles, including tropical equivalents of
spinach. These leaves contain about
2-10 percent protein. They are also
good sources of other nutrients, includ-
ing iron, vitamin C, and riboflavin,
especially the young leaves. Unfortu-
nately, in many communities of the
world, they are often not used as much
as they might be, and, indeed, often may
be regarded as "poor man's food," with
little prestige.
The staple foods poorest in protein
are the various root crops, tubers, and
plantains, which have a protein con-
tent of only 1-2 percent.
As important as the total protein con-
tent of vegetable foods is the fact that
their proteins do not contain the full
range of the eight essential amino acids.
For example, the protein of cereal
grains, such as corn (maize) is deficient
in the essential amino acid, lysine; while
the proteins found in legumes, such as
the soybean and chick-pea are relatively
low in another (methionine). The value
of each of these foods is, therefore, en-
hanced if eaten as cereal-legume mix-
tures, thereby providing the whole
range of essential amino acids.
Expense and Scarcity of Protein
Foods. Diets in tropical countries are
ol.,-t i, ,,uireallv deficient in protein.

especially in those of animal origin, a
fact which is illustrated by a compari-
son of the average milk, other animal
and vegetable protein intake in Latin
American countries with figures from
Canada and the U.S.A. The rapidly
rising populations in developing coun-
tries and the slow increase in agricul-
tural production is tending to widen
this "protein gap" still further.
In addition, all over the world,
whether in New York or equatorial
Africa, protein foods, especially those
of animal origin, are more expensive
than largely carbohydrate staples. In
view of this, the need to use vegetable
protein mixtures, if possible with small
additional quantities of animal protein,
is an important principle of village
level infant feeding (p. 130). Indeed,
many traditional diets in different parts
of the world appear to have evolved
toward largely vegetable protein mix-
tures. These are often of a cereal-leg-
ume combination, in which the amino
acid deficiency of one food is comple-
mented by that of the other ingredient.
Examples include the rice and dhal
(lentil) of India, the beans and corn
tortillas of Mexico, and various fer-
mented food preparations, such as Jap-
anese mise (soybean and rice) and In-
dian idli (black gram and rice).
Functions and Needs of Proteins.
Protein is required for repair of the
body, the cells of which are constantly
being broken down and rebuilt, for the
formation of body enzymes, and also
for growth. It is for the latter reason
that there is a particularly high protein
need in infancy and early childhood
(Appendix I), when growth is espe-
cially rapid.
Carbohydrates as Protein Sparers.
It is important to realize that if in-

sufficient carbohydrate foods are pres-
ent in the diet, protein may be waste-
fully burned by the body for the pro-
duction of energy at the rate of four
Calories per gram. This becomes of
special practical significance in the
treatment of kwashiorkor (p. 80), when
sufficient Calories in the form of sugar
and vegetable oil should be given at the
same time as protein.

Vitamins. The group of nutrients
known collectively as vitamins are un-
related chemically, but are all essential
in small quantities for the maintenance
of good health. Severe deficiency, lead-
ing to depletion of body stores, results
in various forms of clinical malnutri-
tion, which can sometimes be recog-
nized by the appearance of certain signs
or by the use of appropriate laboratory
However, vitamins are required only
in small quantities, so that the mixed
diets, made up of a wide range of dif-
ferent foods consumed in most of the
U.S.A. and Western Europe, usually
supply more than adequate quantities
in the diet itself. There is no evidence
to suggest that extra amounts of vita-
mins are beneficial. Undoubtedly, the
result of much routine taking of vita-
min tablets by well-fed people only
leads to the production of an "expen-
sive" urine, as the unnecessary intake
is promptly excreted.
Nevertheless, vitamin deficiencies of
various types occur in many parts of
the world, especially if a diet is taken
that is limited to a restricted number of
foods. In Britain, the elderly person,
living alone and with a poor appetite
may subsist on tea and toast, and de-
velop various vitamin deficiencies,
especially those of the B complex. His-
torically, the diet of hardtack and salt

pork which was sometimes eaten for
months on end by seamen during the
age of sail was ablost always guaran-
teed to lead to a substantial death rate
from scurvy (vitamin C deficiency).
In some communities of the world,
the basic diet may consist of a very
limited range of foods. This limitation
may be for economic reasons, or be-
cause of local customs, or because the
terrain only permits the growing of
limited crops, or for a combination of
all of these reasons. Difficulties may be
aggravated by seasonal variations in
food supply, in particular by a "hungry
season," which often occurs at the
beginning of the rains when crops have
been planted, but are not yet ready for
As with other forms of malnutrition,
vitamin deficiency disease is much more
likely to occur in the two nutritionally
"vulnerable" groups-young children
and pregnant or lactating women.
Their need for nutrients is high and
their intake is often restricted by vari-
ous harmful food customs (p. 65).
Another factor to be taken into ac-
count in relation to the onset of malnu-
trition due to vitamin deficiency is the
variable degree of storage of different
vitamins in the body. In a well-fed in-
dividual, vitamin A stores in the liver
may suffice for months, even if the diet
is lacking in this nutrient, so that clini-
cal deficiency will only be detected after
this time has elapsed. By contrast,
stores of thiamine last for only a few
The effects, actions, and interactions
of vitamins is a most extensive subject
and it will only be possible to touch on
a few important points here concern-
ing the relevance of vitamins to the nu-
trition of tropical children.

Vitamin A. This vitamin can be taken
in directly, as vitamin A, which is con-
tained only in animal foods, particu-
larly in liver, egg yolk, milk and its
products, :and liver oil from the cod,
halibut, shark and other fish. Alterna-
tively, vitamin A may be synthesized
within the body from orange pigment
foods, containing the pro-vitamin beta-
carotene (vitamin A precursor). Rich
sources of carotene include such or-
ange-colored fruits and vegetables as
the pawpaw, oil palm fruit, carrots,
pumpkins, mangoes, yellow sweet po-
tatoes, and so forth, as well as dark
green leafy vegetables, including vari-
ous tropical equivalents of spinach and
cassava leaves.
Foods containing actual vitamin A
can be obtained only rarely by the av-
erage population of most developing
tropical countries, so that the avoid-
ance of deficiency depends in large
measure upon ensuring an adequate in-
take of carotene-containing foods.
Also, tropical infants are much de-
pendent on their mother's diet in this
respect, both as regards the stores laid
down in the liver in the fetus during
pregnancy, and the vitamin A in their
mother's breast milk. Both of these may
be deficient if the mother's diet has
itself been lacking in carotene-contain-
ing foods.
Problems may also occur because
carotene is not well absorbed from the
intestine, especially in children who
have diarrhea as is very commonly the
case. Storage of vitamin A in the liver
may be hampered in young tropical
children by various diseases of this
organ, which are by no means
Vitamin A is principally required
for the normal functioning of epi-

thelium (surface cells) of the skin and
eye, including the retina. In some parts
of the world, vitamin A deficiency is a
most common and serious form of mal-
nutrition, which is both preventable
and tragic in its consequences, as it
may easily lead to permanent blindness
Vitamin B Complex. The three main
members of the vitamin B complex or
group are thiamine, riboflavin, and
1. Thiamine. Thiamine, which is
required for the metabolism of carbo-
hydrate in the body, is widely available
in a variety of tropical foods, including
cereal grains (mainly in the germ),
legumes, green leafy vegetables, fish,
milk, and meat. Thiamine is water
soluble and easily absorbed. It breaks
down at high temperatures.
Severe deficiency of thiamine in
young children results in a clinical con-
dition known as infantile beriberi (p.
88). Beriberi is a public health prob-
lem of importance mainly in those
areas of Asia where over-milled rice
forms the mainstay of the diet, with a
consequent high intake of carbohydrate
and low levels of dietary thiamine. It
has been termed "white rice disease."
Thiamine in rice can be reduced not
only by overmilling, which removes
the germ, but also by over-soaking or
cooking with too much water which is
subsequently discarded. Parboiling (p.
27) is a method of preparation which
preserves the thiamine content.
An insufficient intake of thiamine in
the mother's diet is also of great poten-
tial harm to the suckling baby, in part
because the stores that he will acquire
during fetal life will be low, but mainly
because the level of thiamine in the

mother's milk varies greatly with her
The daily need for thiamine is re-
lated to the amount of carbohydrate
Calories in the diet, so that feeding
with overmilled white rice from the
early weeks of life is another factor
tending to lead to infantile beriberi
2. Riboflavin. This yellow-colored
vitamin is also widely distributed, but
is in especially high concentration in
milk, green vegetables, meat (especially
liver), fish, and eggs. In tropical diets,
its main sources are usually dark green
leafy vegetables, cereal grains, and
legumes. Starchy root crops contain
only very little.
Lack of riboflavin produces ulcers at
the comers of the lips, and a generally
red, sore mouth.
3. Niacin. This vitamin is found dis-
tributed in numerous foods. Rich ani-
mal sources include meat, particularly
liver, while the best available sources in
tropical countries are legumes, includ-
ing groundnuts, and cereal grains, es-
pecially if they are undermilled and
still contain the germ.
Corn (maize) is a particularly poor
source of niacin, especially if the germ
has been removed by overmilling. Clin-
ical malnutrition due to niacin defi-
ciency-pellagra-is thus principally a
disease of corn-eating communities.
Vitamin C.-Ascorbic acid (vitamin
C) is found in vegetables, especially
green leaves, and various fruits, par-
ticularly those of the citrus group.
There are often especially rich local
sources of ascorbic acid such as acerola
(the Barbados cherry) in the West
Indies, the fruit of the baobab tree in
Central Africa, and the pawpaw and
the guava in many parts of the tropics.

Other sources of ascorbic acid include
germinating cereal grains or legumes,
whether eaten raw, or cooked, or pre-
pared as local beer.
Human milk is a good source of
vitamin C, provided the mother's diet
is adequate in this respect. A breast-
fed baby therefore needs no other sup-
ply of ascorbic acid for the first six
months of life.
Ascorbic acid is both water soluble
and destroyed by heat. It will, there-
fore, be lost if vegetables are left soak-
ing for too long or especially if they
are overcooked.
Vitamin C plays various roles in the
body's metabolism, but is especially
required for the formation of the small
blood vessels. Severe and prolonged de-
ficiency of ascorbic acid produces
scurvy. Because of the walls of the
small blood vessels become fragile,
hemorrhages occur into the skin and
into the gums, which become large,
red, and swollen, and bleed easily when
Vitamin D. This vitamin is unique
in human nutrition in that it can either
be eaten, or synthesized in the skin
when the latter is exposed to the ultra-
violet light of sunshine.
Dietary vitamin D is found only in
certain animal foods, especially fish
liver oil, egg yolks, and milk, and its
products. Human skin contains a sub-
stance which, when irradiated by the
utraviolet rays of sunlight, becomes
converted to vitamin D, which is then
available to the body.
Vitamin D is required for the ab-
sorption of calcium from the bowel and
for the formation of strong, well cal-
cified bones. Deficiency leads to rickets
(p. 90) in children, which is charac-
terized by deformed, soft bones.

It is difficult to give a realistic rec-
ommended daily allowance for vitamin
D, because in tropical regions little
of this nutrient is obtained from the
expensive animal foods just mentioned,
and is mostly synthesized by the skin.
The occurrence of rickets will, there-
fore, depend on various factors likely
to prevent a child from being exposed
to sunshine, including over-clothing,
the degree of cloudiness, and the avoid-
ance of exposure by parents according
to various local customs (p. 90). It is
possible that vitamin D is synthesized
somewhat less easily by children with
darker pigmented skins.

Mineral Salts. A variety of different
minerals is required in the diet for
the healthy functioning of the human
body, including some known as trace
elements, which are needed only in ex-
tremely minute quantities. The present
account will deal only briefly with sev-
eral more important minerals--iron,
calcium, iodine, fluorine, and sodium
Iron. This is principally required for
the formation of the red blood pigment,
hemoglobin, which is responsible for
carrying of oxygen through the body.
The newborn infant relies for his iron
needs, in the early months of life, on
the stores laid down in his liver during
fetal life, again emphasizing the re-
lationship between maternal diet in
pregnancy and the infant's subsequent
nutrition. This is especially important
since both human and cow's milk, the
principal foods most likely to be taken
during the first months of life, are poor
sources of iron.
From at least six months onward, it
is important to include iron-containing
foods in the child's diet, because his

blood volume is growing as rapidly as
his body.
In later childhood, iron needs are
much less, but in many tropical coun-
tries, requirements may be increased by
the continuous loss of small quantities
of blood through certain parasites, espe-
cially the hookworm, which imbeds it-
self in the wall of the small intestine and
feeds on blood sucked from its host.
This continuous loss of blood is thus
a cumulative drain not only of iron, but
also protein.
Dietary iron comes from both animal
and vegetable foods. Meat is a good
source, as is such offal as liver, kidneys,
and pancreas, but these sources are
most unlikely to play a significant part
in the diet of tropical children. Another
source of potential significance to in-
fants is egg yolk, which is, as a whole,
much under-used in infant feeding in
developing countries.
Of more practical consequence are
dark green leafy vegetables, which are
rich in iron; although, as with other
vegetables, the content varies with the
amount of iron in the soil. Grain cereals
are also useful sources. Other factors
which affect the amount of iron taken
in include the concentration in drinking
water and the use of iron cooking pots.
The latter can raise the iron content of
foods very considerably.
Different iron compounds, however,
are absorbed with different degrees of
ease. Various intestinal infections and
diarrheal diseases, such as are common
in children in the tropics, may also fur-
ther interfere with absorption.
Calcium. This mineral is principally
required for the formation of bones and
teeth. In addition, a regular intake is
required because there is a continual re-

lease and excretion of calcium from the
The best sources of calcium are
human and animal milks and their prod-
*ucts, and the bones of small fish. Vege-
table foods, especially cereals and par-
ticularly millet, provide some calcium.
The calcium content of water varies
considerably but, in some circum-
stances, may supply a significant por-
tion of the daily requirements.
The recommended daily allowance of
calcium for young children and for
school children is given elsewhere (Ap-
pendix I). However, this is not always
valid. The absorption and utilization of
calcium is much bound up with the
availability of other nutrients, includ-
ing vitamin D and phosphorus, and
may be impaired by other constituents
of the diet. It seems also that some com-
munities may have become adapted to
higher or lower intakes.
Iodine. This mineral is required for
the normal function of the thyroid
gland and, in particular, for the produc-
tion of its hormone, thyroxine. Defi-
ciency leads to a visible swelling of the
thyroid gland (goiter). If large, this
can be disfiguring or even cause pres-
sure on the trachea (windpipe).
Iodine is widely distributed in the
soil, but is less concentrated inland,
especially in high mountainous areas,
from which it has been washed out over
the centuries by the rain.
The iodine content of vegetables is,
therefore, greater away from moun-
tainous areas. Fish and other seafood
are rich sources.
Fluorine. This mineral is mostly pres-
ent in the skeleton and in the teeth. It
now seems well established that rela-
tively small quantities protect the teeth
from caries.

in some parws 0I. m wu-lu mu w -GJ
supply may naturally contain an ex-
cessively high content of fluorine, lead-
ing to a deposit of this mineral in
bones and teeth fluorosisis"). This can
be recognized in school children by the
scattered patches of dark brownish
mottling on the teeth and, in severe and
long lasting cases in adults, by the de-
velopment of calcification of ligaments,
especially those of the back. This leads
to a rigidity of the spine and other
joints with inability to bend and move.
Various Minerals. The body requires
various other minerals in small quanti-
ties to carry out its function in a nor-
mal way. In particular, in tropical coun-
tries where perspiration can often be
excessive, sodium and chlorine are re-
quired to replace the salt (sodium chlo-
ride) lost in the sweat.
In addition, many communities have
developed a preference for food which
is flavored with salt, either during cook-
ing, added later, or both. So strong is
this drive for salt that in ancient times
it was actually used as currency in
some parts of the world, as witnessed
by the present-day word "salary."
In inland areas of Africa and else-
where, salt caravans were an important
part of the local commerce, while var-
ious salt-containing earths, or prepara-
tions of ashes of plants were used as
salt alternatives.

Water. Water is a vital part of all
diets. The human body is composed of
over 60 percent water, and an adequate
daily intake is required to make good
the losses in the urine, in the feces, in
the moist expired air and in perspira-
tion, both visible and invisible. The
turn-over of water is especially great in
early childhood, and the infant can
easily be precipitated into fatal dehy-

UU.aVU .Uj au.a.t IM s .V.a.Ul v-. -n-
arrhea or vomiting.
Water in the diet may be drunk as
such, or it can be taken in various bev-
erages (including milk, tea, and alco-
holic drinks). In addition, it is also
taken "in disguise" as a part of fruits
and in cooked dishes, as in porridges,
gruels, and stews. The amount of wa-
ter required will, therefore, depend on
various factors--the local climate, the
degree of activity, and on the intake of
other water-containing items.
For young children, the risks of wa-
ter must be appreciated. Most sources
of drinking water in tropical regions
are likely to be contaminated sources of
bacterial infection, and so lead to diar-
rhea from intestinal infection. It is for
this reason that, unless indicated by an
exceedingly hot, dry climate, it is often
best for young babies in tropical com-
munities not to be given extra drinking
water in the first four to six months of
life. It is probable that they can usually
obtain adequate water, as well as other
nutrients, from their mother's milk.
The risk of producing dangerous diar-
rhea by giving dirty, contaminated
water from an unclean utensil is ex-
tremely great.
If water is given to babies and young
children, attempts should be made to
persuade mothers to keep clean water
available, to boil it and to feed the
infant from a clean utensil. However,
for various practical and cultural rea-
sons, mothers are often reluctant to do
this. They often do not understand its
purpose and perceive very clearly the
extra difficulties it will entail, including
use of fuel.
In some communities, it is custom-
ary to give young children weak tea or
various indigenous herbal brews, in-

ose called in the West Indies, regions,
." Some of these have been the blant
e harmful to young children the Bagal
be avoided. However, some unspiced
btedly harmless and may and the
in valuable nutrients, includ- dian cui
n C. Under these circum- Mexico.
may be possible to suggest Extren
uted infusion of a harmless chili, pre
as the leaves of the orange of young
I trees, as this will ensure sary to 1
iter given will be boiled in prior to
Sof making the infusion, substance
On the
s. Various foodstuffs or have little,
tances are used principally the excel
,or, coloring or texture that chilies, a
a foods. Thus, saffron can be and vital
- a yellow color to rice. Okra products.
ngers") is widely used be- Substa
ts viscous thickening prop- cover a vi
voring agents are mostly following
om plant products, which i. Flon
ftinctive tastes and odors, saffron;
he appetite and stimulate 2. Fru
retion. They thus enliven the 3. See,
)hydrate staples, which com-
All- rnf rmnf trrxil ;l-+.

tremes can be seen between
saltless steamed plantain of
la of East Africa, taken with
groundnut (peanut) sauce,
ghly flavored masala of In-
ies or the chili beans of

flavoring, especially with
mnts problems in the feeding
children because it is neces-
epare the foods for infants
te addition of these irritant

whole, most flavoring agents
direct nutritional value, with
ion of the ascorbic acid in
I the increased digestibility
in B content of fermented

;es used as flavoring agents
y wide range and include the

ers and buds: capers, cloves,

s: tamarind, chili;
: caraway, cardamom, pep-
per, mustard, coriander,

Century sailing ships, whose diets were
usually almost devoid of vitamin C.
Dietary Excess. Excessive intake of
certain nutrients can also lead to forms
of malnutrition. In the well-fed indus-
trialized countries, the most widespread
example is obesity, which results from
a Calorie intake that is in excess of the
body's energy expenditure.
With many nutrients, an excessive
intake may be stored, and, when the
stores are full, the surplus is excreted
in the urine. However, a few nutrients
are harmful if taken in very large
quantities, in particular vitamins A
and D. Nevertheless, this is very un-
usual with actual diets eaten by most
human groups, but poisoning by these
two vitamins does occur occasionally
in children in industrialized countries
as a result of the accidental swallowing
of large quantities of vitamin concen-
Dietary Imbalance. Malnutrition may
result from an incorrect balance be-
tween various nutrients in the diet. The
most important example is one of the
severe forms of protein-Calorie malnu-
trition of early childhood, kwashiorkor
(p. 75). In this condition the diet is
unbalanced with a low intake of pro-
tein, but with a relatively high con-
sumption of carbohydrate Calories.


