Food Nutrition Manual Eng

THE HEALTH ASPECTS
OF FOOD AND NUTRITION

A manual for developing countries
in the Western Pacific Region
of the
World Health Organization
Printed and distributed by the
Regional Office for the Western Pacific of the World Health Organization
Manila
and the
Regional Office for East Asia and Pakistan of the United Nations Children's Fund
Bangkok
Available from the WHO Regional Office (P.O. Box 2932. Manila)
and the UNICEF Regional Office (P.O. Box 2-154, Bangkok)
and from country offices of WHO and UNICEF in the
Western Pacific Region
First edition. Manila. 1969
Second edition, Taiwan. 1972
o· "
• r'- ~ ..
• <
World Health organization 1972
This Manual enjoys copyright protection in accordance with the

provisions of Protocol 2 of the Universal Copyright Convention.
The designations employed and the presentation of the material in this

Manual do not imply the expression of any opinion whatsoever on the part
of the Director-General of the World Health Organization concerning the
legal status of any country or territory or of its authorities, or concerning
the delimitation of its frontiers.
The mention of specific companies or of certain manufacturers' products

does not imply that they are endorsed or recommended by the World
Health Organization in preference to others of a similar nature that are
not mentioned. Errors and omissions excepted. the names of proprietary
products are distinguished by initial capital letters.
PRINTED IN T AIW AN
ii
THE HEALTH ASPECTS OF FOOD AN.D NUTRITION
ACKNOWLEDGMENTS
The Western Pacific Regional Office is grateful to the East

Asia and Pakistan Regional Office of UNICEF for providing the
funds necessary for the writing and printing of this Manual.
This office takes full responsibility for the text, but is grateful
to Dr. G.R. Wadsworth (London School of Hygiene and Tropical
Medicine) for writing the first draft of the Manual. The assistance
of WHO Headquarters, and of the Food and Agriculture Organiza-
tion of the United Nations, is also gratefully acknowledged.
This office is also indebted to the authors of numerous publica-
tions and also to nutrition workers in several countries who have
contributed indirectly to the material incorporated in this Manual.
The Manual is to a considerable extent compiled on the basis of
field experiences of WHO staff.
Thanks are due to the following persons or institutions for
permission to reproduce photographic plates:
Burroughs Wellcome Museum of Medical Science, London l4B

Dr. W.J. Darby, Vandel'bilt University ................. . 9A, lOC, D
Department of Pathology, University of Hong Kong ..... . l6A, B
Dr. R. Duckworth, Dental School, London Hospital Medical
College .. , .................. ,'" .. ,." ............ , l2A, B, C
Food and Nutrition Notes and Reviews. Canberra ........ , 2,3
Dr. T. Gillman, Institute of Animal Physiology, Babraham,
Cambridge, England ....... " .................... ,., 14B, C, 15A
Dr. D.B. Jelliffe, Caribbean Food & Nutrition Institute,
Jamaica ... " ................ , .................... . 4-12, 14-17
Journal of Tropical Pediatrics .... " ....... , ......... , .. 2, 3
Institute of Nutrition for Central America and Panama
(INCAP I .. " . . . . . . . . . . . . . , ' , . . . . . " . , .. , .• , ... , ' , ' llA, B
Dr. F.W, Lowenstein, WHO (Joint FAO/WHO/OAU-STRC
Food and Nutrition Commission for Afl'ica) ....... ," 7C, 9B, lOB
Professor D.S, IIlcLaren, American University of. Beirut .. SA, B; 8A, B
Nutrition Program, National Center for Chl'Onic Disease
Control, U.S. Public Health Service (formel'ly Intel'-
departmental Committee on Nutrition for National
Development) , .. , ....... ,", .. , .. '.' " ...... , " " , ,. 9C, D
Dr, I. Polunin, Reader in Preventive Medicine & Public
Health, Singapore. , . , . . . . . . . . . . , . . . . . . . . , , .. , 13
Professor O,H. Wolff, Institute of Child Health, University
of London .................. , .. ,................... l5C
iii
\
TARLE OF CONTENTS
Page
1. INTRODUCTIO:-> 1
The scope of the manual ....................... .
Planning for better nutrition .................... 3
General factors alfecting human nutrition
in the Region ............. . 4
Geographical and agricultural factors .......... 4

