Micronutrient Malnutrition In SAARC - TheNeed For A Food-based Approach

c. Gopalan

The countries of South Asia whichconstitute SAARC (South Asian As­sociation for Regional Cooperation),account for over 22 per cent of theworld's population. These countriesare India, Pakistan, Bangladesh, SriLanka, Maldives and Nepal.

Recent international reports1,2

have presented a rather depressingpicture of the economic, social, andhealth/nutritional status of several coun­tries in this region, While the defi­ciencies stated in these reports willnot be denied, it is important not tolose sight of the remarkable successesthese countries have achieved dur­

ing the last few decades despite for­midable challenges. Practically, allthese countries had emerged from

long colonial rule barely 50 years agowith a heavy backlog of under devel­opment; indeed they are ~ot, as ye~,totally free from the legacies of theircolonial past and from the effects ofthe inequitable world economic or­der of the present. Despite tremen­dous population growth over the last50 years, they have been able tostave off the acute large-scale fam­ines that devastated them at frequentintervals in the past. The Green Revo­lution which they had successfullyengineered had, at least, ensuredthat food-grain availability kept pacewith population growth - no meanachievement.

At the time of their political inde­

pendence 50 years ago, these coun­tries were a veritable museum of themost florid clinical forms of malnutri-

tion. Classical kwashiorkor, kerato­malcia, beri beri (cardiac, dry andperipheral neuropathies) and pella­gra were widespread as major publichealth problems. These florid nutri­tional deficiency diseases have nowceased to be the major public healthproblems that they were in the past.As one engaged in the study of nutri­tion problems in the region for over50 years now, indeed, almost fromthe days of the Bengal Famine, I havebeen witness to this remarkable changein the clinical nutrition scene in thisregion3.

The manner in which this re­markable change has been broughtabout, carries an important message.The control of these diseases wasnot brought about through narrowvertical programmes consisting of thedistribution of synthetic vitamins, drugs,or special formulations, ~~t thro~ghimprovements in the traditional dietsof the people, and through parall~1improvements in their socio-economlcand health status.

Thus, the once rampant cardiacand dry beri-beri and peripheralneuropathies were not elim.inat.edthrough the distribution of thiaminepills; pellagra in the Deccan plateauwas not brought under control throughthe distribution of nicotinic acid tab­lets; kwashiorkor was eliminated as apublic health problem not through thedistribution offish protein concentrates,strongly advocated by the ProteinAdvisory Group and associated Bu­reaus of Commercial Fisheries of some

important 'developed' countries, butby combating calorie deficiency andimproving the diets of pre-schoolchildren using their traditional diets.

Most importantly, keratomalciaas a public health problem was sub­stantially overcome not through theuse of massive doses of syntheticvitamin A. I was instrumental in intro­ducing the massive vitamin A doseprophylaxis programme approach innine states of the Indian Union morethan 25 years ago, long before IVAAGand the present votaries of this ap­proach ever came into being. I rec­ommended this step in the context ofhyperendemicity of keratomalcia insome parts of India then, to be usedonly for children between one andthree years of age, as a purely tem­porary measure. I did not advocateits use in pregnancy, lactation andinfancy. I can now testify to the factthat the implementation of the mas­sive vitamin A dosage prophylaxisprogramme was extremely poor, andreductions in keratomalcia wereachieved in the 1970s and 1980s despitethis. The credit for the subsidence ofkeratomalcia in India does not, there­fore, belong to this much-touted ap­proach. The vitamin A deficiency that

CONTENTS

•Micronutrient Malnutrition in

SAARC - The Need For AFood-based Approach

1

- C. Gopalan •Nutrition News 4

•Recent Advances In

Immunonutrition

5

- Gil Hardy •Foundation News 8

TABLE (Ref 2)Percentage of Infants with Low Birth-weightsSouth Asia

South East Asia

Bangladesh

50Indonesia 14

India

33Laos 18

Nepal

26Malaysia 10

Pakistan

25Philippines 15

Sri Lanka

25Thailand 13

Fiji

18

Vietnam

17we see today in this region is anextremely mild form of the diseasethat was encountered 50 years ago,and is seen in a much smaller propor­tion of the population.

Here, then, is a clear vindicationof the food-based approach to thesolution of our nutrition problems.This rich historical evidence providedby time-tested experience must beconsidered far more compelling andconvincing than the claims being pre­sented to us annually, favouring adrug-based approach based on syn­thetic vitamins.