Foodstuffs not only have to be pro-
duced but also stored, preserved, and
ultimately prepared for human con-
sumption. Problems of food storage and
preservation are considered elsewhere
(p. 45). The present account will deal
with certain general aspects of food
preparation in relation to nutrition,

Preliminary Preparation. While
some foods, such as fruits, are eaten
raw and others with only little prelimi-
nary preparation, many foodstuffs un-
dergo preliminary physical or chemical
preparation prior to cooking. At its
simplest, this may be considered to in-
clude the peeling and cutting up of
vegetables into suitably sized pieces.
Similarly, the removal of the indigesti-
ble husk of cereals and the grinding
of grain into flour are parts of the
same process, whether carried out by
hand in the village or industrially by
the large modem mill.
Various communities have developed
complex preliminary treatment of food-
stuffs designed to improve their flavor,
digestibility or to remove harmful sub-
stances. The Indonesian food, lempeh
consists of soybean on which a special
fungus has been implanted and allowed
to grow, in order to predigest this food.
In many countries, the protein-digesting
properties of the leaves of the pawpaw
tree have been recognized, and meat is
sometimes wrapped in them for some
hours prior to cooking. Similarly, green
unripe pawpaw, which also contains
this enzyme, can be added to protein-
containing stews. A dried extract of the
unripe fruit of the pawpaw is com-
mercially available in Western coun-
tries as a meat tenderizer.
In the preparation of cassava, espe-
cially certain bitter varieties, it is neces-
sary to remove the poisonous hydrocy-
anic acid, which is particularly present
beneath the peel of the roots. Various
methods have been devised by peo-
ples in different parts of the world,
often consisting of cutting the root into
small pieces, washing, and eventually
Much of this preliminary preparation

or oy losS oi waier- me heLio, storage ptac
as a result of over- and by observing theii
igh cooking for too the village kitchen itsd
oater which is then must be based on indigo

cal and physical changes which improve
their digestibility, palatibility, flavor,
appearance, and in some cases, their
keeping quality also. Thus, cooking
causes the swelling of starch granules,
which then burst out of their cellulose
envelopes, and with meat causes coagu-
lation of muscle protein and conversion
of collagen fibres to gelatin. In both
instances, digestibility is improved.
However, over-cooking may defeat its
purpose and actually destroy nutrients,
such as the heat-sensitive vitamin C, or
make certain amino acids unavailable.
There are many ways of cooking
foods, but, in most tropical countries,
they are usually restricted for such eco-
nomic reasons as the cost of fuel and
kitchen apparatus, such as pans and
ovens, by the range of foods locally
available, and by the indigenous culture
pattern. The cooking procedures em-
ployed will, therefore, be simple in type
and limited in scope, and are likely to
rely especially on boiling, steaming, or
barbecuing on the open embers. Some
communities use other less common
methods, such as the umu (stone-filled
cooking pit) of Polynesia, or the plan-

ing practices.


The Westerner working in a tropical
country will find many unfamiliar foods
and therefore all nutritional workers
must have a working acquaintance with
:he more important of these, and must
recognize the nutritional qualities and
other properties of local foods.
Once again, this should not only be
a theoretical knowledge, but should be
reinforced by first-hand observation of
local foods growing, in the market, be-
ing preserved, prepared, and cooked.
It is difficult to classify foodstuffs
rationally and the following account is
based, in part at least, on practical
considerations: (1) Roots, plantains,
and so forth, (2) Cereals, (3) Legumes,
(4) Vegetables, (5) Fruits, (6) Ani-
mals protein foods, (7) Oils and fats,
mnd (8) Miscellaneous.

Roots, Plantains, and so forth.
These foods are considered together be-
cause they are largely sources of carbo-
hydrate Calories, with a low protein

content (1-2 percent), while also con-
taining much water and fiber. For these
reasons regions which use these low
protein staples are very likely to show
protein-Calorie malnutrition of early
These foods are particularly difficult
for children to eat in nutritionally ade-
quate quantities, because they are both
low in protein and also extremely bulky.
It is often difficult for a young child
even to be able to satisfy his Calorie
Yams. These tubers are used in many
parts of the world, especially in the rel-
atively rainy tropical areas, such as
parts of Africa and the New Guinea
coast. The protein content of yams is
about 2 percent. They are not easy
to cultivate and need careful attention.
For storage, they need specially pre-
pared "pits" or dry, ventilated yam
Sweet Potato. This root crop has a
protein content of between 1-2 per-
cent. Yellow varieties have a relatively
high level of the provitamin A, caro-
tene, but the white varieties are used
more commonly in tropical regions.
Cultivation requires some degree of
continuous attention.
Taro (Cocoyams). In parts of Poly-
nesia, some areas in Africa and parts
of the Caribbean, taro forms the staple
food of the community. In Hawaii, a
slightly fermented paste is the ancient
staple (poi), which is still popular.
Cassava (Manioc). Cassava, is easy
to grow, requires little attention and is
able to withstand climatic adversity. It
has a high yield (7 to 10 tons per acre)
and a high Calorie yield per man-hour
of work. It can remain "stored" for
some years in the ground before har-
vesting. It has, therefore, been intro-

duced into various parts of the world,
including regions of tropical Africa,
as a reserve or "famine food." How-
ever, because of the high yield and
ease of cultivation, its use has spread.
This is a matter of considerable con-
cern, because cassava is essentially
only a stomach-filling source of carbo-
hydrate Calories, with a protein con-
tent of less than 1 percent.
As mentioned earlier, hydrocyanic
acid is present beneath the outer coats
of the roots and is removed by different
traditional methods in various parts of
the world. Cassava can be boiled as a
vegetable but is often made into a
flour, which can be used to produce
forms of porridge, unleavened bread,
or various fermented preparations.
Often neglected is the fact that cas-
sava leaves, especially the young ones,
can be eaten and are an extremely val-
uable foodstuff, which, if taken together
with the cassava root, help to improve
the plant's nutritional value.
"Vegetable Fruits." In some parts of
the world, notably in areas of East
Africa, the plantain, a term often ap-
plied to varieties of the banana family
that are cooked when green and unripe,
is the staple food. Again, this is ex-
tremely low in protein (1 percent).
Many different varieties exist. The
plantain can be cooked by boiling,
steaming, roasting, or using a flour
prepared from dried fruits.
Another "vegetable fruit" is the
bread fruit, which is a secondary staple
in Polynesia and in certain islands in
the West Indies. It is usually roasted or
Miscellaneous. Various other foods
are included here not because they are
botanically similar, but because they,
too, have a very low protein content and

p almost entirely of carbo- bread, or
.ories. These include arrow- ious prodi
. is a flour made from the if subsec
lined from the roots of a liquor.
n tuber and sago which is The pre
aom the pith of a variety of young chi
rhey are both almost devoid Boiling v
are almost entirely starch flour is ei
sastrous if used for infants easily digit
,er items of food. Rice. R
thirds of
The group of foodstuffs eluding n
cereal grains are not only more por
sources of carbohydrate Cal- tions, in
[so contain significant quan- world inc
protein (about 10 percent), ica, Afric.
s they are consumed in large Many i
They are also good sources ent parts
d the vitamin B complex. glutinous
*in has a low content of the Malaysia,
aino acid, lysine. name sug
ire prepared by de-husking individual
mes thereafter by milling. adherent,
of de-husking and milling is Thiami
he desired characteristics of quantities
Aduct. The more severe the can be ve
milling the whiter the end milling, o
.d the greater the loss of ing in to
which go with the germ, in- since thi,
ecially thiamine. Overmilled some con
with its low content of paddy is i
s sought after in parts of fore dryii
unfortunate consequences as parboiling
lead to the development of it causes
ficiency, beriberi. Similarly, substance
igh extraction wheat flour Rice is
U.S.A. and Western Europe ing, so a&
eted of its protein and vita- It is impm
lis process. In both Japan than is ne
S.A., the thiamine removed ble by yc
nd wheat by excessive mill- soft and
luce a white end product is prepared i
zed by synthetic thiamine. from soft
t-husking, cereals may be Corn 1
uinch or made into flour and came orif
ired as pastes, gruels, or has been

fermented to produce var-
Its, including gruel beers or,
gently distilled, alcoholic

ration of cereals for use by
[ren is comparatively simple.
th water, especially if the
played, will give a smooth,
stible paste.
ce is the staple food for two
he world's population, in-
>st of Asia. It is becoming
lar, especially for celPF
lany different areas of the
hiding parts of Latin Amer-
and the West Indies.
rieties are grown in differ-
of the world, including the
rice of northern Thailand,
md Viet Nam which, as the
ests, does not boil to form
grains but rather forms an
lutinous mass.
is contained in some
in rice germ. However, it
y largely removed by over-
by over-soaking or by cook-
large a volume of water,
nine is water soluble. In
nunities in India, the rice
eaked and briefly boiled be-
Sand storing. This process,
is nutritionally valuable as
hiamine to diffuse into the
> the grain.
lost usually cooked by boil-
to leave individual grains.
tant not to use more water
essary. Rice is easily digesti-
ng children, and especially
litable preparations can be
i the form of pastes or gruels
oiled rice or from rice flour.
Maize). This crop, which
nally from South America
Lken by man to many parts

ot me world. it nas a mgi
acre, but nutritionally corn I
advantage of being not only
amino acid, lysine, as are al
eal grains, but also being i
the B vitamin, niacin, ar
amino acid, tryptophan, fi
the body is capable of syntl
acin. It is for this reason 1
deficiency, pellagra, occurs
clusively in areas of the w
corn is the major food.
Corn may be eaten on thl
boiling or barbecuing. It ma
at home or commercially to
grees of extraction, prodt
flour, the staple food of ma
communities. Unfortunately,
ration of preferred white floi
overmilling and often repeat,
with water which removes 1
In the Mayan cultures
America, a particularly value
od of preparing corn has
played for centuries. In th
corn is initially treated for
with lime before being cool
tillas. This has the adv
enriching the grain with ca
improving the amino acid
available niacin.
All over the world attem]
duce higher yielding and be!
foods are under way and
mentioned that outstanding!
pears to have been achi.
corn-the so-called "opaqu
ety-which has been shown t
percent more lysine, the limit
acid, than the usual varieties
Millets. Numerous species
eties, particularly finger mill
millet, and sorghum, can b
under this general heading
the advantage of being rel

yleia per sistant to arougnt and can
is the dis- for years after harvesting.
ow in the they require considerable ca
other cer- vation, especially with regain
eficient in ing off animals and birds
I another grain is ripening. In add
,m which small, rather tough grains
sizing ni- crops require much time-,
Lat niacin pounding or milling in thei
Almost ex- tion. This is often carried ,
rid where village and is a considerable
for the housewife; occasion
cob after flour is avaliable commerce
be milled cause of difficulties in cult
trying de- preparation, the millets are
ing corn be grown less, and to be re
y African nutritionally inferior crops
;he prepa- cassava and maize.
r includes The grain itself is usually)
1 washing gestible to be eaten boiled. .
:otein. commonly prepared from th
I Central the form of gruels or so-calle,
ble meth- looking like thick mashed pi
been em- Africa various fermented m
method, ucts are eaten or drunk in tl
ome time alcoholic gruel-beer.
d as tor- Wheat. Wheat is a major
atage of parts of the Eastern Mediter
,ium and West Pakistan and Northe
alue and and in regions of China. It
used as a flour, as in the p:
:s to pro- of unleavened bread pancake
-r quality tis) or Chinese noodles. In L
: may be interesting wheat preparation:
access ap- nutritional value is prepare,
led with form of burghul. In this pr
2" vari- wheat is parboiled so that thi
have 150 is diffused throughout the
ng amino same as with parboiled rice.
The flour prepared after i
and vari- often mixed with locally
bulrush dried sour milk. The result
included sour milk powder is known a
All have and is a valuable food f
lively re- children.

ciu i slb BmJlaulIll aa a piuca- ULIUI Wi
nience food in tropical urban yield ca
s often superior to the local including
n parts of West Africa where larly we
the main local food. In some With
ie world, protein enrichment culty, ar
ias been attempted with soy triton o
t, lysine or fish flour. 75) the I
in world
, Nuts, and Oilseeds. In e cd
is group is not only a good the diet
calories but is also the prin- treatment
source of protein. The u
s. Legumes as, a group con- is lir
is lin
20 percent protein, except ibiity.
particularly protein-rich soy- b
be given
h contains up to 40 percent.
the protein in legumes is can be
deficient in the essential acid, portant
., which is the limiting amino thorougI
mes are also sources of the simple r
x and iron. Their vitamin through
including vitamin C can be stratinin
ful to sta
ly increased by allowing
terminate and sprout before parts of
grain) tF
; are of especial importance to gradu
n together with the staple the latter
was also the case in medi- Possil
pe when pea flour was used sociatior
in the preparation of bread cooked 1
or. ability an
re at least 70 varieties of taboos
'he problem of their identi- parts oft
often difficult, since many children.
es often look different. Also, Most
ames in different languages, whole, al
English, often further con- prepared
sue. cooked x
crops are extremely impor- or gruel
ly nutritionallybut also agri- dry panc
;ince they have the property is applie.
itrogen from the atmosphere gumes w]
it in the soil. a wide E
are compact and take up treatinenl
hult rPomrP *rnrfI*l ctnrnn

a nign percentage ot the
be lost as a result of pests
rodents and insects, particu-
rotein shortage a major diffi-
with protein-Calorie malnu-
early childhood (PCM) (p.
principal public health problem
ide nutrition, legumes can be
:o play an increasing part in
'y prevention, and even the
of PCM.
Sof legumes for infant feed-
ited by their relative indigest-
'nly small quantities should
initially, although the amount
gradually increased. It is im-
o ensure that legumes are as
y cooked as possible, by such
eans as removing the skins
making prior to boiling or by
after cooking. Often it is use-
t with a basic mixture of four
staple (preferably a cereal
one part of legume and then
Ily increase the proportion of

y because of the known as-
of large quantities of ill-
gumes with lack of digesti-
loose stools, there are many
id restrictions in different
e world on their use for young

egumes are usually boiled
hough various flours may be
from them which can be
ith water to produce a soup
r made into a variety of thin
kes. In India, the term dhal
to a variety of different le-
Ich are dried, passed through
wve, and then given several
with a stone grinding ap-
]!_ I- 1 -* A1I

split end product is ultimately boile
to form a thin paste.
It is not possible to consider a
varieties of legumes here. Whereve
work is being carried out, it is nece.
sary to discover the most easily avai
able and economical varieties o
legume to buy, their protein compose
tion, their alleged digestibility, their
cultivation characteristics as regard
yield and resistance to disease and ch
mate, and local attitudes toward thei
use for feeding young children.
Brief notes follow on certain legume
because of their particular significance
1. Kidney bean (French bean, Hari
cot bean, Navy bean), (Phaseolu.
vulgaris). This is one of the most wide
spread of all legumes, although its phy
sical appearance varies from one vari
ety to another. It has a high protein
content and, because it is frequently
easily available, it deserves to be in
eluded more than it is at present ir
village-level infant food recipes. It i,
usually prepared by boiling and ex
perience has shown that it is impor
tant that the skin be removed before
giving the bean to the child to eat. This
can be carried out before boiling (when
it can be accomplished by soaking
overnight or scalding), or after cook-
ing has been completed.
2. Chick-pea (Cicer arietinum).
This legume deserves special mention
because after cooking it can be mashed
easily to produce a very smooth and
digestible paste. Wherever it is avail-
able, it should be seriously considered
as a possible high-protein vegetable
food for incorporation into infant mix-
tures, both in the village kitchen and
when prepared commercially.
3. Groundnuts (Peanuts). This crop

sing a high protein content but als<
because of its 40 percent fat, being ric
I in Calories. The groundnut is also
good source of the vitamin B complex
In villages, the groundnut may b
eaten raw or after roasting. For culi
nary purposes, it is often pounded int,
a powder and then used in pastes
sauces, stews, soups, or milky drinks
If roasted and passed through a minced
a thick peanut butter-like preparation]
will be produced, which is often rel
ished by infants.
Groundnuts are grown commerciallT
mainly for their oil. After this has beei
extracted, the groundnut presscake i
usually sold for animal feeding, but i
represents a largely untapped potential
source of groundnut flour which, aftei
further refining, may then be used foi
child feeding either by itself or incor
porated into a variety of commercial)
prepared high-protein infant food,
(p. 140).
Unfortunately, the situation has beer
complicated by the discovery thai
groundnuts harvested in hot, moist cli.
mates grow a fungus (Aspergillm
flavus) which produces a highly toxic,
water-soluble substance, aflatoxin. This
material is poisonous to various animal
species, especially their young. When,
for example, contaminated groundnuts
were used as the main source of the
diet of young turkey chicks, there was
an appreciable mortality from liver
Although no clear case of aflatoxin
poisoning has ever been described in
human beings, it is necessary to exer-
cise more caution before urging the
increased use of groundnut flour in the
preparation of infant foods. Current
information shows that if groundnuts

soybean preparation) and ketjap (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

amounts ot carotene, vitamin U, and
minerals; while their limited proteins
may supplement those of the staple

Some vegetables are used fresh, al-
though some can be stored or even
dried. Some are eaten raw, although
more often they are cooked, frequently
bv boiling or steaming.
It is convenient to consider vegeta-
bles not with botanical precision, but
in approximate relation to the parts
of the plant eaten, that is, roots, stalks,
fruits, flowers, and leaves.
1. Roots. These comprise certain
root crops which cannot be considered
as staples. They usually contain less
than 10 percent carbohydrate and in-
clude carrots and turnips.
2. Stalks. In tropical regions, these
will include such items as bamboo
shoots, young ferns, and the palm cab-
bage (the heart or growing center of
the palm tree).
3. Fruits. A wide variety of different
items may be classified as "vegetable
fruits." Two of these, namely the plan-
tain and the breadfruit, can better be
regarded as staple foods. Other vege-
table fruits include the large family of
pumpkins and gourds, the tomato and
allied species, and the avocado pear.
The gourd family is important as a
source of carotene. The avocado pear,
which grows widely in many tropical
countries, possesses a soft, easily
mashed, digestible, and high-oil flesh
which can be incorporated very easily
into the food of young children without
4. Flowers. While it is not custom-
ary to think in terms of consuming
flowers, the cauliflower is eaten in the
temperate zone, and in the tropics,
various flowers, including those of the
banana, may form a minor part of the
5. Leaves. Green leafy vegetables are
i nili rontr, nrnlnA ni ITf

many parts of the world. Thus, in the
Western world lettuce, cress, cabbage,
and mustard and turnip greens are
widely consumed. In the recent past,
a wide variety of "wayside herbs" were
eaten, especially by the less well-to-do.
In tropical regions, it is the dark
green leafy vegetables that are particu-
larly valuable and, at the same time,
very often much underused, partly be-
cause they may be regarded as low
prestige food of the poor. Many of these
dark green leafy vegetables are to be
found in a semiwild state and grow
very easily with minimum attention in
household or school vegetable gardens,
or in the compound.
Dark green leafy vegetables, espe-
cially young leaves, are valuable nutri-
tionally. They not only contain impor-
tant quantities of carotene provitaminn
A), vitamin C and the B complex, cal-
cium and iron, but also have a signifi-
cant protein content, the composition
of which complements that of cereal
grains and tubers. Thus, young cas-
sava leaves contain 7 percent pro-
tein and so-called tropical spinach
(species of amaranthus) contains 4
percent. In addition, green bean pods,
which may be eaten as vegetables, con-
tain 2 percent protein.
There is a wide variety of these edi-
ble dark green leafy vegetables available
in most tropical countries, including
the leaves of the sweetpotato, various
beans, and peas, okra, cocoyams,
hibiscus, pumpkins, and baobab. It is
important that these should be used,
especially as there are in some parts of
the world indications that they may be
superseded by vegetables such as the
cabbage, which has more status but is

plucked, although old leaves can be
used if they are cooked rather longer.
If need be, they can be dried, pow-
dered, and stored for subsequent
Increased attention has recently been
given to the possible use of cassava
leaves, as the cultivation of this nutri-
tionally poor staple is spreading. The
nutritional value of the plant may be
considerably increased if the leaves are
also eaten, either by the occasional
plucking of some of the newer ones or
by using all the leaves when the root
is finally dug out for consumption.
Dark green leafy vegetables may be
shredded, chopped, or pounded in a
mortar and subsequently mixed with
other foods intended for young chil-
dren. Alternatively, preserved pow-
dered leaves may be used.

