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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
Nutrition Issues in Developing Countries
Part I: Diarrheal Diseases
Part II: Diet and Activity During Pregnancy and Lactation
Subcommittee on Nutrition and Diarrheal Diseases Control
Subcommittee on Diet, Physical Activity, and Pregnancy Outcome
Committee on International Nutrition Programs
Food and Nutrition Board
Institute of Medicine
NATIONAL ACADEMY PRESS
Washington, D.C.
1992
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
National Academy Press
2101 Constitution Avenue, N.W. Washington, D.C. 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education.
This study was supported by the U.S. Agency for International Development under Contract No. DAN-0262-G-SS-7050-00.
Library of Congress Catalog Card No. 91-62280
International Standard Book Number 0-309-04092-2
Additional copies of this report are available from:
National Academy Press
2101 Constitution Avenue, N.W. Washington, DC 20418
S018
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.
First Printing, May 1992
Second Printing, March 1993
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
SUBCOMMITTEE ON NUTRITION AND DIARRHEAL DISEASES CONTROL
CUTBERTO GARZA (Chair),
Division of Nutritional Sciences, Cornell University, Ithaca, New York
ROBERT E. BLACK,
Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland
KENNETH H. BROWN,
Program in International Nutrition, Department of Nutrition, University of California, Davis, California
RICHARD A. CASH,
Harvard Institute for International Development, Cambridge, Massachusetts
JUDSON M. HARPER,
Colorado State University, Fort Collins, Colorado
GERALD KEUSCH,
Division of Geographic Medicine and Infectious Diseases, Tufts-New England Medical Center, Boston, Massachusetts
GRETEL H. PELTO,
Departments of Nutritional Sciences and of Anthropology, University of Connecticut, Storrs, Connecticut
Staff
ROBERT EARL, Program Officer (from August 1990)
VIRGINIA HIGHT LAUKARAN, Program Officer (until August 1988)
SUSAN BERKOW, Program Officer (August 1988 through December 1989)
JANIE MARSHALL, Senior Secretary
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
SUBCOMMITTEE ON DIET, PHYSICAL ACTIVITY, AND PREGNANCY OUTCOME
MYRON WINICK (Chairman),
University of Health Science, Chicago Medical School, North Chicago, Illinois
CUTBERTO GARZA,
Division of Nutritional Sciences, Cornell University, Ithaca, New York
SANDRA L. HUFFMAN,
Center to Prevent Childhood Malnutrition, Bethesda, Maryland
JANET C. KING,
Department of Nutritional Sciences, University of California, Berkeley, California
MICHAEL S. KRAMER,
Department of Pediatrics and of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
ISABEL NIEVES,
Institute of Nutrition of Central America and Panama, Guatemala, C.A.
JULIAN T. PARER,
Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, California
JOHN W. SPARKS,
University of Texas Health Science Center, Houston, Texas
ZENA A. STEIN,
Department of Epidemiology, School of Public Health, Columbia University, New York, New York
FERNANDO E. VITERI,
Department of Nutritional Sciences, University of California, Berkeley, California
ROBERT WISWELL,
Palo Alto Veterans Administration Hospital, Palo Alto, California
Staff
ROBERT EARL, Program Officer (from August 1990)
VIRGINIA HIGHT LAUKARAN, Program Officer (until August 1988)
SUSAN BERKOW, Program Officer (August 1988 through December 1989)
JANIE MARSHALL, Senior Secretary
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
COMMITTEE ON INTERNATIONAL NUTRITION PROGRAMS
MALDEN C. NESHEIM (Chair),
Office of the Provost, Cornell University, Ithaca, New York
REYNALDO MARTORELL (Vice Chair),
Division of Nutritional Sciences, Cornell University, Ithaca, New York
KENNETH H. BROWN,
Program in International Health, Department of Nutrition, University of California, Davis, California
CUTBERTO GARZA,
Division of Nutritional Sciences, Cornell University, Ithaca, New York
GAIL G. HARRISON,
College of Medicine, University of Arizona, Tucson, Arizona
ROBERT HORNIK,
Annenberg School of Communication, University of Pennsylvania, Philadelphia, Pennsylvania
GRETEL PELTO,