The logical and physiologicalapproach towards combating anynutritional deficiency in a populationmust lie in bringing about appropri­ate corrections in the habitual dietsof the population.

MAJOR PROBLEMS

The four major nutritional prob­lems in South Asia that currently de­mand attention are: (1) Low birth­weights (LBWs) in infants and stunt­ing in under-fives; (2) Anaemia;(3) Iodine deficiency diseases; and(4) Hypovitaminosis A. While the lat­ter three problems are obviously re­lated to micronutrient malnutrition, itis possible that in the genesis of thefirst, protein energy malnutrition mayalso playa role. Unfortunately, therole of micronutrient malnutrition inLBWs and stunting has not receivedadequate attention.

Low birth-weight: Approximately,a third of infants born in South Asiancountries today, are of low birth-weight« 2.5 kg). The majority of these LBWbabies are small for date. The preva­lence of LBW is highest in South Asia.The striking difference in LBW inci­dence between South Asia and SouthEast Asia is indicated in Table. Theincidence of LBW in industrialisedcountries of the West is much lower.

International reports1•4 also pointto the fact that the incidence of stunt­ing in under-fives in the world is aboutthe highest in South Asian countries.It is not the 'smallness' but the im­pairment of the physical and mentalfunctions implied by stunting, thatshould cause concern. In stuntedchildren the innate genetic potentialfor functional performance - physicaland mental - may not find full expres­sion. Where a considerable propor­tion of children - the future citizens of

a country - arestunted, the 'qual­ity' of the humanresources of thatcountry stand se­verely eroded.

The problemof LBW and ofstunting are tosome extent inter­related. LBW ininfants of smallgestational agesignifies intra-uter­ine growth retar­dation (IUGR).Shanti. Ghose'spioneering studiesS, wherein she fol­lowed infants of LBW for 18 years andcompared their growth performancewith other infants and children of thesame socio-economic group born withnormal birth-weights, shows that in­fants born with LBWs continued to

grow in a substandard growth trajec­tory. These observations are in linewith those of studies on adopted In­dian orphans in Sweden6• Apparently,infants suffering from IUGR are 'pro­grammed' to grow and develop in asubstandard growth trajectory, thusswelling the numbers of stunted un­der-fives in the community. While therole of post-natal environmental fac­tors leading to stunting cannot bedenied, it appears that a consider­able part of the stunting in under­fives is the aftermath of the IUGR theyhad suffered.

Earlier, many infants with LBWsuccumbed to diarrhoeal and respi­ratory infections because of immuno­deficiency. However, due to improvedmanagement and control of such in­fections in recent years, there hasbeen a steep fall in child mortality inpoor communities. Child survival,however, is not synonymous with child­nutrition; the inputs needed for thelatter are far greater and need to bemore sustained than those for theformer. Decline in child mortality withouta corresponding improvement in childnutrition, has resulted in an expand­ing pool of survivors and this is beingreflected in a high prevalence of stuntingin under-fives in the poor communi­ties of developing countries.

The precise nutritional deficiency/deficiencies leading to IUGR and con­sequently to LBW is still debatable.Populations in which LBW incidenceis high suffer from a multiplicity of

2

nutrient deficiencies. Studies on the

effect of energy and protein supple­mentation to mothers during preg­nancy7,8,9, have yielded contradictoryresults which are none too impres­sive. Madhavan Nair et al'o at theNational Institute of Nutrition,Hyderabad, found a definite trendtowards adverse pregnancy outcomeat extremes of Hb levels in women ofthe poor socio-economic group oncereal-based diets in a study involv­ing nearly 1,000pregnant women andtheir offspring. This observation raisesthe possibility that in poor populationson cereal-based diets with marginalzinc intake, intensive iron administra­tion may be counterproductive andcould aggravate zinc deficiency.

The role of folic acid: Leela

lyengar9 pointed out the possible roleof maternal folic acid deficiency inthe causation of LBW as early as in1975. Unfortunately, this importantobservation was not followed up. It istime to return to it and examine therole of folic acid deficiency in IUGR.Plasma levels of homocystiene inmaternal and cord blood may be ex­pected to rise, but precise informa­tion on this important aspect has tobe gathered. It is possible that eluci­dating the role of folic acid deficiencyin IUGR may help provide an alterna­tive explanation to Barker et aI'sinterpretation, based on epidemio­logical studies, that infants sufferingfrom IUGR and LBWs are more sus­ceptible to chronic degenerative dis­eases in their adulthood".