Fruits. Once again this is a general
word that is very difficult to define with
precision. Possibly the best definition
is "a cultivated or wild product with a
sweet soft flesh, pleasantly edible when
ripe in the raw state."
Nutritionally, fruits are important
principally as sources of vitamin C and,
in some cases, of the orange-pigmented
vitamin A precursor, carotene. Other-
wise they are composed principally of
water, cellulose, and some fruit sugars.
They have the advantage of not re-
quiring cooking, if eaten ripe.
It is important to appreciate that
there are many tropical fruits which
are extremely good sources of vitamin
C and often much more easily accessi-
ble locally and more economical than
the citrus fruits which are usually
thought of in the Western world. Thus,
in various tropical regions of the world,

baobab tree, fruit of the cashew nut,
and, as a very rich source, the Barbados
cherry acerolaa).
The following fruits may be men-
tioned particularly:
Papaya (Pawpaw). This fruit is very
widely distributed in the tropics and
frequently is not used nearly enough
especially for young children. Various
food attitudes and taboos may be partly
responsible. The dark yellow, orange,
or red sweet edible pulp of the fruit
is rich in vitamin C and carotene. It
is soft, pleasant flavored, easily mashed,
and can be fed to young children with-
out cooking.
Mangoes. The dark yellow or orange
flesh of the mango is particularly rich
in carotene and vitamin C. Also, espe-
cially in the larger varieties, it can be
a source of Calories for school children.
Bananas. Although mainly of value
for its Calories, the sweet banana also
contains small quantities of carotene
and vitamin C. The advantage of the
sweet banana is that when fully ripe, as
judged by the appearance of brown
spots on the skin, the fruit pulp will
have become soft, easily mashed, di-
gestible and sweet, as the starch gran-
ules will have been converted into
sugar. It can, therefore, be used imme-
diately for young infants without cook-
ing and can be mashed and mixed with
other foods with a higher protein
Dates. The fruits of the date palm
are more often used when dried and,
as in the desert regions of North Africa,
may be an important, easily transport-
able, and a preserved source not only
of Calories but also, to some extent, of
protein (2-4 percent).
A wide variety of other familiar and

particular region, both cultivated and
collected wild. These may include pine-
apple, Cape gooseberry, cactus fruits,
a variety of citrus fruits, various types
of soursops, and so forth. Local sources
should be sought for in any region.

Animal Protein. Animal protein
foods are everywhere the most expen-
sive and difficult to obtain, and they
are often used only for celebrations
and as prestige items. All over the world
large numbers of food attitudes, ta-
boos, and prejudices, often of a re-
stricted nature, are associated with the
use of animal protein foods. These often
are directed at women and young chil-
dren and tend to limit their intake of
animal protein.
Animal proteins contain all of the
eight essential amino acids in abund-
ance. If available, even in small quan-
tities, they are best used together with
vegetable foods, preferably with a com-
bination of a legume and a cereal staple.
In this way, the nutritional value of
the plant protein foods can be enriched
as the amino acids in which they are
deficient can be made good from the
rich surplus in the animal protein.
The question of the absolute need
for animal protein in the human diet,
especially for young children, has not
yet been conclusively determined. Most
so-called vegetarians usually take some
form of animal protein food, particu-
larly milk or its products. It has been
shown, however, that young children
grow adequately on vegetable protein
mixtures and that even severe types of
protein-Calorie malutrition, maras-
mus and kwashiorkor, can be cured
by vegetable protein mixtures alone,
although recovery is slower than when

The present view is that vegetable
protein mixtures will form the main-
stay of infant feeding in most develop-
ing tropical countries, but that the
addition of at least small quantities of
animal protein to these diets should be
the aim, wherever possible.
Meat. With the exception of certain
hunter and pastoralist groups, animal
meat plays an extremely limited part in
the diet of tropical peoples. It is usually
reserved for celebrations or special
occasions, when most of it will go to
adults, especially to male elders. Young
children will rarely receive meat and
even when it is available it is usually
tough and often ill-cooked, so that its
preparation for infants poses problems.
Simple, locally appropriate methods oj
chopping, shredding, or grating meat,
either before or preferably after cook.
ing, have to be devised to make meal
palatable for infants.
Meat is a source not only of proteir
but also of the B vitamins and of iron. A
variety of different meats may be eater
by, or prohibited to, different communi
ties in the world (p. 62). These include
such items unfamiliar to the Westerne
as dog, newborn rat, kangaroo, monkey
snake, and hyena. Although unfamiliar
and culturally difficult to appreciate, th,
meat of these creatures is not mud
different nutritionally from that of do
mesticated animals. In addition, ii
many communities insects form a par
of the local dietary, often seasonally. Ii
various parts of the world these include
snails, locusts, grasshoppers, lake flies
various caterpillars, and flying ant,
While insect eating is strange to th
Westerner, it must be remembered thE
the secretion of one insect, the bee i
widely relished as honey.
Blood. In a few communities, notabi

in Africa, blood is used and is obtained
from cattle by puncturing a vein in the
neck and "bleeding" off a quantity,
which can then be drunk as such, or
allowed to clot and mixed with other
foods, or which can be dried to form a
Milk. Man being a mammal, he rears
his offspring with milk. However, man
alone among other mammals, has in.
produced the milk of other animals it
the diet of his young. The composition
of the milk of different mammals varies
considerably. Some, like the seal's, th(
camel's and the reindeer's are rich in
fat; others contain more protein thai
some. However, all contain protein
milk sugar, fat, calcium, and vitamins
both of the fat- and water-soluble kinds
All milks are poor in iron. The concern
tration of these major ingredients alsc
varies considerably from one species t(
another. As a result of the selective
processes of evolution, each species pro
duces the milk whose composition ii
optimal for its young. In other words
cow's milk is the specific food for grow
ing calves and human milk is the bes
food for human infants. Cow's milk cai
only -be regarded as second best anm
artificial in the nutrition of humai
1. Human Breast Milk. This valuable
and traditional source of clean, digest
ble, specially adapted, high quality prc
tein baby food is very frequently ovei
looked, possibly because it is not con:
only sold on the market! Its amin
acid composition is such that it ha
been used as a reference standard o
protein excellence. However, like a
* other milks, it is low in iron. While il
i protein content is relatively unaffecte
by inadequate maternal nutrition, ii
content of water soluble vitamins (th

amine and vitamin C) can become de-
ficient if the lactating mother's diet is
low in these nutrients. Also, if the
mother's diet is deficient, the output of
breast milk may be diminished, espe-
cially in late lactation. Eventually the
nutritional drain will be felt by the
mother herself in the form of maternal
While breast feeding is desirable in
any part of the world, it is of particular
importance in developing tropical re-
gions in terms of nutrition, economy,
and sanitation.
2. Animal Milks. Animal milks used
in various parts of the world, both in
the general diet and as foods for young
children, include the milk of the buf-
falo, ass, sheep, goat, llama, reindeer,
and yak, but cow's milk is by far the
most commonly employed. Its composi-
tion is different from human milk: it
contains two to three times as much pro-
tein, the same quantity of fat, and half
as much milk sugar. The protein of
cow's milk is relatively indigestible;
however, it can be modified to suit the
needs of human babies in the first three
months of life by diluting it with water
to decrease its relative protein content,
by boiling it to make the protein more
digestible, and by adding sugar to it to
increase the caloric content.
Two points concerning cow's milk
require special emphasis, as they are
often not adequately understood by
Westerners. First, cow's milk is ex-
pensive when bought on the market in
developing countries. Because of its
price, it will be given in highly diluted
form. Second, because of environ-
mental conditions described in Chap-

able origin
specially 1
hosen in i
sources and
3. Comme
arge numbi
processed II
aercial corn
ypes are 4
ream and
nilks, evapc
ailk. Their

inies, all

ranean and elsewhere, various forms
of cottage cheese are available and
can be incorporated in infant food

, 0,7

cause of their keeping qualities but also
because they are more digestible and
perhaps less susceptible to infection
with harmful bacteria. Thus, amasi, the
sour milk of South Africa, has been
shown to be somewhat resistant to the
growth of tuberculosis bacilli. Wher.
ever these preparations exist, their use
in infant feeding should be considered.
Eggs. Although these are widely dis-
tributed throughout the world, they
are not generally used for young chil-
dren. Often they may be considered
rather as a form of "cash crop"; while
in many cultures strong food preju-
dices concerning the use of eggs for
infants are to be found. In parts of In-
dia they are considered to be too "hot,"
and in parts of eastern Nigeria, they
are believed to cause baldness in in-
fants. This is a pity, because not only
arp oara ;rh cnIIrF. n- nrnta nrfth

mino acids that t.

well-fed fowl

Eggs may be cooked in a variety of
ways, some of which, including boiling
and scrambling, are especially suitable
for young children. Alternatively, if
culturally acceptable, raw chicken's
egg may be beaten into the infant's
Fish. Fish and other sea products
remain a major unexploited natural re-
servoir of animal protein food in the
world. They are valuable nutritionally,
not only for their high protein con-
tent, but also because they contain
vitamin B complex, vitamins A and D,
calcium, and iodine. Fish also have the
advantage of being small compared, for
example, with the large carcasses of
animals, such as cattle or swine.
In addition to fish as such, a wide
variety of other sea products, such as
shellfish, crustaceans, and seaweeds,
are eaten in some parts of the world
and could be consumed more widely.
The nrinlinnl nrnmhblm limtintr thb

I 1

"r-irl ho 11l

g much attention.

-" bbo Vt VLut Ixo t-- j..-I 11-. ljU.y JJI inEuiCaSt u prIUUUUILIUII 01 U il ail
eaten in some communities, especially the village level is of great practical

of nylon nets and motorized canoes,
and encouragement should be given to
the development of fish ponds or fish
culture in wet rice fields.
Fish ponds have been in traditional
use for many hundreds of years in vari-
ous parts of the world, including China
and medieval Europe. Recent emphasis
has been given to the development of
fish ponds by governments and the
Food and Agriculture Organization of
the United Nations (FAO). Their use
is by no means without; problems. Sev-
eral species of fish need to be intro-
duced at one time, as otherwise very
large numbers of small fish of one
species may result. The pond has to be
cared for and organic vegetable mate-
rial, such as cut grass, has to be added
at appropriate intervals. The risk of
breeding malarial mosquitoes and the
spread of bilharzia has to be borne in
mind. Nevertheless, with due care fish
ponds can represent a valuable con-
tribution to village protein resources,
especially since they bring fish near to
rural homes. In some communities
these ponds can also be used for rear-
ing ducks and growing various water

Oils and Fats. Many animal and vege-
table foods contain fat or oil. In addi-
tion, various so-called "naked fats"
may be taken in the dietary as oils.
Fats are relatively expensive every-
where but owing to their high caloric
value they represent "compact Calo-
ries" which may be important for chil-
dren whose diet otherwise consists of
bulky carbohydrate foods of low calorie
Animal fat is present in meat, egg
yolk, milk and its products, and the
flesh of certain fish. Extracted animal
1... *-- 1---I- i.-t.- _-L__ -!--"1c-,, I ..1

ter), lard, and some forms of marga-
rine. Fats derived from milk are sources
of vitamins A and D.
By contrast, vegetable fats contain
no vitamin A or D. These include oils
obtained from the groundnut, sesame,
mustard seed, and cottonseed, coconut,
and oil palm fruit. The last is of par-
ticular interest because of its extremely
high content of carotene, the precursor
of vitamin A. Other fats derived from
plants, include vegetable ghee and
vegetable margarine.

Miscellaneous. Many foods are
eaten in various parts of the world
which do not easily fall into the cate-
gories already outlined.
Sugar. Most communities eat sugar
in some form or another, whether as
naturally occurring honey or sugar-
cane, or as prepared in the village as
jaggery, or as commercial crystalline
cane sugar. Sugar, especially in its re-
fined form, represents only naked Calo-
ries since it contains no other nutrients.
In industrialized countries, the sugar
intake is undoubtedly too high and, in
part, is responsible for the high inci-
dence of dental caries and obesity. The
same trend is also beginning to occur
in some developing countries.
In some communities, diluted sugar-
water is given alone for prolonged
periods to sick infants, with resulting
Alcoholic Drinks. Most, but by no
means all, communities prepare their
own alcoholic drinks. In some places,
these are prepared from fermented
grains, and take the form of thick al-
coholic gruel-like preparations. In parts
of Africa, these are still widely drunk
and apart from a source of Calories,
also contain vitamin C and vitamins
-,4 R P4, ~ l

prepared by the fermentation of milk,
or honey, or the sap of various palm
trees (palm toddy), including the
coconut, date, and palmira.
In addition, many groups of people
prepare high-alcohol liquors by distil-
lation. These include rice wine,
waragi in East Africa and white rum
in the West Indies. Nutritionally, these
products, in common with similar im-
ported alcoholic spirits, are sources of
energy alone (7 Calories per gram).
As anywhere in the world, the main
nutritional consequence of alcohol, as
far as young children are concerned,
is social in that if the parents spend
excessively on alcohol, then the chil-
dren are likely to be neglected and in-
sufficient money may be left to pur-
chase adequate food.
Caffeine Drinks. Beverages contain-
ing the mild cerebral stimulant caffeine,
are used in many parts of the world,
including, tea, coffee, and mate.
Nutritionally, these may be of little
consequence but supply needed variety
in taste and refreshment. However, in
some parts there is a tendency for a
high percentage of limited budgets to
be spent on tea or coffee or for mothers
to try to feed their young children on
tea with little or no milk with disastrous
results as the child is thus starved and

tant for their iodine content.
Likewise, a wide range of different
types of fungi are eaten in various parts
of the world. Although not making a
major contribution to any dietary, it
may be noted that fungi contain a small
quantity of protein and of the vitamin
B complex.


Although many different dietary pat-
terns exist in different parts of the
world, a certain general similarity can
be found in many regions, especially
among the less well-to-do.
For economic, geographic, or cul-
tural reasons, diets tend to be based on
a limited number of foodstuffs, cooked
in what to the outsider is a monoto-
nously limited range of different dishes.
The main bulk of the diet will be com-
posed of one or more carbohydrate
staples which will be eaten, very often
with smaller quantities of mixtures of
various vegetables, relishes, or sauces.
Nutritionally, the diet of many peoples
in developing tropical countries is
much bound up with the major staple
which is the main source not only of
Calories, but also of protein and other
nutrients. This dominance is often em-
phasized by the use of the same word
in the vernacular both for the staple

rL1;uLUkLUiy aLnu uuou1u1Lauy, Ym Not infrequently, only a limited
production of these caffeine crops is range of the potentially edible local
extremely important since in many re- foodstuffs will, in fact, be eaten. In par-
gions they may be a significant na- ticluar, there is often underuse of vari-
tional and family source of cash in- ous semiwild 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

drate Calories, but also to be relatively qualitative information concerning
bulky. feeding practices in the early years of
life. This can be carried out by means
VALUE OF DIETS of a questionnaire, particularly related
to the preparation, or otherwise, of spe-
1Methods of Assessment. There are cial protein-rich dishes for young chil-
various methods of trying to assess the dren. Local household utensils of known
r.1-h nf hll-nin i pt In mnr nnhqlti- __ .--I .I. -..-. .. _

naires may be issued to householders.
In developing countries, however, if de-
tailed accurate information is required,
it is usually necessary to carry out
dietary surveys by means of home visits,
during which the amount of food used
and cooked for the family can be re-
corded. Problems with this method are
numerous, both at the social level-in
gaining acceptability and in knowing
whether the diet on the days chosen
adequately represents the normal range
of food taken by the family-and at
the technical level-in estimating the
nutrient loss occurring during prepara-
tion and cooking, in taking into account
foods eaten out of the house, and in
allowing for seasonal variation in the
food pattern.
Dietary assessment is particularly
difficult with young children. This
should be a period of a gradual transi-
tion, when new foods are introduced
gradually in variable, but increasing,
quantities. At the same time, the young
child will also often be receiving breast
milk in quantities which are difficult to
Detailed dietary assessment will only
be possible for the non-nutritionist with
supervision. However, approximate
clues may be obtained by observing
food preparations and meals, especially
noting which items are given to young


to assess approximate quantities.
For young children, the question-
naire should cover in particular the fol-
lowing aspects related to the usual lim-
iting factor, protein intake:
1. Breast-feeding: still carried on or
not; complete or partial, i.e., night
2. Carbohydrate foods: types (e.g.,
part of adult foods, or specially pre-
pared gruels or pastes) ; quantities;
3. Protein foods-animal milk: type
(e.g., fresh or boiled liquid from
cow, goat, and so forth, sour milk
products) ; tinned- -powdered, con-
densed, or evaporated; quantities (daily
and monthly) ; cost; number, approxi-
mate timing and volume, dilution, and
other ingredients (e.g., sugar) in feeds;
method of feeding (e.g., bottle, cup, and
spoon, indigenous feeding vessel, and
so forth) ;
4. Other animal proteins: types
(e.g., eggs, fish, meat, etc.) ; quantity;
5. Vegetable protein foods: types
(e.g., legumes, green leafy vegetables) ;
quantity; frequency; method of
The questionnaire should be tried
out first and then can be used on a
sample group of mothers. It should aim
at ascertaining only the foods taken
currently, that is, in the past 1-7 days.

its construcnon win1 De guiueu Dy uitU&L-
ground knowledge of available local
In this simplified, rapid technic, the
mother is first asked to say spontane-
ously what the child has eaten in the
past 1-7 days. Following this, she is
questioned as to how many times a day
each item is being eaten and in what
approximate quantities, using house-
hold measures (e.g., cups, spoons,
gourds, and so forth). The information
obtained is recorded as given by the
mother, e.g., rice, two tablespoonfuls,
twice a day.
When the mother has given her spon-
taneous answers, questions are put sys-
tematically on the use of other foods,
and, in the event of an affirmative an-
swer, on the number of times daily and
approximate quantities.
This questioning should be done
quickly because too much interroga-
tion and cross-checking leave both the
mother and the interviewer confused.
The information may be entered in
columns ruled for each of the local
foods likely to be used for young chil-
dren. The frequency of use of different
foods can be calculated for each three-
month group for the first two years of
life and for six-month age groups there-
after, and expressed as the average
number of times eaten per week in
each group. Approximate quantities
taken can also be calculated for each
Results of such a simple question-
naire can give rough qualitative infor-
mation on the foods given to young
children and those that are not suffici-
ently used. It can form the basis for
relevant advice on improvement of in-
fant feeding using locally available

quantities of foods used by the child
have been determined, it is possible to
calculate the total intake of Calories,
protein, and other nutrients by refer-
ence to appropriate tables which give
the detailed composition of various
foodstuffs. Difficulties may occur with
variations in the composition of foods
from one region to another.


A. M. ALTSCHUL, Proteins, Their Chemis-
try and Politics, Basic Books, Inc., New
York (1965) (T).
W. R. AYKROYD, Food for Man, Pergamon
Press, London (1964) (G&T).
umes in Human Nutrition, FAO, Rome
(1965) (T).
D. B. JELLIFFE, Infant Nutrition in the
Subtropics and Tropics, WHO Monograph,
Geneva (1955) (Second Edition 1968)
M. IATHAM, Human Nutrition in Tropical
A/rica, FAO, Rome (1965) (G&T).
D. H. K. LEE, Climate and Economic De-
velopment in the Tropics, Harper Bros., New
York (1957) (T).
G. B. MASEFIELD, Famine: Its Prevention
and Relief, Oxford University Press, London
(1963) (G&T).
E. REH, Manual on Household Food Con-
sumption Studies, FAO Nutritional Studies
No. 18, Rome (1962) (T)
G. J. A. TERRA, Tropical Vegetables, Royal
Tropical Institute, Communication No. 54,
Amsterdam (G&T).

