Nutrition in Public Health Programmes
A couple of decades after the publication of Burnet and Aykroyd’s report on nutrition in public health, Jose Maria Bengoa, a Spanish expert in nutritional policy who worked for the Pan American Health Organization and the WHO during his exile from Franco’s dictatorship, published a report on nutritional programmes from a public health perspective. He started by expressing the difficulties in setting the specific targets a public health service had to assume in the field of nutrition. In many countries, nutrition programmes were included in general public health strategies, except in cases such as goitre and rickets.
Public health was defined as the art of scientifically organising and orienting collective efforts in order to safeguard, improve and restore health among populations. The second session of the Joint FAO/WHO Expert Committee on Nutrition established certain regulations for the instruction of nutritionists from a public health perspective. At the end of the 1950s there were institutions in many countries devoted to the protection of specific population groups, such as children. When challenging the introduction of more rational feeding habits in one country, experts often created laboratories to analyse foodstuffs. But this was not considered by Bengoa as a public health measure in itself. Food composition tables from neighbouring countries of similar agricultural characteristics could be enough to improve the nutritional state of a population, although it was obviously not sufficient. To assess the results of nutritional programmes, it was essential to have certain indices, in order to compare the initial situation before, during and after the campaign, as well as calculating the budget required to assess efficiency.
Indices used to assess nutritional problems belonged to two different categories: first, the general indices contained demographic, economic and social items, including food consumption in a specific country, and constituted an excellent description of the state of a certain population; second, specific indices regarding more concrete nutritional problems were necessary to evaluate the actual state of nutrition of a population and to subsequently programme adequate measures. Demographic indicators included birth rates, maternal mortality, rate of stillbirths, infant and child mortality, tuberculosis mortality, as well as mortality due to other diseases considered to be influenced by malnutrition and general mortality. Economic indices included: national income per caput; the cost of living; the proportion of the population working in agriculture and industry; the average salary by categories of occupation; the rapport between agriculture and industrial workers; the percentage of the salary devoted to food expenditure; the cost of a standard diet in a working class family; the cost of 100 g of proteins in different foodstuffs; the cost of 100 g of calories in a standard diet; and the cost of workers housing.
Social indices included: the rate of illiteracy; the number of schools per 1,000 children aged seven to 14; the number of play groups and other institutions for pre-school children; the number of newspapers, journals and other information media per 100,000 inhabitants; the number of hospital beds per 1,000 inhabitants; the ratio of doctors with respect to the whole population; and the proportion of unemployed, alcoholics, abandoned and adopted children, etc.
The establishment of indices showing food availability was promoted by FAO experts in order to demonstrate the importance of planning food production, agriculture and commerce, and to determine the proportion of agricultural products used for feeding animals and human consumption. Although these indices did not express the way in which available food was distributed among different social groups, they were considered a good source of information about the conditions that represented the basis of the nutritional problems in a country, although they were not as specific as food surveys. It was difficult to establish exact figures in many countries lacking good national agriculture statistics, but in those cases general indices could provide useful information about the general conditions. They also allowed calorie intake, animal proteins and fats to be calculated, as well as determine milk consumption, proteins per 100 calories, etc.
Specific epidemiological indices contained records on pellagra, beriberi, scurvy, rickets and other forms of avitaminoses, as well as food deficiencies and malnutrition. Clinical surveys, anthropometric surveys and food consumption surveys were essential to assess the nutritional state of a population.
Once again, kwashiorkor, endemic goitre and pellagra were identified as the main social diseases related to food deficiencies, which required specific public health interventions in many African, American and Asian countries. Food supplementation appeared as the main option, but it required detailed expertise to determine the type, definition, doses and legal regulations. Nutrition experts distinguished between several concepts expressing different methods of intervention in foodstuffs: reconstitution, reinforcement, surcharge and equivalence. A foodstuff becomes reconstituted when it is subjected to a process of restitution of its original nutritional elements lost during the production process. Reinforcement meant adding nutrients in a higher degree than in natural conditions and surcharge involved the addition of nutrients over the daily nutritional needs. Equivalence was applied to the process of restoring the equivalent nutritional value to similar foodstuffs, e.g. margarine and butter. It is easy to understand how food industrialisation was influencing the management of foodstuffs.
One of the most urgent targets was the supplementary nutrition programmes applied to special groups: pregnant and nursing women, pre-school children, schoolchildren; other population groups such as industrial workers and the elderly; and other vulnerable groups especially sensitive to the consequences of inadequate nutrition. Once again in public health nutrition, education of the public and open information appeared as a cornerstone. The way in which information campaigns and education to specific groups should be implemented was a major concern of FAO and WHO experts, giving rise to a series of publications on the subject.
-  Bengoa, J.M., Les programmes de nutrition envisages sous I'angle de la santepublique, FAO Nutrition Meetings Report Series No. 20, Rome, FAO, 1957; Molina,G., Organization and Intergration of Public Health Services. First Inter-AmericanCongress of Public Health, La Havana, WHO Document C.I.H./3, 1952.
-  “Nutrition Surveys. Their techniques and value”, Bull. Nat. Res. Coun, No. 117,1949.
-  Chatfield, Ch., Tables de composition des aliments pour l'usage international, Rome,FAO, 1954;
-  Bengoa, J.M., Lesprogrammes de nutrition, 1957, p. 1866.
-  Jolliffe, W., “Clinical examination. Methods for evaluation of nutritional adequacyand status”, Bull. Nat. Res.Coun, Washington.
-  Ritchie, J.A.S., “Pour une alimentation meilleure”, Etudes de nutrition de la FAO,No. 6, 1950; Organisation Mondiale de la Sante. Comite Mixte FAO/OMS d’expertsde la Nutrition, Geneva, OMS, 1954.