The recommended dietary al­lowance of folic acid for pregnantwomen is 400 J.1gdaily. While animalfoods are rich in free folate, plantfoods on which poor populationsgenerally subsist are deficient in folic

acid content but for some green leafyvegetables (GLVs) and pulses. TheGLV content in the diets of poor com­munities are low. Pulses, thanks tothe Green Revolution which concen­trated on cereals such as wheat andrice, by-passing pulses and legumes,are today in short supply in develop­ing countries and beyond the reachof the poor. Apart from being a goodsource ofthe amino acid lysine, pulsesare also a good source of folic acidand riboflavin. The solution for cor­recting pulse shortage with lysinesupplementation of wheat, as pro­posed by some technologists, seemsto totally ignore the fact that pulsesare a good source of important mi­cronutrients such as riboflavin andfolic acid.

There are no detailed studieson the bio-availability of total folatein the diet. On an average, onlyabout 50 per cent of free folate infoods is bio-available, and allowingfor a loss of 50 per cent in cooking,the current folic acid intake in dietsof poor communities may be ex­pected to be well below the recom­mended levels. The prevailing dietsin pregnant women of poor communi­ties can provide only a fraction of therequired amount. The poor intake offolates in diets is reflected in subnor­mal red cell folate levels « 125 ng/ml)in about 50 per cent of pregnant sub­jects'2. The reported high incidence ofneural tube defects in some popula­tions of India13 is also in line with thisobservation.

Unfortunately, in national pro­grammes for the control of anaemiain pregnancy, folic acid and iron areadministered in the last trimester ofpregnancy (100 mg of iron and 500J.igs of folate). The importance of folicacid in the early stage of pregnancy,and indeed even at the time of con­ception, has now been established14.Since animal foods are beyond thereach of the poor, a diet based onwheat, Bengal gram, amaranth, clus­ter beans and colocasia could pro­vide enough folate to meet daily re­quirements. Unfortunately, the con­sumption of even these plant foods ishard to come by among the poor.

Apart from folic acid, the role ofother micronutrients, especially zinc,as a cause of LBW and stunting inunder-fives also merits consideration.Data gathered by the Nutrition Foun­dation of India on a large number of

pregnant women indicates no rela­tionship between serum retinol levelsand LBWs among poor communities.

Stunting: Normal growth is de­pendent on the regular supply of amultiplicity of macro and micro nutri­ents. In earlier years, stunting wasusually attributed to protein energymalnutrition, but the possible role ofmicronutrients such as zinc, iron, folicacid, calcium, vitamins A, Band D, isnow being better appreciated. Whilemany of these deficiencies co-existin poor countries, there could also beinstances wherein a micronutrientdeficiency could be the first limitingfactor. Indeed, with the gradual cor­rection of erstwhile gross energy deficitsin the diets, micronutrient deficien­cies may emerge as the major factorsresponsible for growth retardation inpoor communities around the world.

The degree of growth retarda­tion in children of "a poor communitymay be dependent on the nature ofprevailing nutrient deficiencies. Somenutrient deficiencies may depressgrowth more than others. Thus, aspointed out by Golden15, while seliniumdeficiency could result in low tissueconcentration of selinium without muchimpairment of growth, zinc deficiencycould result in stunting with mainte­nance of normal tissue zinc concen­tration. Zinc depletion in the soil re­sults in low yield; it is only in theadvanced stages of zinc deficiencythat its depletion is seen in plant tis­sues. The mix of nutrient deficienciesin a given diet is thus the determinantof the degree of growth retardation.Not all nutritional deficiencies maybe expected to depress growth to thesame extent.

Stunting is also associated withthe impairment of mental and physi­cal functions, but the nature and ex­tent of such impairments may againdepend on the precise mix of nutrientdeficiencies in a given population.Like stunting, the associated impair­ment of mental functions is also asum effect of multiple deficiencies ofnutrients which have a role in brainfunction. The effects of nutrient defi­ciencies on growth and mental func­tion need not necessarily run paral­lel, since impairment of growth andmental function are not mediated bythe same mechanisms. No linear re­lationship between the degree of stunt­ing on the one hand and the degreeof impairment of physical and mental

3

function on the other may be expectedin situations wherein, prevailing pat­terns of nutritional deficiency are widelydifferent. The mix of nutrient defi­ciencies in poor diets can vary fromcountry to country depending on thedietary pattern.