Nutrition and Dietetics, Second Edition,
Livingstone, Edinburgh (1963).
G=Recommended for the general reader.
T=Recommended for the technically trained
health worker.
N. JOLLIFFE (Editor), Clinical Nutrition,
Second Edition, Harpers, New York (1962).
H. SINCLAIR and D. B. JELLIFFE (Editors),
Nicholl's Tropical Nutrition and Dietetics,
Fourth Edition, Balliere, Tindall and Cox,
London (1961) (T).




Food production, distribution, and
marketing within a country are-directly
elated to the feasibility of achieving
adequate nutrition. Therefore, any pro-
ram aimed at improving the nutrition
f children must be made not only
withinn the framework of the present
inge and availability of foods in the
articular region but must take into
account changes that may occur at the
resent and in the future. It must also,
s far as possible, consider methods of
proving food production and utili-
ition, both at the national and local


The effectiveness of methods of food
reduction depends on many inter-
-ting factors, including the soil, the
imate and rainfall, the level of health
nd vigor of the community, the cus-
ams and social organization of the
"]. 1-1 ~m. .-A -A--n~



ests and diseases of plants and
While modern methods of food pro-
uction are being introduced increas-
1gly into limited areas, for the most
art agriculture, rearing of livestock,
nd fisheries are dependent on methods
iat are in a sense traditional and time-
ested, but which, at the same time,
re by modern standards inefficient
nd unproductive. To understand this,
t is necessary to consider briefly the
methods employed, including problems
f available labor, land ownership, and
Ail characteristics, as well as custom-
ry methods of storage, preservation,
nd marketing of food.

abor Force and Equipment. In
iost tropical countries, methods of
ood production will be essentially "la-
or-intensive" -that is, relying on hu-
ian labor rather than on machines.
traditionally, the labor force is made
p of the fainily, the clan, or the peo-
le of the same village. Much of the
ard work is often the duty of women,
_--1-.-l :_ A~t-:-- lr-tL_-J-_ ---__


ally based on the use of limited crude
equipment, such as the hoe and entail
a large expenditure of energy and ef-
fort for a small return. The daily
round of digging, grinding, pounding,
and carrying heavy loads involves a
tremendous expenditure of time and
Additionally, the physical energy of
a chronically malnourished, diseased,
and parasite-ridden community is re-
duced, leading in turn to the vicious
circle of defective food production and
continuing malnutrition.
Often only simple methods of
ploughing and irrigation will be avail-
able. There may be an inadequate real-
ization of the need to rest the soil or
-rotate crops, except perhaps by means
of clearing new cultivation areas each
year by so-called "slash and burn"
methods. In fact, "farming may be
mired in Babylonian technology."
Large-scale mechanized agriculture
can undoubtedly play a major role in
increasing food production in some
parts of the world, perhaps using
machines, such as tractors, hired from
cooperatives. Often, a more realistic
approach than the use of expensive,
difficult to repair, elaborate machines
may be the introduction of minor
improvements ("intermediate technol-
ogy"), such as an ox plough, or rela-
tively simple mechanization, as, for
example, the introduction of a man-
ually operated thresher, a mechanical
walker tractor, or a groundnut digger.
This type of approach also has the ad-
vantage of maintaining employment.
An advantage of mechanized farm-
ing in parts of Africa is that it is a
man's job, as opposed to traditional
cultivation which is usually a woman',

permit women to spend more time on
other things, including the care and
feeding of their children.
A further problem with regard to the
production of food is that in some
countries the labor force is itself being
reduced by the movement of men to
towns in search of more lucrative and
supposedly exciting employment. Not
only may this migration deplete the
rural labor force, but also, at the same
time, it adds to the numbers of town
dwellers needing to be fed by the rural
In many parts of the world, much
greater use could be made of village
gardens, which with very little change
could often produce much more food
which would be immediately available
to the family.

Land Ownership. In most tropical
regions, the question of land owner-
ship greatly complicates the problem
of modifying methods of food produc-
tion. In some regions, ancient feudal
systems may still persist. In other parts
of the world, various complex systems
of land ownership and inheritance are
based on family ties and clan rights.
Often land is split into very small por-
tions, and a family may own several
small areas situated far apart. Farming
under such conditions is inconvenient,
difficult, and uneconomical.
For large-scale food production us.
ing modern mechanized methods, some
form of land consolidation is desirable
as a part of a sound agricultural policy
based on the rational and economic use
of land. However, with the worldwide
deep emotional attachment of peasant
people to the land and with current
complicated systems of ownership, nee
essarv reforms cannot be brought aboul

In addition to consolidation of land
into large and economically sound
holdings, in some tropical countries it
may be possible to reclaim new land
by settlement, by clearing bush or for-
est, by draining swamp lands, by in-
troducing irrigation systems, or, in
parts of Africa, by the eradication of
the tsetse fly, the carrier of sleeping

Soil and Climate. In tropical coun-
tries, the soil is often shallow and
leached of the minerals contained in
the organic humus that are needed to
make it fertile and productive, partly
because of the heavy rainfall and soil
erosion. In some places, land is over-
used agriculturally, or by overgrazing.
Livestock may be kept in too large
numbers for their prestige value rather
than for their food potential. Likewise,
available animal manure may not be
used as fertilizer, as in India where cat-
tle dung is employed principally for
fuel. Other fertilizers, including com-
post and chemicals, are also underused.
Agriculture everywhere depends on
the climate but in developing tropical
countries this dependency for survival
is often nearly absolute. In India, wide-
spread food shortage or even famine
is at the mercy of the annual monsoon.
In some tropical countries, rainfall may
be too abundant, leading to soil ero-
sion, or too scarce, leading to aridity,
which may be further increased by

Seeds and Stock. Variation in
quality, including nutritional value, al-
ready exists between different strains
of a particular crop, and the popular-
ization of the best variety can be of
great value. In addition, modern de-

breeding have already led to great im-
provements in yields and quality. It is
increasingly possible to develop strains
that are adapted to special needs, such
as being resistant to particular climates
and diseases, bringing a higher over-all
yield, possessing improved nutrient
content, or being unattractive to in-
sects, rodents, or bird pests.
However, experience has clearly
shown that careful testing of community
acceptability of these new varieties is
as important as their scientifically
proved values. They must possess the
appearance, taste, and cooking prop-
erties that are acceptable to the people.
Considerable attention has also been
given by stock breeders in recent years
to trying to develop strains of cattle
and other animals which have a high
yield, are adapted to a tropical climate
and available fodder, and resistant to
local diseases, such as trypanosomiasis
in Africa.

Food Protection and Storage.
(figs. 2 and 3) Much loss of food can
occur while it is still growing, as a
result of the ravages of rats and birds
and, in some places, monkeys, porcu-
pines, and other creatures.
In most places it is necessary to storo
food harvested to last until after the
next cultivation season. With present
methods, there is frequently a very
considerable wastage, so that in India
it has been estimated that about one
third of the food harvested and stored
in traditional granaries is destroyed by
insect pests, rodents, and molds. This
worsens the seasonal shortage likely to
occur prior to the next harvest-the
"hungry season"!-when both fresh
foods and stored staples are likely to

FIGURE 2.-Traditional raised rice
granary (Madagasear).

desirable famine crops are used, espe-
cially cassava.
In some places, farmers recognize
that this loss is likely to occur and, un-
fortunately, sell most of their harvest
at once. This means that they need to
buy the same foods for their own con-
sumption from shops later in the sea-
son at much higher prices.
The provision of insect-, rodent-,
and mold-proof granaries would in-
crease the availability of foodstuffs im-
mensely. These granaries can some-
times be cheaply made concrete comr
munal stores; while, at village level,
considerable improvement is frequently
possible by means of such relatively un-
complicated methods as trying to en-
i.to .CI 4n 1nI lnl M.-I

granaries that are raised off the ground
md protected by inexpensive insecti-
-ides that are not toxic to man.

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 opportunities. 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-
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.
Drying is the method most com-
monly employed, using either the sun
or fire. Drying can 'be used for certain
vegetables, including okras and pep-
pers, for some fruits, such as dates,
apricots, and figs, for meat cut into thin
strips (bitong, charqui, jersey) (Fig.
4), for small fish (Fig. 5) and shrimp,
for some mushrooms and other fungi,
for edible insects, such as grasshoppers
and termites, or for various green
leaves (which 'are then sometimes
pounded and stored as a powder).
Smoking, salting (or brining) or
spicing (e.g., with red pepper) may also
be employed, and several processes may
be used together to reinforce one
another, as when fish is salted and then
dried in the fire-smoke for prolonged
periods. In addition to salt, various
other substances and spices may be
used as preservatives, especially vine-
_ __ T __r --- -1.1

L:; L I

~1-- r ~

lage sh
lets for
that aj

FIGURE 4.-Sun-dried strips
(North Kenya).

form of traditional market c
This marketplace often acts a
point for the community where
can be brought for sale or bi
where information and news c
changed. Traditional markets
extremely important as sites J
tion education activities (F
and 7).
Minor improvements in
can be most valuable to the fa:
nomically and to the commune
tionally. Simple modificati
strengthening of bicycles ca
greater loads to be carried
distances to market.
More recently, small villa
selling a simple range of go
become a feature of many trol
munities. Undoubtedly they ai
a part in spreading goods to i

balance in iheir cultivation b
locally-grown, nutritious diet
for the family or village itself
crops, such as coffee, cotton, ai
of beef which are the main or sole s
cash income for the family f
school fees, and household gc
ntinues. the chief source of foreign i
a focal for the nation.
produce However, it is increasingly
ter and that nutritious food "crops,"
n be ex- beans and eggs, can also be i
ire also as cash earners if grown i
Tr nutri- quantities.
gures 6
Finance and Incentive to
transport Many peasant farmers in di
ner eco- tropical regions are unre
:y nutri- bound down by chronic poi
as and indebtedness. The development
permit ernment assisted cooperatives
increased surance schemes, and bank a
systems may enable the cull
e shops obtain loans of money and
ds have the form of insecticides,
cal com- strains of seeds, and equipm(
playing can enable him to start on th
mote re- modest prosperity.

FIGURE 5.-Sun-dried, smoked fisi

itives to increase production tries
change to new crops are also more
These may be supplied by gov- corn,
tal assurance of a market with tion r
anteed remuneration per acre ries a
ed, or by import restrictions on of th<
that are producible within a protei
ible Protein Foods. The pro- both c
i of foods in most tropical coun- is usu

on sticks (Uganda).

i usually dominated by one or
local starchy staples, such as rice,
or yams, upon which the popula-
lies for the majority of its Calo-
id, indeed, for much of the rest
nutrients of its diet, including
i. A top priority must therefore
be the increased production of
red quality staple.
production of protein foods,
F vegetable and of animal origin,
Illy deficient, sometimes because


FIGURE 6.-Traditional markE



(Mali West Africa), showing mixed li

lURE 7.-Traditional floating market or

zculty of producing these foods, In
ore usually because their nutri- desir.
value is not appreciated. In par- incre
, pulses or legumes very fre- oped,
y are not produced in nearly the ance
ties that are desirable or feasible. perce
different varieties exist and ef- Le
ire obviously needed, both on a time
al and on an individual cultiva- and s
isis, to increase their production, taken
wes are, and in the future will be- weev

canal (Bangkok, Thailand).

ome countries, it would be most
Ale if some inducement to their
sed cultivation could be devel-
possibly by governmental assur-
of a local market for a certain
tage of the yield.
umes may be eaten fresh at the
f harvest or, more usually, dried
)red, when special care has to be
to prevent their infestation with
a and other insects.
4-l-,.1 -.-A 1-t i n A

production of aflatoxin-free
nuts (p. 30) and of using the p
obtained after the extraction of
soybeans (p. 31) and cotton
32) to prepare high-proteil
suitable for infant feeding.

Animal Protein Foods. Th
great need to increase the pr
of animal protein foods in
countries, except for certain
groups, such as fishermen, pas
and, in rare places, hunters.
same time, the production od
protein foods is often not t
biologically efficient or econorn
of using available land. Prol
lated to local geography and
such as scarcity of water anc
and the disease pattern may n
mal husbandry difficult.
Milk. Increased dairying ii
regarded as an important aspe
mal protein production wh
special relevance to young
However, as has been noted el
animal milk, although an e:
valuable food, especially fo:
children, is by no means nect
evidenced by the fact that m,
munities have reared their
successfully without this fL
example, the Chinese and the
Often with international as
various tropical countries hi
making great efforts to incre,
milk production, both from c
from buffaloes. With small
stock raisers, it is necessary
duce some system of rural mi]
tion, using robust, simple eq
and to devise some method ,
porting the pooled mixture to a
ing center. This should, in
k11 I-rc-h^ r n- r o.wr -.+r4n -

,round- expensive 'bottling, and ec<
esscake distribution and sale. Preferah
il from should be some system for ,
sed (p. that at least a part of the end
flours reaches the young children wh
Most indigenous tropical cal
re is a very little milk, and to-increast
auction tion to an economic level it is i
Topical either to introduce such hit
favored exotic breeds as Channel Isla
oralists, or Fresians, or to develop hyl
At the tween exotic and local species.
animal cases, it is usually necessary
e most special care with disease protu
Mal way means of immunization and 1
eis re- trol, and to ensure the animal
climate quate diet and water supply.
fodder, this is difficult for an un
ike ani- farmer to realize or, indeed
into practice, without some
rightly subsidy or inducement from
of ani- ernment. However, in some pa:
,h has world, as in Uganda, a smali
children. creasing percentage of "Pri
where, Farmers" are rearing cattle
tremely these precautions and finding
young profitable to do so, thus provi
sary as financial motive for others t
y com- their example.
children In some places, it may be p<
)d-for produce a relatively ine
Polyne- "toned" milk, made up of loc
duced fresh milk mixed wi
instance, pensive imported dried skimnr
'e been In particular, this has been ti
se their
success in Bombay, India, whe
ws and
fat buffalo milk (7-9 percent)
Sintro- mixed with imported low-fi
collec- milk, with a resultant mixtui
ipment, similar to cow's milk.
F trans- Meat. Increased meat produce
)rocess- be possible in some regions, I
irn, be of improved breeds and by bx
ion in- tection against disease. Eau

predators and from accidents is

uch as feast days. they are acceptable to the local cultural
certain favored tropical regions, pattern. In various parts of the world,
ig schemes may be practicable, these may include pigs, goats, rabbits,
.n some parts of Africa, attempts guinea pigs, and agoutis.
een made to obtain meat on a Eggs. In many parts of the world,
ling commercial basis by game- eggs are particularly underused as
ig, either in extensive fenced-in food, especially for infants. Frequently
or in natural circumstances as this is because they are considered as

nost tropical villages, chicKens marK<
ie found, although usually living cultui
i-run" existence on the rubbish preve
sects to be found in the corn- child
These birds are small, with lit- Fis
Lt and with a low yield of under- being
ggs. Their mortality from small of fi

. in aanumon, however, many
s have traditional beliefs that
t their being eaten by young
a (p. 64).
* Basic and applied research is
carried out on improved methods
Ling appropriate to particular

tropical communities. For example,
strong nylon nets can be made avail-
able at relatively low cost and loans
can be supplied to purchase outboard
motors. Often, a major problem is
preservation and distribution; and if
this could be improved, the incentive
to obtain larger catches would ob-
viously increase greatly.
In some parts of the world special
fish preparations are much prized as
foods, as with the fermented, predi-
gested fish and shrimp pastes of parts
of Asia. Investigations aimed at im-
proving the nutritional value and in-
creased yield are plainly of importance.

Vegetables and Fruits. As a general-
ization, it may be said that vegetables
and fruits are not grown or eaten as
much as they might be, especially dark
green leafy vegetables. The production
of these foods could very often be in-
creased easily by the development of
improved home gardens or school

New Sources of Food. Intensive re-
search into new sources may be ex-
pected to play a role in the world food
scene in the future.
Synthetic Amino Acids and Vita-
mins. The economical synthesis of cer-
tain essential amino acids, notably
lysine, has suggested the possibility of
reinforcing cereal flour with this lim-
iting amino acid (p. 2). Cost and
practicability make this approach un-
likely for most tropical communities.
The use of synthetic vitamins, es-
pecially thiamine, to reinforce over-
milled rice and wheat flour has been in
effect for decades in limited areas of
the world.

added to livestock rations as a high
protein source.
Microbial Protein. Recent research
has shown that microbial protein may
be grown on petroleum. The end result
appears to have promise at least as ani-
mal feed.
Food Yeast. Highly nutritious food
yeast can be easily grown in molasses.
[ts use as a protein additive for various
commercially prepared infant foods is
being explored.
Leaf Protein. Methods have been
devised to extract protein from various
types of leaves and the resulting dark
green powder has been employed ex-
perimentally in the feeding of young
However, it must be stressed that,
with the exception of oil seed residues
which are not at present much used for
human food, the solution to the world
Food problem lies principally in the di-
rection of augmented production and
improved quality of traditional,
orthodox food sources.


Two problems of extreme impor-
tance to food production and to the
nutrition of populations as a whole,
mand especially to young children, have
merged in the past few decades, par-
ticularly since World War II. These are
(a) a rapid population increase, and
(b) urbanization. Almost all countries
have been affected, although to very
different degrees.

Population Increase. Tradition-
oriented people all over the world
desire to have large families, as an ex-

strength to the clan, group, or tribe, as
a work force, as a source of insurance
in old age, and, in some places, as a
source of wealth, either from bride
price or doweries. In addition, politi-
cians tend to equate numbers with
Over the centuries, communities
have become accustomed to a high
child wastage, often with over half the
children born dying before adolescence.
A high birth rate was required to com-
pensate for child wastage. However,
with the introduction and acceptance
of at least some aspects of modern
methods of medicine and public health,
and with the establishment in most
places of some degree of law and order
the death rate in childhood, although
still extremely high, has decreased
greatly. In fact, death control has oc-
curred without parallel fertility con-
trol. As a result, the population has
increased ever more steeply, so that the
present world population of about three
billion is expected to reach seven bil-
lion by 2000 A.D.
Population Pressure and Food
Needs. There is a widening gap between
the growing world population and
available food supplies. Of especial
seriousness is the fear that the most
rapid increase in population has oc-
curred in the parts of the world where
food production has lagged, that is, in
developing tropical regions. This is
especially striking in some Latin Ameri-
can and Asian countries who were food
exporters some years ago, but who
now have to supplement their own
production with imports and whose
food production is increasingly inade-
quate even as regards Calories. The
situation is plainly precarious with food
supply dependent to a great extent on

the import of foodstuffs from elsewhere
and extremely vulnerable to natural
hazards, such as droughts or floods or
man-made disasters, such as wars and
civil strife.
In many other regions, food in-
adequacy is particularly related to pro-
tein, resulting in a poorly balanced
national diet.
Population Pressure and Arable
Land. Administrators in many coun-
tries do not seem to appreciate that
with the present geometrical progres-
sion in their population increase, they
too may meet the extreme problems of
the more over-crowded Asian countries
in the coming decades, unless appro-
priate action is taken now. Thus, even
in the apparently underpopulated areas
of East Africa, it has been shown that,
by the year 2000 A.D., the population
density in Kenya in relation to useable
land, will approximate that of India
Population Pressure and Social
Services. Another nutritional and
health consequence of an over-rapid in-
crease in population is that the hard-
won advances in "development," both
economic and social, constantly lag be-
hind the extra numbers of people ex-
pecting to share in these advances.
General and health education through
schools are important methods of nu-
tritional improvement; with a too
rapid increase in child population, the
building of adequate numbers of
schools will never catch up with the
number of children. The result is a
growing number of uneducated young
people unable to find jobs.
Child-Spacing and Malnutrition. An
often ill-appreciated, but highly im-
portant, aspect of over-large families is
related to child-spacing. If children are

born at too close an interval, severe
nutritional consequences occur, both
for the mother and for her offspring.
Many tropical women marry young
and commence child bearing before
they have completed their own growth.
Thereafter, their life may be one of
continuous reproductive nutritional
drain, as one pregnancy and prolonged
lactation is followed by another. In
mothers, this cumulative "maternal de-
pletion" may sometimes manifest itself
as a definite deficiency of a certain nu-
trient ('as for example iron-deficiency
anemia), or alternatively may lead to
general malnutrition, with weight loss,
thin muscles, and subcutaneous fat,
and with premature aging and death.
If children are born with too short
an interval between them, this may lead
to the newborn baby himself being un-
derweight and with less than adequate
stores acquired from an already nu-
tritionally depleted mother. Also in
tropical village circumstances, both
prolonged breast feeding and close and
careful attention by the mother are de-
sirable for the child's nutrition and
The ideal gap between children is
probably between two to three years
because, if children are born in rapid
sequence, the period of breast feeding
and of close maternal care is too short
and the possibility of the infant devel-
oping protein-Calorie malnutrition
(p. 75) is greatly increased. Many com-
munities had traditional customs which
ensured child spacing.
Family Planning and Nutritional
Needs. Family planning is required
nutritionally both to achieve child-
spacing and to control the "population
explosion." Recent changes in opinion
in many parts of the world and new
technological advances have made this

type of approach a practical possibility
although it is still fraught with many
cultural, religious, and political mis-
understandings and difficulties. In par-
ticular, the use of the plastic intrauterine
device (I.U.D.) has revolutionized the
approach to family planning, as it is
a method which is inexpensive, often
culturally acceptable, practical, simple
and, once inserted, does not entail any
alteration in customary sexual behavior.
The move toward family planning
has increasingly involved greater areas
of the world, although there are still
many countries or regions where this
approach is unacceptable and the dan-
gers of over-population are either not
appreciated, or are thought to be amena.
ble to increased food production, to
technological advance, and to raised
standards of living leading to reduc-
tions of family size. The inescapable
conclusion is that increased food
production and family planning are
complementary and that both are
urgently needed.
Many countries now have family
planning projects, often on a vast scale
as part of official government policy,
e.g., India, Pakistan, Egypt, Tunisia,
and so forth. Still more have small-
scale family planning associations or
activities which are increasingly sup-
plying the demand of the well-to-do
and middle classes (the trend-setters of
the future), although they have no di-
rect, open support from governmental
authorities, largely for political reasons
since they may be misconstrued as sin-
ister attempts at genocide or at re-
stricting the "power" of a particular
group, community, or nation.

