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 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 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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