Departments of Nutritional Sciences and of Anthropology, University of Connecticut, Storrs, Connecticut
BARRY POPKIN,
Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
BEATRICE LORGE ROGERS,
School of Nutrition, Tufts University, Medford, Massachusetts
Staff
VIRGINIA HIGHT LAUKARAN, Program Officer (until August 1988)
SUSAN BERKOW, Program Officer (August 1988 through December 1989)
JANIE MARSHALL, Senior Secretary
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
FOOD AND NUTRITION BOARD
RICHARD J. HAVEL (Chair),
Cardiovascular Research Institute, University of California School of Medicine, San Francisco, California
HAMISH N. MUNRO (Vice Chair),
Human Nutrition Research Center on Aging, U.S. Department of Agriculture, Tufts University, Boston, Massachusetts
EDWARD J. CALABRESE,
Environmental Health Program, Division of Public Health, University of Massachusetts, Amherst, Massachusetts
DORIS H. CALLOWAY,
Department of Nutritional Sciences, University of California, Berkeley, California
WILLIAM E. CONNOR,
Division of Endocrinology, Metabolism, and Clinical Nutrition, Department of Medicine, Oregon Health Sciences University, Portland, Oregon
DeWITT GOODMAN (deceased),
Institute of Human Nutrition, Columbia University, New York, New York
M.R.C. GREENWOOD,
Office of Graduate Studies, University of California, Davis, California
JOAN D. GUSSOW,
Department of Nutrition Education, Teachers College, Columbia University, New York, New York
JOHN E. KINSELLA,
College of Agriculture, University of California, Davis, California
LAURENCE N. KOLONEL,
Cancer Center of Hawaii, University of Hawaii, Honolulu, Hawaii
BERNARD J. LISKA,
Department of Food Science, Purdue University, West Lafayette, Indiana
REYNALDO MARTORELL,
Division of Nutritional Sciences, Cornell University, Ithaca, New York
DONALD B. McCORMICK,
Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia
WALTER MERTZ,
Human Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, Beltsville, Maryland
MALDEN C. NESHEIM,
Office of the Provost, Cornell University, Ithaca, New York
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
J. MICHAEL McGINNIS (Ex Officio),
Office of Disease Prevention and Health Promotion, Department of Health and Human Services, Washington, D.C.
ARNO G. MOTULSKY (Er Officio),
Center for Inherited Diseases, University of Washington, Seattle, Washington
Staff
CATHERINE E. WOTEKI, Director (beginning April 1990)
ALVIN LAZEN, Acting Director (August 1989 to April 1990)
SUSHMA PALMER, Director (until August 1989)
FRANCES M. PETER, Deputy Director (until June 1990)
SHIRLEY ASH, Financial Specialist (until August 1991)
UTE S. HAYMAN, Administrative Assistant (until March 1991)
MARCIA S. LEWIS, Administrative Assistant (beginning July 1991)
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
Contents
PART I: DIARRHEAL DISEASES
INTRODUCTION
1
1
SUMMARY
5
2
FEEDING PRACTICES AND THEIR DETERMINANTS
9
Feeding Practices, Food, and Diarrhea Risk
9
Sociocultural Determinants of Breastfeeding
9
Women's work
10
Health services and personnel
10
Marketing practices of infant formula manufacturers
11
Urbanization
11
Initiating Breastfeeding: Colostrum and Prelacteal Feeds
11
Introduction of Foods in Addition to Breast Milk
12
Feeding Methods
13
Severance: The Cessation of Breastfeeding
13
Specific Determinants for Intervention Planning
13
Food availability to the community
14
Food availability at the household level
14
Food availability to the child
15
Child feeding methods and practices
17
Summary
17
3
RELATIONSHIPS BETWEEN NUTRITION AND DIARRHEA
21
Evidence that Malnutrition Predisposes the Host to Diarrheal Disease
21
Immunological Consequences of Malnutrition
24
The Contribution of Diarrhea to Malnutrition
25
Human Milk and Diarrheal Diseases
26
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
Protective factors in human milk
27
Lactation performance
28
Weaning Foods
31
Nutrient composition of common foods
31
Bioavailability of nutrients
33
Nutrient Requirements of Infants and Young Children
34
Summary
35
4
FEEDING PRACTICES, FOOD, AND DIARRHEA RISK
43
Food Contamination
43
Fecal Contamination of Weaning Food in Developing Countries