Urbanization. Many tropical coun-
tries are in the relatively early stages of

industrialization and, indeed the nei
problems of the present and the do:
nant problems of the future are in inm
cases bound up with the partly plan
but mostly haphazard urbanization t
is occurring in the same way as h
opened in the Industrial Revolution
Europe in the early 19th century.
People, and especially men, come
the towns to seek work, where it see
to them that more modern, prestige(
and lucrative opportunities exist tl
in the rural areas. As anywhere, tl
are also attracted by the bright ligi
excitement, and bustle of town life. .
too often, only a few can obtain ga
ful employment and reasonable Ic
cost housing, so that the majority m
find themselves living the "detrib
ized" lives of discontented, und
privileged, unemployed slum dwelle
with immense potential for soc
Family Instability. Under these c
cumstances, the traditional custo:
and restrictions of the home comn
nity are abandoned, often with a r
in temporary marital liaisons, illeg:
macy, venereal disease, alcoholis
broken families, and abandoned cl
dren. The last is particularly striking
certain African cities, since in tra
tional society children born out of wi
lock are usually absorbed into the cl
or tribal structure, whereas in towns I
neglected or abandoned underno
ished young child is nowadays becc
ing an increasingly serious problem.
Nutritionally Relevant Infectio
As regards nutritionally important
fections (p. 72), in some ways the to
child is at an advantage. For examt
malaria and certain types of parasi
will usually be much less of a probli
However. as a result of the overcroi

er ing, some infections of nutritional c
i- sequence, particularly tuberculo
Ly whooping cough, and diarrhea, 4
i, often occur more commonly than tl
at do in rural areas.
?- Changing Food Habits. Most dire&
in relevant to the nutrition of children i
be the change in food habits that 4
;o occur as a result of moving fron
is rural traditional way of life to an urt
is situation, where the family concern
n will depend, in major part, upon a ci
:y economy-that is, upon food bou,
s, rather than the food grown throi
11 home cultivation. This situat
i. poses problems of budgeting for
I- experienced "new townsmen," expo!
y to many understandable temptati(
I. to spend their limited resour
*- wastefully.
3, Often the main foods that have bi
il customary in the home area, include
even the staple, may not be easily tra
portable and hence may not be fou
is to any large extent in shops in tow
i- For example, millet-eaters migrating
ie towns do not usually find this cer
i- available to them and often have
i, move over to less nutritionally dev
1- able, cheap, easily storable stap
n available in the stores, including c
i- sava or maize (corn) flours. In gene
I- there is also often a tendency to i
n convenient, refined, less nutriti(
Le foods, including white overmilled fio
r- sugar, tea, and carbonated beverage
I- However, the people do have an ,
portunity for wider exposure to nul
s. tion education, which should be mn
i- available to them, and are often do
n to limited health services.
e, Another point of considerable i
s portance is that many rural peo
a. make use to a very considerable ext
I. of a variety of different foods of ve

able, and occasionally of animal,
rigin which occur wild or semiwild in
he countryside. These may include
variouss green vegetables, fruits, ber-
ies, eggs, and, in some communities,
oney and insects. These are no longer
available in towns.
Of particular importance as far as
he feeding of young children is con-
erned, is the fact that urbanization
eems to be paralleled by a harmful
rend away from breast feeding toward
artificial feeding with cow's milk, often
rising a feeding bottle.
In addition, rural mothers exposed
o the advertising of the towns are ex-
remely likely to buy not only impos-
ibly expensive milk preparations but
Iso a variety of costly largely carbo-
ydrate tinned foods, which are eco-
omically beyond their reach, nu-
ritionally of low value, and a misuse
f their limited budget.


In the past decades, very large quan-
ities of food from agriculturally highly
productive countries have been used as
food aid" for developing regions. The
ast majority of this has come from
arplus foods produced in the U.S.A.,
s, for example, the low fat
dried skimmed) milk distributed by
JNICEF, CARE, and the Catholic Re-
ef Service, and the foods distributed
y the Food for Peace Program.
These have been used on a very large
-ale and have been of much value in
-ying to deal with actual malnutrition
rough supplementary feeding pro-
rams, as with dried skimmed milk for
ie therapy and rehabilitation of
oung children with varying degrees of
irotein-Calorie malnutrition.

kimmed milk has helped increase at-
endance at child health services, has
rawn attention to the problem of
childhood malnutrition and has, in
ome places, stimulated the local pro-
uction of low-cost, high-protein foods
uitable for young children.
The disadvantages of this approach
re that it was geared to the use of
urpluses that were not necessarily the
iost suitable foods for the area and
hat it could discourage local produc-
The situation has changed radically
n the last few years and the previously
uge food reserves in the U.S.A. have
decreased greatly, mainly because of
massive food aid to avert famine in
ndia but also because new markets
.ave developed.

Var on Hunger Program. In view
if recent developments, the policy of
he U.S. War on Hunger Program is to
ry to deploy more specifically needed
ood aid to deal with defined nutri-
ional problems, especially those of
oung children and, at the same time,
2 assist in the development of indig-
nous food production.
With this in mind, farmers in the
T.S.A. will be induced to grow specific
oods that are required for the prob.
-ms of particular regions, expanding
ultivation to use previously idle land.
These foods will be related to actual
nutritional problems and will, there-
ore, frequently be the animal or vege-
ible protein foods, such as dried
kimmed milk or legumes, especially
ie soybean, produced to combat pro-
-in-Calorie malnutrition of early
Lastly, and most importantly, food
id will, as the name suggests, be

the negative effect it has often exerts
on agriculture in the past.

World Food Program. In a simil.
way, this multilateral U.N. program
principally designed to assist with fo4
aid from a variety of participa
countries in the support of technical
sound and feasible projects intended
improve a country's economic develop
ment and especially its own food pr
duction. Thus, in the building of a da
designed to increase land irrigation,
well as produce power, part of tf
salaries of the labor force may be ma
available in the form of food. Tl
enables food production to be increase
and, at the same time, mobilizes ma
power and provides employment.
Other projects covered by the Woz
Food Program include subsidizing ed
national development through schc
feeding, direct preschool child feed
schemes, and assistance in the develc
ment of locally produced high-prote
foods for young children. In the h
category, sorghum (a millet-like cereE
flour has been made available in Senel
for incorporation into a processed :
fant food which is being manufacture
there. It is hoped that this initial redi
tion in cost of the product will enal
it to be launched more easily a
that local sorghum flour will be us


Realization of the Situation. I
world population is increasing tw
as fast as the increase in food prod
tion, and the gap is especially marl
in developing tropical regions. 1
threat of extensive major food shc

I possibility for large areas of the wor
in which all age groups would be i
volved, although young children wou
be the principal sufferers.

I Over-all Policies. There is in mai
t countries an awakening awareness
r this problem, especially in light of tf
current lack of food surpluses from t
U.S.A. The message seems clear.
sound food production policy based
i the nutritional needs of the county
s coupled with some sort of locally t
e ceptable family planning program,
e what is required.
s These programs rank even high
I in urgency than educational develc
ment or the extension of all but t
simplest health services. Of course, th
I are not as attractive politically as su
prestige items as national airlines
1 grandiose public buildings, and th
g require the support of technical advis(
and workers if they are to gain acce
n ance.
t The aim should be an increase
diversified national food production
tI using both large scale and domes
I- level approaches, with special relati
d to vegetable protein foods, and w
the object of improving the family d
e with particular reference to you
d children.
d A balanced approach is need
between measures designed to i
prove a country's wealth--that is,
economic development-by means
industrialization and the cultivation
cash crops on the one hand, and the
.e measures to increase food product
:e by agriculture, animal husbandry, a
c- fisheries on the other. However, in m
d countries there has, in the past, bl
ie an over-emphasis on industrialization
t- and cash crops. In the context of 1

worlu in me near LuUrU, IL Iiay wr- r,
possible to appear to be developing the
economy of a country favorably and
still be short of food.
That an increased national food pro-
duction is needed for full insurance
against national food shortage is em-
phasized in a recent speech by Presi-
dent Ayub Khan of Pakistan when he
said: "The time has arrived when the
world cannot produce food for us and
after some further time it will not be
able to supply us with food even for
gold. We have to feed ourselves."

Blocks to Increased Food Produc-
tion. It is now recognized that blocks
to vastly increased world food produc-
tion are neither technical nor even
"natural," that is, related to geography
or climate, but that limitations are
rather due to economic, social, and
cultural factors.
Improvement appears mainly to re-
quire education and motivation of gov-
ernments and ultimately of the farmers
themselves. More efficient marketing
systems are particularly needed, thus
supplying both incentives to the food
producer and also lowering the price
for consumers.

The Field Worlker and Food Pro-
duction. In addition to wider issues

J~ ~L^J~~U H-f JAU~L&W&J.aj. Lf&aV~t, UJ ^ a*L^~
provement in food production can be
achieved at village level by the use of
high yield seeds and fertilizers (includ-
ing manure, compost, or mulching), by
pest control (especially with insecti-
cides in stored grains arnd legumes),
and by the increased cultivation of pro-
tein foods (as with legumes and dark
green leafy vegetables in home gardens,
or with fish ponds). In these important,
small-scale activities, the field worker
may be strategically situated to help in-
troduce and popularize new or modi-
fied ideas in collaboration with the
local agricultural extension services,
village clubs, and other organizations.


challenge to health workers of every nation,
Family Planning, (1966) (G&T).
J. M. MAY, The Ecology of Malnutrition
in Middle Africa, Hafner Publishing Co.,
New York (1965) (G&T).
A. T. MOSHER, Getting Agriculture Mov.
ing, Agriculture Development Council, Inc.,
New York (1966) (G&T).
Time Magazine, "'The struggle to end hun-
ger," Time Essay, August 12, 1966. p. 42 (G).
H. D. TINDALL, Fruit and Vegetables in
WVest Africa, FAO, Rome, (1965) (G&T).

SG= Recommended for the general reader.
T= Recommended for the technically trained
health worker.



Each of the many different commu
nities of mankind has its own pattern o
behavior, customs, and beliefs, whidl
together are termed its "culture." Thi
complex set of attitudes and ways o
life are by no means inherent; they arn
learned after birth by instruction fron
parents and others, but mostly by mean,
of subconscious imitation of the be
havior of the family and other mem
bers of the community. By the tim,
later childhood and adulthood havy
been reached, the individual has beei
conditioned to accept the ways of hi
particular group as the correct anm
proper way to behave, and, indeed
often to regard other culture pattern
as bizarre and absurd, if not positivel-
In fact, all different cultures, whether
in a tropical village or in a high
urbanized and technologically sophii
ticated community, contain some prac
tices and customs which 'are beneficii
to the health and nutrition of the grout
and some which are harmful. No cu
ture 'has a monopoly of wisdom or al
surdity. For a worker from a Westen
industrialized society, it is absolute

Pter iv


necessary to realize the existence of thi
"cultural relativity," especially the uni
versality of scientifically unsoum
The conditioned responses and be
havior of a community which make u]
its culture are particularly important ib
relation to food and eating practices
and to methods of food production. A]
understanding of some of these vari
ables is imperative, if cross-cultura
misunderstandings and clashes are t,
be avoided or minimized.


All the aspects of a culture are intei
related and interact one with another
so that an understanding of the leader
ship structure, kinship systems, li1
goals and values is helpful in trying t
understand local health and nutrition
problems, and in carrying out a prn
ventive program.
Two "nonnutritional" cross-culturi
problems often of importance in nutr
tion work may be mentioned t

1. Specimen collection, which may
be misunderstood and resisted through
fear that the blood or urine may be used
for occult purposes, or that its loss may
weaken the donors;
2. Difficulties with names and num-
bers, which arise when the culture for-
bids that one's own name or that of
one's husband or child, or the num-
ber of children in the family, should be
mentioned before strangers, or when
names are changed for various reasons.
Nevertheless, there are certain cus-
toms that are more obviously and di-
rectly relevant to child nutrition and
feeding. Certain of these can now be

Food Classifications. These are often
of great complexity and usually the
result of numerous interlocking his-
torical, social, and economic factors
that have influenced the culture
These subconscious classifications
comprise one of the most deep-rooted
aspects of all culture patterns. They are
learned by imitation in early childhood
and are notoriously difficult to modify
or change.
The food classifications employed
usually have no relation to scientific
divisions (e.g. protein, vitamins, and
so forth). They seem complicated to the
outsider, but appear natural, normal,
and correct to the particular commu-
nity. It is most unusual for there to be
any recognition of the relationship be-
tween the type or quality of diet eaten
and health or disease due to malnutri-
tion. In fact, trying to convince peo-
ple of this concept is basic to much
nutrition education, and is particularly
diffimllt tn ah-h;Pup hP,-ancA a-vlvla- -f

the benefits of a good diet are not
quickly produced.
Basically no human group eats all
the potentially edible material available
to it, but arbitrarily classifies these
items into food and nonfood (fig. 8).
Thus, in the U.S.A., dog, although a
good source of animal protein, is cate-
gorized as nonfood. Certain hunting
groups in remoter Tanzania, hard
pressed as they are for food, do not eat
fish, even if it is available to them. Also,
the categorization into food and non-
food may be on a ritual or religious
basis, as with the avoidance of beef by
Hindus, and of pork by Muslims.
Cultural Super-Foods. In all com-
munities, one or more items have be-
come the cultural super-food. The
characteristics of cultural super-foods
are that they are usually, but not al-
ways, the dominant staple and main
source of Calories. Their production
and preparation occupy a major part of
the community's work time, both agri-
culturally and domestically. If the cul-
tural super-food is a grain, its preferred
preparation is usually overmilled and
as white as possible (e.g., wheat or corn
flour, rice).
Because of their importance for the
survival of the particular community,
they often have semi-divine status, be-
ing interwoven into local religion,
mythology, and history. They have pro-
found emotional value to the group
concerned and tend to dominate the
local dietary so much that often a
vernacular word for "food" is the same
as for the staple.
Examples of cultural super-foods in-
clude rice in most of Southeast Asia,
matoke (steamed plantain) in Bu-
ganda, corn (maize) in Central Amer-
:__ ~_ 1 -.i :- *_ M -._ rVT_ __ _

LUIUeI jUJetL-LV aUI. auLL IL e m UJLI.. ExaplesU LU.U.nclude - i ,
millets, are at an automatic, baseline munity. Examples include chicken i

t.L. 1

-u ~' ;: -'. ~ a

tS- .-~r
i. Ir

Africa, various special milk deserts in
parts of India, camel hump in some
traditional Arab groups, and the pig in
New Guinea. Equally, in the U.S.A., a
nutritionally equivalent quantity of
steak would certainly have greater
prestige than a corresponding quantity
of cheese.
Examination suggests that, even in
so-called vegetarian societies, prestige
foods are usually protein, frequently of
animal origin, often a milk product.
They are usually difficult to obtain, so
that they are expensive.
Body-Image Foods. Many cultures
have their own body-image that in-
cludes their own culturally defined con-
cepts concerning the workings of the
body and its physiology, which are to-
tally different from modern scientific
views. These ideas may be systematized
as with the ancient Hindu classi-
fication of body physiology into doshas
humorss), especially "heat" and
"cold," or the similar systems found
in Latin America and the Eastern
The importance of these classifica-
tions is that both foods and illnesses are
usually categorized in this way, so that
the diet permitted may be of consider-
able influence in both health and
disease, in relation to its supposed
influence on the body. For example,
in Bengal diarrhea is classified as a
"hot" illness and, to the village mother,
it is plainly dangerous to feed her child
with milk, even during recovery, as
this is also classified in this system as
being "hot."
Relics of ancient classifications exist
in industrialized countries. For exam-
ple, the Galenic humoral concept of ill.
ness may influence modern food intake.
One reason that spleen is not eaten to

any extent in Britain is that, by this
classification, it is traditionally the
prime seat of "melancholic humor."
Sympathetic Magic Foods. All over
the world some foods are eaten or
avoided, at least in part, because of
subconsciously assumed "sympathetic
magic" properties. That is, it is felt that
the appearance or original function of
the food may affect the eater. Thus, in
Gujerat the convoluted walnut is re-
garded as a brain-food; while under-
done steak-symbolically representing
vigor, energy and masculinity-was
used for training university athletes in
Europe until recently.
Physiological Group Foods. Special
foods are often reserved for, or forbid-
den to, certain physiological groups,
including males (especially elders),
women (particularly when pregnant,
after delivery, or lactating), and chil-
dren (most importantly in the early
years of life). For example, in Malaysia
fish is the most available source of ani-
mal protein locally, but is still some-
times thought to be unsuitable for chil-
dren in the early years of life because
of its alleged capacity to produce in-
testinal worms.
There may also be foods considered
to be particularly suitable for young
children. Sometimes they may be soft
and easily fed to infants, including
squash, sweet banana or arrowroot
paste, but otherwise nutritionally infe-
rior. Occasionally, high protein foods
are considered especially appropriate,
as bone marrow in Northern Tanzania.
General dietary restrictions -for
women are quite common, as with eggs,
chicken, mutton, and certain types of
fish in East Africa, and with pork in
D-l.._.-_ T1 U ....-

In Burma and elsewhere, the mother's
diet may be restricted during preg-
nancy, in an attempt to have a small
baby and an easy delivery. These
practices mean that the fetus receives
inadequate stores of nutrients from the
As restrictive dietary practices often
apply to women, especially in preg-
nancy, they may be in worse nutritional
condition than men. In addition, the
tropical mother is often in a continuous
state of production; if she is not produc-
ing a baby, she is lactating. In many
cultures, it is also customary for her to
continue her normal hard physical work
in the garden or in collecting wood and
Nutritional Significance of Food
Classifications. Affluent societies with
an abundant supply of foods, covering
a wide range, can, as it were, "afford"
the idiosyncrasy of scientifically absurd
food restrictions. In Western Europe,
the taboo on protein-rich grasshoppers
or dogs (prized foods in parts of
Africa) is not important. A parallel
avoidance of fish for young children in
Malaysia may be disastrous.
Examination of the food classifica-
tions briefly presented here suggest
that they often have a significance in
public health nutrition in developing
regions. In general, they are often
related to protein foods, especially those
of animal origin. While they may be
nutritionally beneficial, they more
often tend to restrict or limit the use
of available foods ("cultural blocks")
They are often aimed at mothers anc
young children. They can have, there
fore, a direct and important relevanc<
in contributing to the dietary causatior
of malnutrition in these vulnerable

new Customs. At all times in history,
cultures are always undergoing a slow
process of change. However, in recent
decades the speed of modern communi-
cations has increasingly brought tradi-
tional non-Western societies in contact
with both the science and the cultural
assumptions--two very different as-
pects-of Western, technologically de-
veloped communities. This has led to
obvious and rapid changes in some
customary forms of behavior usually
related to convenience or status, as, for
example, the use of Western style
clothes for men, the bicycle and other
wheeled transport, and the telephone.
In the field of child nutrition, many
traditional practices have remained un-
changed. However, especially in towns,
there has been an unfortunate tendency
for unsophisticated, less well-to-do
mothers to try to follow certain types of
Western practice, in particular the use
of bottle feeding.
Other problems of infant feeding in
towns (p. 58) include adapting to a
money economy, unavailability of some
customary staples, and the use of nu-
tritionally valueless dilute tea or car-
bonated beverages (which often cost
more than milk).

