Introduction

Morbidity and mortality attributable to diarrheal disease in infants and young children can be reduced by a variety of preventive measures and by improved clinical management of those episodes that occur. Previous reports of the Committee on International Nutrition Programs have focused on improved case management, including oral rehydration therapy (NRC, 1981) and appropriate nutritional therapy (NRC, 1985). This report considers the dietary and nutritional factors that may affect the risk of contracting diarrheal disease. Recent evidence indicates that the incidence of diarrheal disease can be diminished by decreasing exposure to enteropathogens that frequently are present in foods, and that the severity (purging rate and duration) and frequency of illness can be diminished by improving the host's nutritional status. This evidence is reviewed and the programmatic implications of these findings are discussed.

Dietary practices are in a state of flux throughout the world. Traditional dietary patterns are being modified by the introduction of an increasing number of commercially produced foods. The development and reorganization of transportation and marketing infrastructures are altering food systems dramatically in all but the most remote rural areas. Women's roles in the work force continue to expand beyond the household. The responses of households to these large-scale social and economic changes typically differ and result in a wide variation of food preparation and eating practices within communities.

Decreased exposure to food-borne enteropathogens is possible through exclusive breastfeeding; improvements in the hygienic preparation, storage, and serving of foods; and possibly, by the use of specific food additives and the application of appropriate food processing and/or packaging techniques.



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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation Introduction Morbidity and mortality attributable to diarrheal disease in infants and young children can be reduced by a variety of preventive measures and by improved clinical management of those episodes that occur. Previous reports of the Committee on International Nutrition Programs have focused on improved case management, including oral rehydration therapy (NRC, 1981) and appropriate nutritional therapy (NRC, 1985). This report considers the dietary and nutritional factors that may affect the risk of contracting diarrheal disease. Recent evidence indicates that the incidence of diarrheal disease can be diminished by decreasing exposure to enteropathogens that frequently are present in foods, and that the severity (purging rate and duration) and frequency of illness can be diminished by improving the host's nutritional status. This evidence is reviewed and the programmatic implications of these findings are discussed. Dietary practices are in a state of flux throughout the world. Traditional dietary patterns are being modified by the introduction of an increasing number of commercially produced foods. The development and reorganization of transportation and marketing infrastructures are altering food systems dramatically in all but the most remote rural areas. Women's roles in the work force continue to expand beyond the household. The responses of households to these large-scale social and economic changes typically differ and result in a wide variation of food preparation and eating practices within communities. Decreased exposure to food-borne enteropathogens is possible through exclusive breastfeeding; improvements in the hygienic preparation, storage, and serving of foods; and possibly, by the use of specific food additives and the application of appropriate food processing and/or packaging techniques.

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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation Unfortunately, there is limited practical experience with program aimed at reducing the incidence of diarrheal disease by these kinds of interventions. This report provides an overview of factors that are expected to guide the development of nutrition-related strategies for the prevention or amelioration of enteric diseases. Its focus is the relationship among the host's nutritional status, food, food preparation and eating practices, and enteric disease. Its premise is that failure to deal effectively with the food-related causes and nutritional consequences of diarrhea predisposes the host to repeated and increasingly severe nutritional deficiencies and enteric illnesses that too often result in death. Equally important strategies that concentrate on the improvement of water supplies, waste disposal systems, primary health care schemes, and other important public health measures were not considered in order to focus attention on nutritionally related components of programs directed to the control of enteric disease. This report is designed to assist health planners in the development of programs to reduce diarrheal disease through improved feeding practices. Chapter 1, the Executive Summary, presents an overview of the report. It looks at determinants of infant and child feeding practices in specific socioeconomic contexts. Breastfeeding as it relates to the mitigation of enteric diseases is highlighted. The conclusions and recommendations are summarized. Chapter 2 presents an overview of feeding practices and discusses the social, economic, and cultural factors that influence them. However, the extent to which these practices are found in any given community and the specific determining factors must be identified as part of the planning process. Therefore, Chapter 2 also presents an algorithm for identifying the primary determinants in a given situation. The purpose of this algorithm is to assist in the task of identifying the most important factors causing diarrheal disease in a specific region. These are the factors that must be addressed when implementing the changes recommended in Chapter 6, Conclusions and Recommendations. Chapter 3 reviews the evidence concerning the relationships between diarrheal disease and nutrition. This is followed by a discussion about the scientific basis for the link between breastfeeding and diarrhea prevention, which provides the rationale for emphasizing breastfeeding as part of a campaign to reduce diarrheal disease incidence and severity. Chapter 3 concludes with a presentation of the general principles of nutrition during the weaning period and important biological issues that should be considered in programs designed to improve lactation. The first part of Chapter 4 discusses diarrhea-causing pathogens in relation to food and feeding practices, including a review of the sources of contamination. The second part of Chapter 4 describes potential interven-

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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation tions that can be used to reduce contamination in the foods given to infants and young children, particularly with respect to improving food handling. Chapter 5 presents other information that is essential for developing improved feeding programs: the technical issues concerning food processing, preparation, and storage. The report concludes with a set of recommendations to guide the process of planning suitable nutrition interventions. The subcommittee wishes to express its gratitude to the Committee on International Nutrition Programs and the Food and Nutrition Board for their reviews of the drafts of this report. We wish to acknowledge the interest and support of the late Martin J. Forman from the Office of Nutrition, U.S. Agency for International Development (AID). This report is an example of Mr. Forman's strong commitment to the nutritional well being of the world's children. The subcommittee also acknowledges the interest and support of Mr. Forman's successor, Dr. Norge Jerome, and Dr. Nicolaas Luykx also of the Office of Nutrition, AID. The subcommittee also recognizes the contributions of Dr. Sushma Palmer, Director, Food and Nutrition Board who reviewed the report, Ms. Janie Marshall, who provided administrative and secretarial assistance, and Mr. Michael Hayes who edited the report. Special acknowledgment is due to Drs. Susan Berkow and Virginia Laukaran, Program Officers, Food and Nutrition Board who worked closely with the subcommittee at various stages of this report's preparation. Their contributions were particularly valuable to the subcommittee. REFERENCES NRC (National Research Council). 1981. Management of the Diarrheal Diseases at the Community Level. Report of the Committee on International Nutrition Programs, Food and Nutrition Board, Assembly of Life Sciences National Academy of Sciences, Washington D.C. NRC (National Research Council). 1985. Nutritional Management of Acute Diarrhea in Infants and Children. Report of the Subcommittee on Nutrition and Diarrheal Diseases Control, Committee on International Nutrition Programs, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C.

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