44
Source of contamination
45
Relationship of weaning food contamination to diarrhea
47
Potential Interventions to Reduce Weaning Food Contamination
47
Personal and utensil hygiene
47
Summary
48
5
PROCESSING TECHNIQUES SUITABLE FOR WEANING FOODS
51
Processing
51
Processing techniques
51
Selection of processing location
57
Comparison of Strategies for Supplying Supplemental Foods
60
Summary
61
6
CONCLUSIONS AND RECOMMENDATIONS
65
Conclusions
65
Recommended Interventions
66
Research Recommendations
67
Behavioral modification
67
Transmission of enteropathogens
67
Enhancement of breastfeeding and weaning practices
68
Relationship between nutritional status and diarrheal disease
68
Timing of supplementary food introduction
68
Nutrient bioavailability and caloric density
68
Improved food processing technologies
69
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
PART II: DIET AND ACTIVITY DURING PREGNANCY AND LACTATION
1
SUMMARY
73
2
OVERVIEW OF THE SOCIOECONOMIC AND HEALTH STATUS OF WOMEN IN DEVELOPING COUNTRIES
77
Economic Situation and Food and Nutrition in Developing Countries
77
Status of Women: Health and Social Issues
78
Literacy
78
Fertility
79
Access to Health Care
79
Family planning
79
Infant and child mortality
80
Maternal mortality
81
Nutritional anemia
81
Low birth weight—Health and nutritional status of the mother
82
Breastfeeding
83
Physical Activities of Pregnant Women in Developing Countries
83
Patterns of energy expenditure and intake and low birth weight
86
Activity patterns of women in rural areas
87
Income from agricultural labor
90
Seasonality
92
Activity patterns of women in urban areas
94
Informal sector activity
97
3
PHYSIOLOGY OF NORMAL PREGNANCY AND THE EFFECTS OF UNDERNUTRITION
103
Body Weight and Composition
103
Maternal energy expenditure and energy balance
105
Potential energy-sparing mechanisms
107
Blood volume and composition
109
Undernutrition, blood volume expansion, and placental blood flow in animal models
109
Gestational Effects on Organ Systems in Pregnant Women
110
Pregnancy-related changes in maternal metabolism
111
Metabolic adaptations
111
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
Metabolic and Transport Function of the Placenta
116
Placental transport in malnourished women and animals
117
Effect on nutrient flux
117
Fetal Metabolism and Nutrition
118
Iron status and work performance
119
4
NUTRIENT METABOLISM AND PHYSICAL ACTIVITY
125
Energy
125
Resting or basal energy requirements
125
Energy requirements for activity
127
Sources of energy
131
Protein
132
Iron
132
Pregnancy and Oxygen Consumption
133
Pregnancy, Work, and Substrate Metabolism
134
Hormonal changes
134
Temperature
134
Effect of Maternal Undernutrition or Physical Activity on the Fetus
135
Effects of Undernutrition on Physical Activity
136
Productivity
137
Discretionary physical activity
138
Physical work capacity
138
5
EFFECTS OF DIET AND PHYSICAL ACTIVITY IN PREGNANT HUMAN POPULATIONS
143
Effects of Energy Intake
144
Background
144
Gestational duration
146
Fetal growth
146
Spontaneous abortion
147
Congenital anomalies
148
Maternal mortality
148
Other pregnancy complications
149
Effects of Maternal Work and Physical Activity
149
Background
149
Gestational duration
151
Fetal growth
155
Spontaneous abortion
159
Congenital anomalies
160
Maternal mortality
161
Other pregnancy complications
161
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
Combined Effects of Maternal Nutrition and Physical Activity
162
Background
162
Gestational duration
163
Fetal growth
165
Other pregnancy outcomes
165
Direct Evidence of Combined Effects
167
6
IMPACT OF PHYSICAL ACTIVITY AND DIET ON LACTATION
175
Influence of Physical Activity on Fat Storage During Pregnancy and Lactation
176
Related Functional Aspects of Energy Stores
179
Influence of Physical Activity During Pregnancy on the Efficiency of Milk Production
180
Cardiovascular Adaptations
181
Field Studies and Lactation Performance
181
Summary
185
7
CONCLUSIONS AND RECOMMENDATIONS
187
Conclusions
187
Recommendations
188
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation
PART I
DIARRHEAL DISEASES
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