Child Rearing Practices. Local
methods of bringing up children must
be known, including the pattern ol
infant feeding (Appendix II), how the
child is separated from the breast (i.e.,
whether suddenly or slowly, whether
the infant is sent away, and so forth),
the way children are disciplined,
ceremonies at different stages of life
(rites de passage), and the commu.
nity's ideas about the relative impor
tance of girls or boys.
Various rites may be significant nu
tritionally, as with the rice-feedinj

ceremony of Hindu infancy, before
which rice may not be given to the baby.
Customs in relation to child spacing
are important both as regards the likeli-
hood of a baby being breast-fed, and
as regards the health and nutrition of
the mother. Some communities forbid
sexual intercourse for parents until a
child has reached one year or more.

Ideas about Illness. Parents will
usually have quite different ideas as to
what they believe to cause disease in
their babies (i.e., evil spirits, witch-
craft, ritually incorrect behavior, eating
forbidden food, and so forth), and it
is important to know what is in their
Local concepts of the causation, cure,
and prevention of disease are often
complex. Illnesses, especially diarrhea,
are often treated by dietary changes,
mainly of a restrictive nature, as well
as with herbals and appropriate
magical ritual.
The advanced, and therefore more
obvious, forms of malnutrition are
often recognized and classified by un-
educated indigenous peoples. The terms
used usually refer descriptively to some
striking feature, or to the presumed
causation. For example, the Luganda
word obwosi, synonymous with
"kwashiorkor", "disease of the dis-
placed child" indicates astute insight
into the social background, but reveals
no understanding of the actual dietary

Food Preparation. The traditional
methods of food preparation are
plainly of great practical importance,
as far as the feeding of young children
is concerned. Foods may be cooked by
boiling, by steaming, by barbecuing, or

a variety of other different methods.
The cooking utensils may be of various
types, but are often very limited in
range and number. The type of stove or
fire used and the availability of fuel are
also relevant, as are village methods of
measurement, as, for example, the types
of spoons, bowls, bottles, gourds, or
other containers.
Numerous customs may influence
practices in food preparation; for in-
stance, in traditional Hawaiian society,
the man did the cooking, but had to
cook food for himself and his wife in
two entirely separate pits.
It is necessary to know whether
food is cooked in pots, in leaf packets
or in various other types of containers.
The appearance, consistency, flavor or
lack of it, color, and temperature may
greatly influence acceptability of food.
To some people it is highly important
that cooked food should be hot, whereas
the temperature is quite immaterial to
other groups. In the Highlands of New
Guinea no liquid foods are used at all,
a practice which must be taken into
consideration in attempts at providing
protein supplements for the young
Obviously the methods by which at-
tempts are made to prevent malnutri-
tion through nutrition education will
need to be kept within the framework
of local home economics and the reali-
ties of the kitchen.

Meal Patterns. In some communities,
it is usual to have only one or two meals
daily, which means that the nutritional
needs of young children are particu-
larly difficult to meet, unless extra meals
are arranged for them. In much of the
world there is little appreciation of the
special needs of children.

Also, the method of eating and the
intrafamilial distribution of food may
be of relevance. If, as is often the case,
the family eat together and use their
fingers rather than cutlery, then young
children are often at a considerable dis-
advantage. Not only are the more nutri-
tious foods given preferentially to the
older males, but the small child is in-
experienced and less adroit at feeding
himself and often tends to get'the car-
bohydrate staple rather than the pro.
tein-rich sauce or relish, which is often
somewhat liquid. In some cultures
forced hand feeding of young children
by the so-called "swallow or suffocate"
method can lead to aspiration pneu-
Many practices encountered in devel-
oping countries will seem rather ridicu-
lous unless certain patterns in Western
culture are considered. In the 1955
edition of a standard American book
on etiquette, there is a chapter titled
"Foods That are Sometimes Difficult,"
referring to certain foods that can be
eaten by hand without offending one's
host or neighbors and certain foods
which must be eaten only with the aid
of various utensils. The fact that these
are classified under the heading of eti-
quette in no way makes them different
from equally absurd and arbitrary cus-
toms elsewhere.
The prechewing of food is practiced
by numerous communities in various
parts of the world, including the Hadza
of Northern Tanzania, some Eskimos,
and various Polynesian groups.
The order in which various members
of the family eat at meal time is im-
portant because sometimes the adults,
particularly the father, may eat first
and receive the more desirable portions
of food, leaving little for the children.

Another important point with regard
to meal preparation is the realization
that the tropical mother's day is ex-
tremely busy and full. She will have
many chores occupying her from dawn
to dusk, including collecting wood, car-
rying water, and, in some communities,
cultivating the fields. Under these cir-
cumstances, suggestions concerning the
use of local foods for young children,
or the attempted introduction of new
processed foods, are not likely to be
followed if they impose much extra
burden on an already crowded and
over-full day.

Food Production. As is understand-
able in view of its importance to sur-
vival, traditional agricultural practices
are everywhere much bound up with
rites and customs, so that attempts to
change may be extremely difficult and
likely to meet with opposition or, at
least, with lack of enthusiasm.
The planting, harvesting and storing
of the cultural super-food is particu-
larly likely to be the occasion for cere-
monies and rites of fertility. Phases of
agriculture are also likely to be related
to the calendar.
Disasters to food crops, such as
drought or locust swarms, may be
equated with the influence of ultra-
human forces, often especially with
witchcraft. Specialists may exist for
specific problems, in Africa particu-
larly rainmakers.
Animal husbandry may be much
influenced by the particular symbolism
of certain animals in some communities.
In New Guinea, the pig is important for
status and not eaten except rarely at
large-scale, nutritionally wasteful feasts.
In much of Africa, especially among
pastoralists, cattle represent wealth,
prestige, and bride-price, In rural

tionally reserved for divination rites.

Pattern of Authority in the Family.
Of great importance to practical nu-
trition education is to discover which
member of the family is responsible
for the final word on the choice of diet
for the young child, and also for the
control of the family purse and deci-
sions as to management in illness. Very
often this may be the father, although,
in communities with extended families,
the grandmother or the mother-in-law
may be at least responsible for decisions
as to what food the young child should
be given and when.


All those working outside their own
culture pattern, especially when in
direct contact with communities, must
have a clear understanding of cultural
relativity, and realize that all their own
practices and customs may not be
logical and ideal anywhere, and partic-
ularly that they may not be appropriate
outside their own community. For
example, in the Western world, it is now
realized that strictly regulated "by the
clock" breast feeding is incorrect, and
that a more permissive attitude toward
timing-such as is practiced naturally

of the newborn is common in some
areas because dung, a product of the
sacred cow, is used as a dressing on the
umbilical cord. In Buganda, kwashi-
orkor is partly related to the over-
valuation of the plantain-the local
cultural super-food-in the diet of
young children.

Effectiveness of Health Education.
Secondly, much improvement in the
field of nutrition is sought through
health education-that is, by attempts
to persuade people to modify their pres-
ent dietary behavior. This is particu-
larly difficult to do in the field of food
and nutrition, but can be best ap-
proached with most chance of success
by working within the frame of refer-
ence of local ideas.
In fact, it is a classical mistake to
assume that the parents concerned have
no ideas on food and infant feeding
themselves, and that all that is required
is to make available to them modern
factual knowledge. Methods of trying
to persuade parents to change feeding
practices are considered elsewhere
(pp. 95-114).

Acceptability of New Infant Foods.
In many parts of the world, attempts
are being made to introduce low-cost,
L:i. -L --*.-i J T. 2- __- L1_i-i

I at ula.
eral, anthropological, Beneficial custom
)oks or papers con- adopted into nutr
dar region, and must these means it se
.1 1

apparently weil-miormea, moaern-
educated local people and foreigners
long resident in the country are often
helpful, although the bias of the par-
ticular informant has to be borne in
If it is realized that differences in
practices and customs are certain to be
found, a great deal can be learned by
unobtrusive observation and, when
sufficient rapport has been achieved, by
friendly inquiry.


It is often possible to classify cus-
toms roughly into four groups accord-
ing to their apparent effect on health
and nutrition.

Beneficial Customs. These are cus-
toms which appear to benefit the
health and nutrition of children,
although they may be very different
from Western practices. For exam-
ple, prolonged breast feeding (p. 120)
up to two years or so is a beneficial
practice in most of the tropics, especi.
ally in areas of Africa where no cattle

Unimportant Customs. Certain
practices may appear strange and un-
necessary to an observer reared in the
U.S.A., as, for example, avoiding giv-
ing double-bananas to pregnant women
in case twins are produced, or using
special meat from the nose of the hyena
to help blind children to move around
If, however, they are of no signifi-
cance one way or another to the health
and nutrition of the child, they should
be left well alone.

Customs of Uncertain Effective-
ness. Sometimes customs will be found
which appear to have both beneficial
and harmful effects, so that it is difficult
to say how they should be classified. Foi
example, in some African communities,
various clays or earths are fed to chil.
dren. Without analysis, it is impose
sible to be certain of their value 01
With customs in the uncertain group,
further observation and investigation
is required before undertaking an)

luarmflu tus mas. in an cuuMiL
there are practices which are harm.
ful from the point of view of health and
nutrition. In Western countries, the
excessive use of sugar and over-refined
flour is undoubtedly in part responsibhk
for the high incidence of dental caries,
In various tropical countries, the
following practices may be mentioned
as being harmful nutritionally-thc
prolonged starvation of children with
diarrhea, the restriction of protein
foods for pregnant women, and ar
under-usage of eggs for young chil
dren, because they are too "hot" or lead
to baldness or for other cultural
Health education is often largely
concerned with the last category-thal
is, with harmful customs. Suggested
methods for use in trying to deal with
deleterious feeding practices are giver
It is absolutely essential to try to con
vince parents of the need to modify tht
particular practices-that is, to moti
vate them to want to learn how tc

uuangue p. o). wimour mouvanon,
improvement is not likely.
Occasionally, it may be possible to
plan infant feeding so that it is nutri-
tionally correct and is acceptable in the
local culture pattern. Thus, milk, which
is "hot," will not be given by a Bengali
mother to her child recovering from a
"hot" illness, such as diarrhea. How.
ever, she will be very ready to give
home-made acidified milk, which she
categorizes as "cold," thereby achiev-
ing the same nutritional goal.


D. B. JELULFE, Infant Nutrition in thi
Subtropics and Tropics, WHO Monograpt
No. 29, Geneva, (1955) (G&T).
--Culture, Social Change and Infanm
Feeding, Amer. J. Clin. Nutr. 10, 19, (1962)
B. D. PAUL (Edit.) Health, Culture ant
Community, Russell Sage Foundation, Nea
York, (1955) (G&T).
M. REsa, Culture, Health and Disease
Tavistock Publications, London, (1966)

1 G=Recommended for the general reader
T=Recommended for the technically trainee
health worker.

chapter v


also p
causation of all forms of mal- An
r, from marasmus (p. 82) to to
is always complex, and this is t
y so with malnutrition in young beyond
i in developing tropical regions. this is
:alization is fundamental be- to e
a different parts of the world, 2. (
ie type of malnutrition may able ii
ith very different causative fac- nity h
ponsible. It is plainly necessary times
the detailed causes of malnutri- or soi
a particular region, because or mai
this knowledge it is not pos- 3. 1
plan and to carry out a pre- edge o
program relevant to local group
tances. tary n
s main groups of causative fac- the hi
ill be considered here: (1) this pI
inadequacy, (2) infections, posur
socio-cultural factors, possib:
and i
r Inadequacy. In tropical any a,
i, malnutrition is often in large conceit
ectly due to dietary inadequacy, 4 I
this be a lack of nutrients or "wron
balance. However, at the same ally si
rure" dietary malnutrition is the the ti
in, and other precipitating (p. 61


such as infections, are usually
adequate diet may itself be due
riety of causes:
poverty may put various foods
the budget of the family, and
especially the case with regard
nsive animal protein.
,rtain foods may not be avail-
adequate amounts in a conmmu-
;ause of poor production, some-
,cause of an unsuitable climate
or defective food distribution
Lere is usually a lack of knowl-
the best foods for different age
and especially the special die-
eds of young children, such as
i requirement for protein during
ise of rapid growth. Without ex-
to modern knowledge, it is im-
Sfor an intelligent but illiterate
,educated individual to have
areness of modern nutritional
istly, what may be termed
knowledge" may be nutrition-
nificant. This may form part of
ditional local culture pattern
or may be a recent importation

into the community. r or exu
Bengal a study was carried c
showed that, although kwashih
most usually mainly due to
there were, in fact, a range
available protein foods which
being given to the child for a
different cultural reasons

Infections. Much work has
ried out recently on the inter;
tween nutrition and infection
been shown that many infecti
more easily, persist longer, ai
much higher mortality rate in
ished children; while infect
eases also play an important I
initiation of malnutrition itself
Many infections are characi
poor appetite, and sometimes
ing and diarrhea. Apart fro:
has been shown that during ei
infections the body's need fc
and other nutrients increases
some communities the diet c
fections may be severely rest
the child starved, as a misgu
of treatment.
Infections are of particular
tance in the production of mal
especially marasmus, kwashio
vitamin A deficiency, becau
the early years of life, they I
immunity, while infections an
ly common, repeated, and ol
Particularly important in I
tion of kwashiorkor and othei
malnutrition are measles,
cough, infectious diarrhea, a
culosis. In some places, esp
West Africa, measles is pa
serious in this regard. Whoop
can also be of importance,
because of the vomiting, wtl

simple, in follows tme --wnoop" at tne (
)ut which characteristic bout of cough
)rkor was Infections with various par
poverty, may have nutritional rele,
of locally some countries, young chi
were not continually exposed to malai
variety of early childhood, and apart
'"cultural general effects of any fever
lions of malarial parasites tf
the child's body also affect tht
been car- directly, as they too have neei
action be- ious nutrients which are der
is. It has the host child. Also of impol
ons occur be heavy infections with var:
id have a tinal parasites, especially wi
malnour- worms and hookworms.
tious dis-
.ole in the Socio-cultural Factors.
If. socio-cultural factors can pl
terized by in the causation of malnutrit
by vomit- Separation from the Br
m this, it method of separation from
ten minor is often very relevant-partici
ir protein and when this is carried out. I:
. Also, in communities, this may be
luring in- ages, with different degrees
ricted, or ness or gradualness. Sometin
ided part tutes may be given in the for
delicacies, and sometimes t
ir impor- be actual geographic separa
nutrition, the mother when the youn
rkor, and sent to stay with a relative.
se during There is no doubt, especial
have little parts of Africa, that the sudd
e extreme- tion of the child, who previ
ten occur been in close contact with tf
both day and night, can le,
:he causa- chologic illness. The "maternm
- forms of tion" that results may be cha
whooping in the child by poor appetite
nd tuber- ing, which are of obvious ii
ecially in nutritionally, as is the loss of
particularly milk.
ing cough Length of Breast Feeding.'
especially of breast feeding is also a soc
lich often factor of significance as, a

else, nreasi m1IIIL U OtIL 1 FCp- i picV c
of the few sources of good protein
iimal protein. In most tradi- preparat
ieties (including the Western the your
il very recently), breast feed- As discu
tried on for at least two years feeding
ie next pregnancy or the next for the
been born. All over the world addition
there is a tendency toward plied b3
period of breast feeding than 1 to 2
r. In the tropics, this has as nutrition
ed mainly town dwellers, and While
rity of rural people usually the nutr
Ad in the traditional way. that this
reparation and Meal Pattern. tion, hei
pattern of eating obviously herself.
ficance as far as satisfactory diet bas
ling is concerned and conse- vegetable
k the prevention of malnutri- protein,
se patterns will include the during
of cooking, the number and also nee
meals, and the priorities of and nul
)n of different types of foods pregnant
.Child Interdependence. In- I
practices with regard to child PR
re of much nutritional rele-
ildren born too close together When
ie mother nutritionally and children
more liable to malnutrition age gro
s, because they have a rela- infants
)rt period of breast feeding children
another is not able to care for prbr
;elf for sufficient time. with the
with the
11 children are usually very
ieir mothers most of the time,
continual care, protection, so that,:
action This close contact tioned.
another and child leads to great ple treal
gical dependence of the young prevent
lis mother, these cc
le stores of nutrients obtained
mother in the last three months dfer
ncy are important to the grow- present
it. After birth, breast milk to their fi

a al cuu4tv1 utwi USttU, tl2 tjul[-
food requiring no kitchen
on and carefully adjusted to
g child's digestion and needs.
,sed elsewhere (p. 124), breast
done is all that is required
first 4 to 6 months, while the
.1 supplement of protein sup-
prolonged breast feeding of
years can be of significance
this book is concerned with
tion of children, it is obvious
is much related to the nutri-
.th, and survival of the mother
The mother needs a generous
-d on local, usually largely
: foods, containing adequate
minerals, and vitamins, both
pregnancy and lactation. She
Is a reasonable period of rest
ritional recuperation between


considering malnutrition in
it is useful to differentiate two
ips-preschool children,' i.e.
rd 1- to 4-year olds, and school
as they have very different
i. The present account deals
most important forms of mal-
found in developing regions
or example, obesity is not men-
.he causation, diagnosis, sim-
nent, and main approaches to
mn are considered for each of
rm "preschool child" is defined in
vays by various authorities. In the
;count it refers to all children up
th birthday.

lt.I. jlI W n IW v ILUza, a= ul.Uii-J
acteristic of a healthy, well-fe
child, and the growth curves
commonly in young children
tropical countries are revealinE
indicate the type of circuit
which can easily lead to the
ment of malnutrition.
Growth curves in less well-tc
dren in many tropical com
often show four stages:
Birth to 6 Months. Birth w,
tropical babies are usually s
below the standards consider
"normal" in Western countrJ
sons for this may vary from or
to another but include materni
trition and overwork during pr
malarial infection of the plac
adequate prenatal care, and
(genetic) differences in divers
groups. However, it is probi
genetic differences are less i
than previously considered, as
weight of the babies of well-fe
socio-economic groups cor
much more closely with
If the infant is breast-fed as
nately, still the case in me
tropical communities, weight
usually very good during the
6 months of life, as he is recm
abundant supply of protein a
ries from his mother's milk an
own stores acquired during pi
to rely upon. During this earl.
the weight gain may be superit
of bottle-fed Western babies,
no exaggeration to say that
communities an individual m
be better nourished throughout
at the age of 4 to 6 months.
6 to 12 Months. During the
months of life, breast feeding i

cai cnar- conunuea, DDuI me quantity is i
I young sufficient for the larger infar
seen so tional foods given to him wi]
in many often consist of insufficient q
, as they of carbohydrate pastes and gn
instances little in the way of protein or
develop- rich foods. Also, at this time tl
will be losing the immunity w.
-do chil- passed to him across the place,
unities his mother and will begin to bi
tible to various infections.
,ights of Usually, therefore, during tb
)mewhat 6 months the growth curve is 1
ed to be than in the early months of
es. Rea- though, if breast-fed, severe i
e region tion is usually not seen. Hoq
1 malnu- lactation fails, nutritional mar
egnancy, likely to develop.
enta, in- I to 3 Years. The next 1
inherited growth is undoubtedly the rr
e human gerous, often especially the
ble that year. Breast feeding may or
nportant be continued during some or z
the birth time, but the amount of prod
d, upper plied in this way is small. The
responds ing this period will all too fi
Western be largely composed of ra
cooked, indigestible vegetab
is, fortu- often predominantly carbohy
st rural nature. The protein content ol
gain is will be low, while at the same
irst 4 to child will be involved in a co
iving an succession of bacterial, vii
id Calo- parasitic infections. Also, this
I has his a time of considerable emotion
egnancy during adjustment from babl
'period, childhood proper.
Tr to that It is during this transition
ad it is that in many areas the grow
in some becomes seriously abnormal.
ay never may continue to increase ver,
it life as or the curve may remain all
during some or all of this p4
second 6 some children, the weight may
3 usually decrease during this period s

is by no means unusual to see a child of
18 months who has reverted to his
original weight when 6 months old.
Failure of weight gain is the earliest
sign of malnutrition and may herald
decline into the severe forms--maras-
mus and kwashiorkor.
Over Three Years. After the age of
three years, the young child has fre-
quently acquired a certain degree of
resistance to various infections and is
able to obtain and digest a wider range
of the family diet. Under these circum-
stances, although he may remain below
standard weight and height for years,
he starts growing slowly.
However, in the event of famine,
war, or complete family breakdown,
such as may occur with refugees, mal-
nutrition may be seen in older children
or even in adults.
While the ultimate impact of lesser
degrees of protein-Calorie malnutrition
on physical development in later life
requires further study, there is no
doubt that the short stature and under-
weight physique of some communities
is the result of childhood malnutrition
together with continued inadequate nu-
trition thereafter. Long-term effects in-
clude possible mental retardation and
narrowed pelves, which in women lead
to difficulties in childbirth.