In view of these considerations,it may be wrong to attempt compari­sons between countries with respectto their nutritional status on the basisof the extent of stunting in their un­der- fives. International Reports haveseriously erred in making such a sim­plistic assumption and in arriving atthe unwarranted conclusion that South­Asian children are more malnourishedthan those of the Sub-Saharan Africaor Sudan',2,4. Golden's wheat plantgrown in soil low in selinium mayhave better growth than the onegrown in soil low in zinc, but theformer could be more diseased andunhealthy.

All this is not to deny that growthperformance is a useful yardstick ofnutritional status and that stunting,however brought about, is undesir­able. 'Small' is certainly not 'healthy'16.While the degree of stunting cannotbe used for inter-country compari­sons of the nutritional status of popu­lations for reasons stated above, stunt­ing and its functional implications needto be combated by an all-round im­provement of the diet and the correc­tion of the deficiencies that may beresponsible, rather than arbitrary con­coctions of synthetic nutrients.

Iron deficiency anaemia: In manydeveloping countries where moder­ate and severe anaemia in pregnancyis widespread, current control pro­grammes undertaken by public healthagencies have consisted largely inthe administration of iron/folate tab­lets (60 to 120 mg iron, 500 mcgfolate) in the last 100 days of preg­nancy as part of antenatal care. Thisis generally not accompanied by se­rious efforts towards improving dietsin poor households and, more impor­tantly, towards improving the diets ofwomen during pregnancy.

That this strategy has been in­adequate has been shown by theIndian experience as reported by theIndian Council of Medical Research(ICMR)17.

The practice of routine iron supple­mentation of all pregnant women hasbeen recently challenged18. The studiesof Madhavan Nair et a/'o referred to

above, also point to the need for cau­tion with respect to excessive ironmedication as the sole answer to theproblem of anaemia, especially in poorcereal-eating populations suffering frommultiple micronutrient deficiencies.The possible role of deficiencies ofzinc and other micronutrients in suchpoor diets needs to be elucidated.

The message that stands outfrom this finding is that in cereal­eating populations, the control ofanaemia will call for the effective con­vergence of three major approaches:

• Dietary improvement, especially bythe inclusion of vitamin C-rich fooditems which could increase the bio­availability of food iron

• Iron/folate tablet administration

• Fortification of appropriate food itemswith iron

Iodine deficiency: The inexpen­sive technology, a time honoured andtime tested one, for the control ofgoitre is the iodation of common salt.Programmes for goitre control mustrest squarely and socially on thistechnology.

Periodic parenteral administra­tion of iodated oil (notpresently manu­factured in any SAARC country) hasbeen suggested as an alternativeapproach especially in areas 'inac­cessible' to common salt.

It is difficult to imagine any ar­eas in South Asia which are now 'in­accessible' to common salt but readily'accessible' to disposable syringesand to an army of 'injectors'. Therehas been a steep rise in the HIVseropositivity rate among drug ad­dicts in our countries during the lastfew years. Those familiar with real lifesituations in the field will realise that'disposable' syringes will not bedutifully 'disposed off'. Under the cir­cumstances, the consequences ofresorting to a technology which isdependent on repeated injections (us­ing 'disposable' syringes) could bedisastrous.

Vitamin A deficiency: The coun­tries of South Asia are blessed with awide array of inexpensive foods richin pro-vitamin A carotenoids. A wholerange of inexpensive local foods forcombating vitamin A deficiency in poorpopulations is available in thisregion.

There is also the possibility of

augmenting the cultivation of red palmin India, Indonesia and Bangladesh.Now that techniques by which thepro-vitamin A fraction of red palm oilcan be retained in an acceptable andpalatable form have been identified,red palm oil could become a power­ful tool for combating vitamin A defi­ciency. The above foods can easilymeet the vitamin A requirement.

Spirulina, a source of pro-vita­min A carotenoids, has been devel­oped from the blue-green algae,Spirulina fusiformis19• With further re­search and improved technology, itshould be possible to identify waysby which spirulina, which can be widelyharvested, can be incorporated in apotent, inexpensive and acceptableform in the dietaries of developingcountries.