Protein-C a I o r i e Malnutrition
(PCM) of Early Childhood. Studies
in the last decade have clearly shown
that the most important form of malnu-
trition in developing tropical countries
is what is termed "protein-Calorie mal-
nutrition of early childhood" (PCM).
This can occur with several different
clinical appearances, as will be de-
scribed below, and in many parts of the
world is so prevalent as to be the pri-
mary public health problem, often af-

fecting in some degree over half the
young child population.
The term PCM is, in fact, a collective
term and refers to a variety of different
clinical forms of malnutrition. These
can be best visualized in the form of a
triangle, which is intended to show that
there is a gradation between the
normal, healthy, well-fed child at the
apex of the triangle and severe PCM
at its base. In between, mild and
moderate degrees occur. Two types of
severe PCM-nutritional marasmus
and kwashiorkor--can be easily recog-
The term PCM is used for this group
of conditions because all of them are
due to a diet low in protein but with
different levels ol intake of carbo-
hydrate Calories. The name also draws
attention to the fact that Calories are
important in the diet of the young child
and also in the treatment of PCM. The
rather vague label "early childhood"
is deliberate, because PCM has a
slightly different age incident. in var-
ious parts of the world, alth(c.gh always
having its main occurrence in the early
years of life.
PCM has recently been shown to have
long-term consequences among survi-
vors which are of a greater importance
than previously realized. Not only do
the severe forms of PCM have a high
mortality, and the lesser degrees make
children more susceptible to infections,
but also they may result in physical
stunting and permanent brain damage.
Therefore, all possible means for pre-
venting this condition must be brought
into action.
KWASHIORKOR. The word "kwashi-
orkor" was introduced to medical
literature by Dr. Cicely Williams in the
early 1930's. It is from the Ga language

of West Africa and means "disease that
occurs when displaced from the breast
by another child." It is interesting that
other African languages have names
for the same condition which also
referred to this association. However,
although as noted earlier, kwashiorkor
often does occur after weaning from the
breast, it can also develop months after
separation from the breast.
Causation. Kwashiorkor is one of the
severe forms of PCM. It is due to a diet
which is very low in protein, especially
animal protein, but one which contains
Calories in the form of carbohydrates.
In other words, it is not starvation, but
is due to an unbalanced diet. While it
can occur at a wide range of different
ages from infancy even up to adult life,
it is usually most common during the
third growth period mentioned above-
that is from 1 to 3 years.
During this period, the child has high
needs for protein for growth, and yet
is often receiving an indigestible, bulky,
largely carbohydrate diet, and is still
further nutritionally burdened by many
common, often multiple infections, in-
cluding measles, malaria, and infective
diarrhea. As noted earlier, psycho-
logical factors also often play a part,
especially if the child has been abruptly
separated from the mother's breast.
Kwashiorkor is, then, a disease
principally due to an unbalanced,
largely carbohydrate diet, but is always
in part caused by infections and para-
sites, which make still worse the basic
dietary nutritional inadequacy.
The detailed factors causing kwashi-
orkor may vary considerably from one
part of the world to another. Thus, in
one part of Uganda hookworm infec.
tion is very common in young children

protein-rich blood from the small in-
testine, it can lead not only to anemia,
but can be an additional factor leading
to kwashiorkor. By contrast, in another
part of the same country, the round-
worm is a very common intestinal
parasite, and in heavy infections, sev-
eral hundred of these large worms may
assist in the development of malnutri-
tion as a result of their absorbing food
from the intestinal contents.
Diagnosis. (Figures 9 and 10) The
clinical appearance of kwashiorkor
varies in different parts of the world,
both because of the genetic character-
istics of different human groups and
also because the detailed causation of
the condition varies as regards diet, as-
sociated infections, etc. The signs found
in kwashiorkor can be conveniently
divided into three groups: (1) always
present, (2) usually present, and (3)
occasionally present.
1. Signs Always Present. Four signs
are always present in children with
kwashiorkor: edema (swelling of the
feet, ankles, and elsewhere), growth
failure (especially a low weight for
age), psychological change (misery,
poor appetite), and weak, wasted
muscles, with some overlying sub-
cutaneous fat.
Edema is the cardinal sign of kwashi-
orkor. It is usually obvious on inspec-
tion and commences on the feet and
lower legs. Other parts of the body,
including the back and hands, may be
In mild cases it can be demonstrated
by pressing firmly with one finger on
the ankles or on the upper surface of
the foot for three seconds, when a
definite pit will be produced. The edema
is partly the result of the low protein

FIGURE 9.-Kwashiorkor in two-year (
wasted muscles (with fat present) si
changes and a marked "flaky paint" n

d Ugandan child, showing edema, misery,
I growth failure, together with slight hair

FIGURE 10.--Kwashiorkor in Guate
malan child, showing edema, misery
wasted muscles (with fat present) and
growth failure.

with subsequent leakage of fluid fronr
the small blood vessels.
The growth retardation, which is z
characteristic feature of kwashiorkor
is to some extent masked by the water
logging effect of the edema. In fact, f
truer picture of the degree of under
weight can better be judged after somn
days on treatment, when, as the edemi
disappears, the weight at first decreased
before commencing to gain as the child
starts to grow again.
Children with kwashiorkor are no
tably miserable, apathetic, withdrawn
immobile and with little interest. They
also have a poor appetite. Variowu
factors may be responsible for this, in
eluding the psychologic upset produce
as a result of separation from the breast
Also, actual changes in the brain, bott
biochemical and anatomical, may be ix
part responsible. During recovery, th<
child's return of interest in his sur
roundings is an excellent indication oa
Muscle is the body's principal store
of protein and is used up by the chilc
developing kwashiorkor as emergency
rations of this nutrient. The thin
wasted muscles can easily be seen, es
specially in the upper arm and in the
neck, where they may be so reduce
that the child is unable to hold up hii
head. By contrast, there will usually b(
a layer of subcutaneous fat present
which reflects the child's intake o:
carbohydrate Calories.
2. Signs Usually Present. Although
not required for diagnosis, various hail
and skin changes, anemia, and loose
stools are usually present in children
with kwashiorkor. Characteristically,
the hair is light in color, silky i7

and only loosely attached to its roots,
so that it can be plucked out easily. Ob-
viously, assessment of hair changes will
depend upon the normal appearance
for the particular genetic group.
Plainly, a standard for Swedish chil-
dren will be different from that for
Indonesian infants.
Hair abnormalities in kwashiorkor
can vary considerably, especially with
regard to color change. If kwashiorkor
develops suddenly, the hair may be
completely normal. Also, abnormal
light colored hair can be seen in young
children in the "kwashiorkor age
group" who are plainly not suffering
from this condition. However, this
usually occurs in communities where
children's diets are protein-poor and
predominantly carbohydrate, and some
of these children may probably repre-
sent lesser degrees of PCM.
Especially in darker complexioned
children, there may be a parallel lighten-
ing in color of the skin itself, which is
often particularly noticeable on the
face. Both lightening in color of the
hair and skin 'are probably mainly due
to deficiency of certain amino acids.
Another feature usually but not
always present is anemia-that is, an
inadequate production of red blood
cells. This may be due to a variety of
causes including the low protein oon-
tent of the diet together with lack of
other substances required for the for-
mation of blood, especially iron. In
many communities, there may also be
other conditions likely to aggravate 'any
dietary anemia present, including
malaria and hookworm disease.
Some degree of loose stools is usually
present in kwashiorkor. This may
sometimes be due in part to an infective

by the child, but may be due to a reduc-
tion in the body's enzymes, as these re-
quire protein for their production. Low
levels of intestinal enzymes lead to in-
adequate digestion of food and the pass.
ing of loose or semi-solid stools.
3. Signs Occasionally Present. A
wide variety of other signs may be
present in children with kwashiorkor,
including a flaky paint rash (Fig 9),
an enlarged liver, ulcers and open sores
on the skin, and sometimes the features
of associated deficiency of various
vitamins, such as vitamin A.
Treatment. Severe cases of kwashior-
kor should be admitted to a hospital for
treatment, if at all possible, as even
there the mortality may be up to 30 per-
cent. They need special biochemical
investigations and other tests to exclude
less obvious infections and to guide
more detailed treatment. In general,
treatment should include dietary ther-
apy and nutrition education of the
1. Dietary Therapy. The main es-
sential in the treatment of kwashiorkor
is to keep the child warm and to supply
what has been lacking from his diet-
that is, protein-in a form that he can
take and easily digest, together with an
adequate supply of Calories.
Usually a milk formula is used, fre-
quently based on dried skimmed milk
(low-fat milk), as this is economical
and sometimes available either from
UNICEF or some other organization,
or commercially from shops or stores.
Alternatively, suitable formulas for
treatment can 'be prepared from fresh
cow's milk, full cream dried milk, or
evaporated milk,

all these milk formulas to prevent td
protein being 'burnt as Calories by ads
ing cane sugar and, in the case 4
dried skimmed milk, preferably by ad,
ing both sugar and a digestible, edib
vegetable oil. The dried ingredients-
that is, the milk powder and tl
sugar-are mixed first in a bowl
plastic pail. The vegetable oil, which
may be sesame, cottonseed, or othi
edible oil, is then stirred. in slowly ar
thoroughly with a wooden spoo:
Finally, the cooled boiled water
mixed in to make up the final liqu:
diet. If there is a refrigerator in d
hospital, it is useful to make up tl
total quantity for the day at one tim
This will often be 40 fluid ounce
(1,100 cc).
The following simple but effect,
formulas may be used:
a. Dried skimmed milk powder :
level teaspoons2 (10 level desse
spoons), sugar 4 level teaspoons, ec
ble oil 6 level teaspoons, to 20 flu
ounces (550 cc) of boiled water;
b. Full cream milk powder 20 lev
teaspoons (10 level dessert spoons
sugar 4 level teaspoons, to 20 flu
ounces of boiled water;
c. Boiled liquid cow's milk 20 flu
ounces with sugar 4 level teaspoons;
d. Reconstituted evaporated milk
part milk, 2 parts boiled water), wi
sugar 4 level teaspoons added to
fluid ounces.
These mixtures can often be pi
pared more simply by the use of local
available measures (e.g. tins) of knov
The volume of teaspoons varies, but thi
formulas refer to those of 5-6 cc volur
One dessert spoon has twice this voluh
(approximately 10-12 cc).

formulas can be calculated approxi-
mately by multiplying weight in lbs. by
2 which gives the 24-hour total in
fluid ounces. In the hospital this will
often be best administered through an
intragastric plastic polyethylene tube,
either as a milk drip, or by giving cal-
culated feeds by syringe down the tube
at 2-3 hourly intervals.
11 it is absolutely impossible to admit
a child with kwashiorkor to a hospital,
treatment should be tried using one of
the milk formulas suggested in the total
quantity advised, but divided into eight
small feeds given at two-hour intervals
throughout the day, from 6 a.m. to 10
p.m. This method requires much pa-
tience and can be very time-consuming
as a result of the child's apathy and
lack of interest in food. It can be at-
tempted with supervision in the child's
home, or in a feeding center, or a nu-
trition rehabilitation center.
As soon as the child shows signs of
improvement as evidenced by disease in
edema, by a general improvement in
alertness, and by returning appetite,
other foods should be introduced into
the diet in addition to the milk formula.
These additions should be based on
the range of foodstuffs available in the
particular region. The aim should be to
give as wide, as mixed, and as econom-
ical a diet as possible, with special
emphasis on digestible protein foods
both of animal and vegetable origin, as
well as those known to be rich in
vitamins and minerals. If vitamin A
deficiency is common in the area, a
vitamin concentrate or fish liver oil
should be included in the early treat.
ment of all cases.
2. Nutrition Education. The recovery
of a child with kwashiorkor as a result

f correct diet is not only of therapeutic
alue, but also of educational value, as
i many tropical hospitals mothers,
others, or other relatives accompany 3
ieir children into the wards or visit
In areas where kwashiorkor is corn-
ion, group discussions and demon-
trations should be carried out in the
'ards with, if possible, the mothers
assisting in preparing and cooking the
eight dishes and in feeding them to
ieir children. The changing appear-
nce of the improving child is, in fact,
"visual teaching aid" for the group
It must be stressed again, however,
iat kwashiorkor cases require hos-
ital treatment if at all possible. Medical
supervision is needed to deal with com-
licated cases, to diagnose correctly,
nd to treat effectively the often multiple
ifections present and associated vita-
lin or mineral deficiencies which the
hild often has at the same time.
Prevention. There are four main
principles in the prevention of kwashi-
rkor: (1) a high-protein diet in the
early years of childhood, (2) the pre-
-ention of infections, (3) adequate
-hild spacing, and (4) the early
recognition and management of mild
i- __- D ir "Itr

maternal diet during pregnancy and
2. Prevention ol Inlections. Various
measures can be attempted from the
iblic health point of view to minimize
Le burden of infections to which
opical children are continuously
posed. These measures include im-
mnization against whooping cough,
iberculosis, and measles; the routine
ie of antimalarials; health education
aimed at measures to decrease the
icidence of infective diarrhea, includ-
ig the encouragement of breast feed-
ig, the use of clean foods and feeding
tensils, and the boiling of water; and
lalarial suppression in areas where this
ifection is common.
3. Adequate Child Spacing. Kwashi-
rkor often follows the sudden stopping
f breast feeding because the mother is
regnant again. In order to prevent this
tom happening, mothers should be
aught how to postpone their next preg-
ancy until a nursing infant is slowly
'eaned and eating independently.
furthermore if they do become preg-
ant, they need not stop nursing sud-
enly, but should be taught to do so
gradually while eating more protein
themselves because of the extra drain
n them.

oo. sgnt rro ux traoit &c& rcu- Early Cases. Kwashiorkor is one ad-
ood. Basically in most tropical circum-and it
I 1 .1 vanced, severe form of PCM, and it

)gnize t
,- *--

stages of the condi

producedd locally, available commer- of
-ially in stores, or issued in a supple- 84)
nentary feeding program (p. 141). In
addition, the roots of successful infant N
feeding must be recognized as being in mar
arge measure related to an adequate lanj

y PCM is considered later (p

f .... 1_ I-

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
towns, and in many parts of the world
is much more common than kwashior-
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
Once again, the basic dietary inade-
quacy is made worse by various asso-
ciated infections, and children with this
condition may well be suffering from
tuberculosis, infective diarrhea, and
-,o1 A1, 1, t T, -. ___ C-f, t 4C ,l


white patches scattered over the inside
of the cheek and gums).
Diagnosis. The signs of marasmus I
may be considered in two groups: (1)
always present, and (2) occasionally
1. Signs Always Present. Marasmus
SS ig FIGURE 11.-Late nutritional marasmu!
is always characterized by extreme in two-year old child, showing vera
in two-year old child, showing ver
growth failure, so that the body weight wasted muscles and fat, and severe
will only be 60 percent or less of what underweight (Guatemala).

would be expected for a child of that
age. Secondly, there will be a very
marked wasting of the child's muscles
and also his subcutaneous fat. This con-
trasts with kwashiorkor, and is due to
the fact that the marasmic child has
been living on his own body stores of
both protein and Calories.
Again, by contrast with kwashiorkor,
marasmic infants are usually more
vigorous and tend to have a better ap-
petite; their hair is relatively normal;
and there is no edema. In marasmus,
the face is thin, wizened, and has -a
"little old man" or skull appearance
compared to the often rounded "moon-
face" of kwashiorkor. Also, the head
seems very large in contrast with the
thin, wasted body (Figure 12).
2. Signs Occasionally Present. A
variety of other features may some-
times be present, including those due


Hair Changes -* I

Misery I
Misy3 Moon Face

Thin Musc
/ \Fat Presen



FIGURE 12.-Clinical features of two i

to associated lack of vitamins, anemia,
and diarrhea, sometimes with signs of
dehydration (drying up of the body).
Treatment. Cases of severe marasmus
should be admitted to a hospital, and
even here their response to treatment is
often extremely slow, much more so
than with kwashiorkor. Basically, the
treatment is the same as for kwashi-
orkor--that is, with one of the milk
formulas already described, in order
to supply protein and Calories (p. 80).
However, in view of the extreme under-
weight of the infant, it is better to try
to increase the total quantity of feeds
as soon as practicable and to base the
calculation of the daily quantity on
expected rather than actual weight.
Hospital admission is particularly
required for investigations to exclude
the possibility of tuberculosis and to
treat diarrhea. Thrush, if present, can


normal "

SOld Man's

Thin Muscles
SThin Fat

No Edema

Very Underweight

lain severe forms of PCM--kwashiorkor

mJr DAUAlJk `- -u ...a... FAOA -J j
painting the inside of the mouth three
times daily with 1 percent gentian
Prevention. Prevention is based on
the same principles as have been men-
tioned for kwashiorkor, but with special
reference to the first year of life-thai
is, (a) a high-protein diet, (b) the pre-
vention of infections, and (c) the early
recognition and management of mild
and moderate PCM.
In practice, for the majority of trop-
ical children this will mean (1) breast
feeding, (2) the avoidance of artificial
feeding, (3) the introduction of other
foods only when required nutritionally
(e.g., 4-6 months of age), (4) the pre-
vention of tuberculosis by BCC im-
munization, and (5) the avoidance of
infective diarrhea by breast feeding, by
boiling drinking water, and by using
clean foods and feeding utensils.
If artificial feeding is absolutely
necessary, particularly if the mother is
dead, a cup and spoon or a feeding cup
are preferable to a feeding bottle, as
the latter is particularly likely to be-
come contaminated and a major source
of infection. If, however, a relative in-
sists on using a feeding bottle, then
advice must be given her as to how she
can attempt to minimize the risks of
MILD-MODERATE PCM. For every case
of severe PCM, whether marasmus or
kwashiorkor, there are many hundreds
of thousands of young children suffer-
ing from the earlier stages of mild to
moderate PCM. Plainly, it is necessary
to try to detect cases in the early stages
and by suitable advice and management
to prevent them from ever reaching a
severe degree.
Diagnosis. The detection of mild to
-..i--. D Nm :_ i.._

constant. Biochemical tests are being
developed but are still under trial and,
in addition, will not be available to
most workers in the field away from
major laboratory services.
The earliest sign of PCM of early
childhood is growth failure, and this is
best detected by a low weight or a fail-
ure to gain weight normally.
The careful weighing of young chil-
dren is the most important method o)
recognizing PCM in its early stages.
Useful information may sometimes
be gained by a single weighing, but
serial measurements at intervals are al-
ways preferable as they give a contain.
uing picture of the individual child's
progress or otherwise.
In tropical communities, two prob-
lems have to be faced when trying to
assess the significance of children's
weights. Firstly, the question of locally
appropriate standards of comparison
has to be considered. Standards may
occasionally be available from measure-
ments made on healthy, well-fed chil-
dren of the local elite. Usually, they are
not, and the standards given in the pres-
ent book are those collected in Boston
in the 1930's (Appendix III). Although
they may not always be genetically ap-
propriate, they are convenient and
widely used. Also, present evidence sug-
gests that really well-fed children of
different ethnic groups are more
similar in weight than previously
Secondly, a major difficulty in many
tropical communities is that of age as-
sessment. Precise ages are not usually
known, as they have little significance
in most traditional societies. This poses
an obvious problem, as weights in
young children have to be compared

Attempts must be made to see if docu-
mentary evidence of birthdate is avail-
able, or if the mother in fact does not
know the age but can recall the actual
day or month of birth. Alternatively, a
calendar of local events can be con-
structed from which the child's birth-
date can be approximately pinpointed.
The stage of dental eruption may
also be helpful at least in giving a
lower limit, especially as this seems to
be little affected by malnutrition. How-
ever, as is well known, there is much
variation in the appearance of teeth
even in healthy, well-fed children
(Table 1).
A simple approximation can be used
where the age in months is calculated
by adding six to the number of teeth
If only a single weighing is possible,
this can be compared with standards
for age given in tabular form in Ap-
pendix III, or as a graph (p. 156). Both
representations show the "standard"
(or average for well-nourished chil-
dren) and levels for 80 percent and 60
percent of this standard.
If the weight is below 60 percent or
if edema is present, hospitalization is
indicated if possible. If the weight is
between 80 percent and 60 percent, the
child should be seen frequently (prefer-



Central incisor ........................
Outer incisor ..........................
Canine ................................
First molar b . . . . . . . . . . .....
Second molar b .............. . . . ...

1 Reproduced by permission from Massler
o Incisors range 2 months.
h T ArI_ ____ mA n t-

ably at least fortnightly), and the
mother should be given careful advice
on locally practicable infant feeding, is-
sued with dried skimmed milk or other
protein food supplement, and also, if
practicable, the child should be fol-
lowed up by means of home visiting.
If the weight is between 80 to 100
percent of the standard, the mother
should be given advice on infant feed-
ing, and weighing continued in the
future at monthly intervals.
Serial weighing should always be
the aim, and results can best be plotted
on weight graphs, if such are available.
By this means, failure to grow can be
detected early by a falling or station-
ary weight curve for the particular
child. If weight graphs are not avail-
able, levels of "inadequate weight gain"
may be used (Table 2).
Both an abnormal weight curve or an
inadequate weight gain should alert the
observer to deteriorating nutrition and
the need for careful advice on infant
feeding, for more frequent supervision
and for the issue of supplementary pro-
tein food if available.
In many tropical circumstances, it
may be impossible to obtain the exact
age, although in surveys dental second
year may be defined as children with


Lower Jaw Upper Jaw

.. 6 months ............... 7y months.
7 months ............... 9 months.
16 months ............. 18 months.
12 months .............. 14 months.
20 months ............. 24 months.

Schour (1944).


Age (months) Minimum Len
Observation (n

0-6 1
7-12 2
12-24 4

between 6-18 teeth. Under these cir-
cumstances, a rough assessment of
early PCM may be attempted by two
means. Firstly, serial weighing at in-
tervals may be feasible when "inade-
quate weight gain" (Table 2) may sug-
gest commencing malnutrition.
In addition, the measurement of the
arm circumference, taken with a tape
measure halfway between the elbow and
the point of the shoulder, may be useful.
This is much reduced in severe PCM
and also appears to be affected in lesser
degrees of malnutrition. It is especially
useful in the second year of life when,
in normal children, the arm circum-
ference remains more or less constant
(16 cm) throughout the whole of this
year. The reason for this is that the
components of the arm are changing
with the fat of infancy being replaced
by the muscle of the toddler, but with
the overall circumference remaining
about the same.
To detect early PCM if the age is
not known exactly, the arm circum-
ference of children in tle second year
of life may be compared with various
percentages below standard (16 cm):
90 percent, 14.4 cm; 80 percent, 12.8
cm; 70 percent, 11.2 cm; 60 percent, 9.6
cm. Experience suggests that children
with measurements below 80 percent
of standard (12.8 cm) require surple-
mentary feeding if practicable.
Prevention. The main aspects of the
nrtven-tinn nf all rdprrppc nf PCM khav


th of Inadequate Weight Gain

Y2 Ib (226 g) per month.
1 Ib (453 g) per 2 months.
1 Ib (453 g) per 4 months.

been mentioned when discussing
kwashiorkor and marasmus (pp. 81-
84) and will be elaborated later (p.
Treatment. The management of mild
and moderate PCM is considered later
(p. 141).

Vitamin Deficiencies. The present
brief account can cover only certain
major aspects of the commoner vitamin
deficiency diseases, especially those
which are public health problems in
various parts of the world.
A is seen occasionally in young children
in all tropical regions, but is a common
and important condition in certain
regions including parts of India, Indo-
nesia, and the eastern Mediterranean
Causation. The condition is caused
by a very low intake of vitamin A, both
as the vitamin itself and in the form
of the orange-pigmented foods contain-
ing carotene, the precursor of vitamin
A (p. 18). It is particularly likely to
occur in children whose mothers are on
a diet poor in vitamin A and who have,
in consequence, transferred only a
small quantity to the fetus during preg-
nancy, and whose breast milk is also
poor in this nutrient.
Severe avitaminosis A may accom-
pany kwashiorkor. It is also notoriously
associated with ill-advised attempts to
F~nF~Pp r~ ~r-4 .411.14 -~er

condensed skimmed milk which are
lacking in this fat-soluble vitamin.
Severe vitamin A deficiency is pre-
dominantly a problem of the early years
of life.
Diagnosis. Vitamin A is required for
the normal functioning of certain
epithelial cells of the body. Deficiency
may produce "night blindness," but
this is extremely difficult to detect in
the young children, who are principally
affected with severe degrees of this con-
dition. In addition, various forms of
dry and roughened skin may sometimes
be associated with lack of vitamin A.
However, the main effects of vitamin
A deficiency are on the eye. The con-
junctiva becomes dry and brownish in-
stead of glistening and moist. Some-
times a silver or white superficial,
roughly triangular patch appears on
the conjunctiva of one or both eyes
(Bitot's spots). This may be followed
by a dryness and cloudiness of the
cornea which in turn may lead to a
softening of the cornea and a rupture
of the eyeball. Both eyes are usually af-
fected, but often to different degrees.
Treatment. Young children with a
dry conjunctiva should be referred foi
medical attention or, if this is not avail.
able easily, should be treated with vita.
min A (6,000 international units daily
by mouth for 2 weeks). This can be ir
the form of vitamin concentrate or fist
liver oil (cod liver oil contains aboul
2,000 I.U. of vitamin A per teaspoon;
shark liver oil, 1,000 I.U. of vitamin
A per teaspoon). At the same time
health education should be undertaker
to persuade parents to widen the child'&
diet to include locally available caro
tene-containing foods.
If cloudiness, bulging, or rupture o
the cornea have occurred, this should,

and the child should immediately be
given 100,000-20,000 international
units of vitamin A intramuscularly or
by mouth as drops on the back of the
tongue. Thereafter, treatment should be
continued with a daily dose of 25,000
I.U. vitamin A by mouth for 5 days, to-
gether with a high-protein diet and a
course of antibiotics, probably penicil-
lin or sulfonamides, as infection of the
eyeball is likely to have occurred
through the weakened cornea.
In areas where vitamin A deficiency
is common, 25,000 units should be
given by mouth to all children follow-
ing measles or diarrhea.
Prevention. The prevention ol
avitaminosis A of early childhood
should commence in pregnancy when
the mother's diet should contain a gen.
erous quantity of this nutrient or, more
usually, of carotene-containing foods
(p. 18). This will ensure adequate feta
stores. This diet should also be en.
courage during breast feeding.
In areas of the world where sever
vitamin deficiency is common in younE
children, the fetal stores may be raise(
by giving women a single dose o:
300,000 I.U. by mouth in the lately
months of pregnancy.
During infancy the baby should bI
breast-fed, and after 4 to 6 months o:
age, when a mixed diet is introduced
this should contain local sources o
vitamin A, such as fish and anima
liver, and egg yolk, and of carotene
including dark green leaves and a wid
range of orange-pigment fruits an,
vegetables (p. 18). The pawpaw i
often widely available and a rathe
little-used food for young children. I
is a valuable source of vitamin i
precursor and. being soft and easil

If an area is known to be one of
high risk for vitamin A deficiency in
young children, it may be useful and
practicable to introduce a special sup-
plement of vitamin A during the period
of greater incidence-that is, from 6
months of life until 2 years. This can
be in the form of cod liver oil (1 tea-
spoon a day), or red palm oil, or shark
liver oil (2 teaspoons a day).
Alternatively, if the risk is consid-
ered great and it is felt unlikely that
daily supplementation will be followed
by mothers, and if no form of house
supervision can be divised, a single
depot dose of 100,000 international
units of vitamin A may be given by
mouth or by intramuscular injection,
which may last the child for several
months and can be repeated thereafter.
If the child is artificially fed with full
cream cow's milk, then no supplementa-
tion with vitamin A is required. Dried
skim milk is not recommended for the
feeding of young infants below 6 to 12
months of age. However, circumstances
may be such that this is the only form
of milk available; when it will have to
be used, it should be reinforced with
Calories in the form of sugar (p. 15),
and also should be accompanied by
vitamin A administration, either as
daily fish liver oil or red palm oil, or
an intramuscular injection, which lasts
for several months.
thiamine (vitamin B1) produces a dis-
ease known as beriberi. This occurs in
older children in the same form as in
adults. In addition, a particular and
often fatal form of the condition occurs
in babies and is known as "infantile
Causation. Severe thiamine defi-
ciency is almost confined to those parts

of the world where overmilled rice
forms the main part of the diet. In
particular, it is a problem in exten-
sive areas of Southeast Asia. Uniquely,
infantile beriberi is due to dietary in-
adequacy in the mother, both during
pregnancy and particularly during
breast feeding, leading respectively to
poor stores of this nutrient in the fetus
and more importantly to a very low
breast milk thiamine content.
Diagnosis. Babies developing infan-
tile beriberi usually appear plump and
well-nourished and, indeed, have been
receiving adequate protein and Calories
from their mother's breast milk. They
are usually aged between 5 to 7 months.
The illness often comes on suddenly
with soundless crying aphoniaa), con-
vulsions, and signs of heart failure,
such as blueness of the lips and rapid
breathing. Many other illnesses in
young children can produce much the
same picture, a fact which makes beri-
beri difficult for trained doctors to diag-
nose. However, in areas where infantile
beriberi is common, it is quite justifi-
able to give emergency treatment on
the basis of this diagnosis, provided it
does not interfere with their speedy at-
tendance for medical advice.
Treatment. Infantile beriberi should
be treated as an emergency with an
intravenous or intramuscular injection
or an oral dose of 50 mg of thiamine,
followed by 10 mg of thiamine daily
for 14 days. Health education of the
parents is required to persuade them to
introduce thiamine-containing foods
into the baby's diet. The child should
be sent for medical advice and will
probably be admitted to a hospital.
If thiamine is not available, any
available thiamine-containing multi-
vitamin preparation may be used, or

in this nutrient, such as yeast, or tik
tiki (a fresh extract of rice bran), or
soup of green gram.
While the baby is being treated, td
mother should be given thiamine b
mouth (20 mg a day) for 4 weeks.
Prevention. The prevention of infai
tile beriberi lies essentially in improvit
the diet for the mother in pregnancy am
Theoretically, this may be achieved i
a variety of different ways. The ove
milled rice, which may be much pr
ferred from the cultural point of viei
can be combined with a wider gener,
diet, especially including vegetables at
legumes. In some circumstances, it me
be preferable and easier to make avaJ
able to mothers either thiamine (20 n
daily) or a local source of this vitamin
such as tiki-tiki, which they can tal
during this period.
Basically, the problem of beribei
both in adults and babies, lies with tl
overuse of white rice as the main bu]
of the diet. The situation may be it
proved, as mentioned before, by wide
ing the diet or, alternatively, by tryir
to ensure that rice is undermilled 4
commercially enriched with thiamine 4
Finally, as soon as the infant is i
produced to mixed foods, care should I
taken to see that these contain loc
sources of thiamine.
of vitamin C in young children is r
ferred to as infantile scurvy. It usual
occurs in the first two years of life, mo
often between 6 to 18 months of age.
Causation. Vitamin C deficiency
rarely seen in the breast-fed becau
the mother's diet usually supplies a
adequate quantity of ascorbic adcid i

fortunately increasingly the case, babies
are reared on a cow's milk formula
based on either fresh boiled, or pov
dered, or evaporated milk, the condition
is likely to develop unless an addition
source of ascorbic acid is also give
This is because vitamin C is destroy
by heat, as occurs with the boiling c
fresh milk (which is required to ki
bacteria), and also in the processing c
preparing powdered and evaporate
milks. However, it may be noted thi
some brands of commercially prepare
milk add vitamin C to their products.
Diagnosis. Infantile scurvy has a dij
ferent appearance from that of the clai
sical picture in adults. For example, re(
swollen, bleeding gums are only foun
if teeth are actually present.
The characteristic features of infai
tile scurvy are produced by hemol
rhages in various parts of the bodi
especially under the covering (per
osteum) of the bones. This leads to th
picture of an irritable, anemic infax
with a tender limb or limbs, which ma
be thought to be paralyzed because h
is unwilling to move them because (
the pain.
Treatment. Hospitalization is ro
quired, especially as there are man
other diagnoses which give a simile
type of clinical appearance. Treatmea
in medically proven cases will then b
with large doses of ascorbic acid give
by mouth (250 mg four times daily
for 7 days).
Health education is required to pea
suade parents to include vitamin (
rich foods in the child's diet.
Prevention. The most natural pn
vention for infantile scurvy is u
doubtedly breast feeding, provided th
lactating mother's diet contains vitami

:-rich foods. Again, atter 4 to 0 months,
then the diet is widened, it is important
3 see that these also include sources of
scorbic acid, such as vegetables, fruits,
nd germinating pulses.
It must be stressed that for the breast-
ed infant there is no need for any
itamin C supplementation in the first
* to 6 months of life. Infantile scurvy
i extremely rare in the breast-fed, and,
that is more, the danger of introduc-
ring fruit juices from various unclean
sources very much outweighs any
doubtful advantage, as they pose a con-
iderable risk in terms of infective
In artificially fed infants, however, it
s necessary to introduce a source of
itamin C into their diet, unless the
particular milk preparation used has
ieen already enriched by the manu-
acturer. In these children, vitamin C
aay be given in the form of a locally
available fruit juice or as ascorbic acid
ablets, and should be continued until
he child is having a full, mixed diet.
t will be noted that orange juice,
vhile a good source of ascorbic acid,
ossesses no special or magic properties,
nd the best, cheapest, most easily
availablee fruit juice with a high vitamin
: content should be used in preference
p. 16). It may be more convenient and
conomical, and with less danger of
atroducing infective diarrhea, to make
.se of ascorbic acid tablets (30 mg per
itamin D is contained in expensive
animal foods such as dairy products
p. 15), so that, for the majority of
tropical children, the vitamin D intake
s in no way related to the diet, but
entirely proportional to the degree of

exposure ot the skin to me ultraviolet
.ght of sunshine.
Causation. Vitamin D deficiency
rickets) occurs most easily in cloudy,
emperate zones with little sunlight and
7ith cold weather which requires con-
iderable clothing and keeps children
doors. However, at the present time,
here is relatively little rickets in these
egions because of a fairly wide aware-
ess of the problem and because many
oods, including milks, are often rein-
orced with vitamin D. By contrast and
paradoxically, rickets is common in
certain subtropical and tropical
countries. In some towns, housing may
*e so close together that little sunshine
an penetrate into the dark courtyards.
n other places, infants may purposely
e kept covered by their mothers when
hey are outside, sometimes to avoid
the evil eye" and sometimes to prevent
darkening the skin.
Diagnosis. Vitamin D is required to
.ssist the absorption of calcium and
3 ensure the formation of normal
trong bones. In rickets, walking is
delayed, while the eruption of the first
et of teeth will also be later than usual.
'he skull is larger than normal, and
he back is bowed. The long bones may
*e bent or bowed, and there is a thick-
ned prominence at the ends of the
,ones, especially noticeable at the wrist.
Treatment. Unless in a part of the
rorld where the condition is well rec-
gnized, it is usually necessary to carry
,ut further investigations on the child
y way of X-rays of the wrist and bio-
hemical tests of the blood.
Severe cases of rickets are treated
nder medical supervision by large
loses of vitamin D. This can be given
rally as a concentrate or as fish liver
il, in a dose of about 2,000 I.U. daily

for 1 to 3 months. Alternatively, a
single intramuscular dose of 100,000-
300,000 I.U. of synthetic vitamin D
may be given, which lasts for 3 months.
Mild or suspected cases can be given
smaller doses of vitamin D (1,000 units
per day) for 1 to 3 months together
with exposure to the sunshine for the
whole body for at least one hour in the
morning or afternoon.
Fish liver oils are frequently avail-
able and may often be used for the
treatment or prevention of rickets--1
teaspoon of cod liver oil contains about
350 I.U. of vitamin D, and shark liver
oil, 100 I.U.
Prevention. In tropical countries, the
best way of ensuring an adequate avail-
ability of vitamin D is by exposing
children to the sunshine, and this is
emphasized by the absence of rickets
in most rural tropical communities.
However, in some areas, such as
Ethiopia, the practice of covering up
young children when they are outside
the house is deeply held in the local
culture, and health education to per-
suade parents to allow their children
to be exposed to sunlight is difficult to
put over effectively.
In high risk areas, it may sometimes
be desirable and sometimes feasible
to issue vitamin D as a supplement for
young children, either in the form of
fish liver oil or of actual vitamin. This
should be continued from 6 months to
2 years at a dose of 400 I.U. per day.
Alternatively, in areas of high risk, it
may only be practicable to give children
a single intramuscular depot of 300,-
000 units of vitamin D, which will last
them for 6 months. This will only be
done under medical supervision.
In urban communities, possible en-
richment of foods must be taken into

account, including margarine, vege-
table fats, and milk, including dried
skimmed milk.
IRON DEFICIENCY. Iron is needed to
make hemoglobin, the oxygen carrying
pigment of the red blood cells. An in-
adequate intake of this mineral leads
to an iron deficiency anemia in which
there is a defective production of red
blood cells owing to lack of this essen-
tial ingredient.
Causation. Poor stores. of iron may
be acquired during pregnancy from a
mother'who is herself deficient iiriron,
as can occur for various reasons, in-
cluding a too rapid succession of
This is particularly important, as all
milks, including human and cow's, con-
tain negligible iron, so that the infant
who has a high iron need during this
time of rapid growth and increasing
blood volume, has to rely to a very con-
siderable extent on the stores in his
own liver.
From the age of 4 to 6 months on-
wards, the child's body stores are
largely exhausted, so that it is impor-
tant to ensure that the diet the child re-
ceives in the second six months of life
contains local foods which are rich
sources of this nutrient, including
green vegetables and egg yolks.
Anemia is extremely common in
tropical children but, it must be noted,
is often due to several causes at one
and the same time. Thus, there may
often be a coincident nutritional iron
deficiency together with hookworm in-
fection, further draining blood from
the child, and also with malaria infec-
tion. Investigation with suitable blood
tests is indicated whenever practicable.
Diagnosis. The main sign of anemia,
whether due to iro,1 or from other

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