It will thus be clear that SAARC

has a vast potential for further aug­menting the production of carotene­rich foods. It would be extremely short­sighted and imprudent notto putthesevaluable, indigenous and inexpen­sive resources to proper use.

The general message that standsout from these considerations is thatpolicies for combating micronutrientmalnutrition (indeed malnutrition it­self) must be firmly rooted in a food­based rather than a 'drug-based'approach. We should look to ourfarmsand not to our pharmacies for thesolution of our nutrition problems.

Based on the keynote address by the author at

the FAO-sponsored SAARC conference held in Dhaka,

Bangladesh, in November 1997 on 'Prevention andControl of Micronutrient Malnutrition Through Food­

based Approaches in SAARC Countries'.

References

1. Mahbub ul Haq: Human development in SouthAsia. Human Development Centre. Oxford Univer­sity Press, 1997.

2. Human Development Report. United NationsDevelopment Programme. Oxford University Press,1994.

3. Gopalan, C.: The changing profiles of undernu­trition in India. NFl Bulletin, 12(1):1-5, 1991.

4. The State of the World's Children, 1998. UnitedNations Children's Fund. Oxford University Press.

5. Ghosh, S., Bhargava, S.K. and Moriyana, I.W.:Longitudinal study of the survival and outcome of abirth cohort: report of the research project 01-658­2, NCHS, Maryland, USA.

6. Proos, L.A.: Growth and development of Indianchildren adopted in Sweden. Acta Universitatis

Upsaliensis, Uppsala University, 363, 1992.

7. Prentice, A.M., Cole, T.J., Foord, FA, Lamb,

4

W.H. and Whitehead, R.G.: Increased birth-weig~after prenatal dietary supplementation of rUr<African women. Am J Clin Nutr, 46:912-925,1987

8. Kusin, J.A. and Kardjati Sri (Eds). Maternal an,Child Nutrition in Madura, Indonesia. Royal Tropcal Institute, The Netherlands. 1994. ICG Printin!Dordrecht.

9. Iyengar, L. and Rajalakshmi, K.: Effect of foliacid supplementation on birth-weights of infantEAm J Obstet Gynecol, 122(3):332-336, 1975.

10. Madhavan Nair, et a/: National Institute of Nutrition, Hyderabad, 1998 (To be pubiished).

11. Barker, D.J.P.: Intra-uterine growth retardatioland adult disease. CUff ObstetGynaecology, 3:200206,1993.

12. Raman, L., Subbalaxmi, P.V., et a/: Iron anIfolic acid nutritional status of women in slum. Nut

Rep International, 39(1):73-80, 1989.

13. Aggarwal, S.: In health care: technology visiol2020. TIFAC, Department of Science and Technology, New Delhi, 219-231, 1996.

14. MRC Vitamins Study Research Group. Prevention of Neural Tube Defects. Results of the Medica

Research Council Vitamin Study. Lancet, 338:131137,1991.

15. Golden, M.N.H.: The role of individual nutriendeficiencies in growth retardation of children a~exemplified by zinc and protein. In: Linear GrowttRetardation in Less Developed Countries. John CWaterlow (Ed). Nestle Nutrition Workshop SeriesVolume 14. Raven Press, 1988.

16. Gopalan, C.: 'Small is Healthy?' For the pOOlnot for the rich. NFl Bulletin, October 1983:1-4.

17. ICMR Task Force Study. Field SupplementatiorTrial in Pregnant Women with 60 mg, 120 mg anc180 mg of Iron with 500 mcg of Folic acid. ICMA.New Delhi, 1992.

18. Stear, P., et a/: Relationship between maternahaemoglobin concentration and birth-weights irdifferent ethnic groups. Birth Med J, 310:489-491,1995.

19. Annapurna, V.V., et a/: Spirulina as a source 01

vitamm A. In: Plant Foods for Human Nutrition.Kluwer Academic Publishers, 1991.

NUTRITIONNEWS

• 'Dietary Guidelines for Indians'

This Publication prepared by NIN,was released by Prof N.K. Ganguly,Director General, ICMR, on June 1,1998, at NIN, Hyderabad.

• 'Diet, Nutrition and Chronic Dis­ease - An Asian Perspective', pub­lished by Smith Gordon, UK, and jointlyedited by Dr P.S. Shetty and Dr C.Gopalan, has been released. Thiscontains the proceedings of asymposium organised by NFl in Feb­ruary 1997.