Socio-economic factors ....................... 5
Conclusion .................................... 7
II. THE PRINCIP AL FOODS USED IN THE

REGION ..................................... 8
Foods which are primarily sources of energy ...... 9
Rice ....................................... 9
Maize ...................................... 13
Sorghum and millet; wheat ................... 14
Sweet potato ................................ 15
Taro; yam .................................. 16
Potato ..................................... 17
Cassava ................................ ,... 17
Banana and plantain ......................... 18
Sugar; sago .................................. 19
Coconut .................................... 20
Breadfruit and jackfruit; oils and fats . . . . . . . . . 21
Alcohol............. ........................ 22
Foods which are primarily protein sources .... ' . . . . 22
Milk ....................................... 23
Meat; eggs ................................. 30
Fish ....................................... 31
Other animals; soybean ....................... 32
Green gram ........... ~ . . . . . . . . . . . . . . . . . . . . . 33
Peanut; other dried beans and peas ........... 34
Nuts ....................................... 35
iv
CONTENTS
Page
Foods which are primarily sources of minerals
and vitamins .: .......................... ,..... 36
Green leafy vegetables .... . . . . . . . . . . .. . . . . . .. . 37
Roots; vegetable fruits ........................ 38
Stalk; flowers; seaweeds; fruits . . . . . . . . . . . . . . . • 39
Extras 40
III. THE PRINCIPAL NUTRITIONAL

DISORDERS IN THE REGION
Protein-calorie deficiency and growth retardation 41
Introduction ................................ 41
Clinical features ............................. 58
Causes, epidemiology and prevention . . . . . . . . . . ... 61
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Vitamin A deficiency .................... . 67
Clinical features ....................... . 67
Causes, epidemiology and prevention 69
Beriberi .............................. . 71
Introduction ............................ . 71
Clinical features and epidemiology ............. . 72
Prevention ................................. . 73
Other vitamin deficiencies .................. . 75
Riboflavin .............................. . 75
Pellagra ................................... . 75
Scurvy 76
Rickets 77
Vitamin K ................................. . 78
Anaemia
Endemic goitre 82
Dental diseases 84
Nutrition, infection and mortality ..•. . . . . . .. . . . . . . 86
Obesity 88
v
Page
IV. NUTRITION OF VULNERABLE GROUPS ...... 92
Infants and toddlers ......... . . . . . . . . . . . . . . . . . . . 92
Nutritional status at birth .................... 92
Normal and retarded development . . . . . . . . . . . •. . 98
Breastfeeding ........ ". . . . . . . . . . . . . . . . . . . . . 99
Artificial feeding ............................ 102
Supplementary feeding of infants ..... . . . . . . . .. 108
Special problems ............................ 114
Toddlers .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
School age .................................... 118
Normal and retarded development. . . . . . . . . . . . .. 118
Food supply and shortages .................... 119
Nutrition and associated conditions ............ 121
I Vulnerable adult groups ........................ 121
Pregnant women ........................... . 121
Lactating women ........................... . 123
The elderly and destitute ..................... . 127
V. NUTRITION SURVEYS 128

Orientation 128
Training 180
Ecological factors ............................ . 131
Food availability and production ............. . 181
Food patterns and consumption ............... . 131
Environmental hygiene and conditioning infections 186
Socio-economic and cultural influences ......... . 186
Health and other services .................... . 186
Surveys of nutritional status ................... . 187
General organization 187
Clinical examination 138
Anthropometry· ............................ . 142
Laboratory ................................ . 148
Reporting ................................. . 151
vi
CONTENTS
Page
VI. NUTRITION EDUCATION AND
SUPPLEMENTARY FEEDING................ 152
Orientation ................................... 152
Health channels 11>2
Other channels ............................... . 156
Methods 157
Planning .................................. . 157
Community education and community development 158
Implementation ............................ . 159
Techniques ................................ . 160
Some instructional aids ..................... . 161
How to make a food demonstration ............ . 166
Supplementary feeding 167
Orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 167
School feeding .............................. 168
Nutrition centres for infants and toddlers ...... 170
VII. FOOD HYGIENE AND STANDARDS........... 179

Food hygiene ................................. 179
Orientation 179
Some hygiene hazards of certain foodstuffs ..... 182
Some food handling hazards .................. 184
Hygiene in the home ...................... .. 187
Organization and legislation .................... 188
Personnel 189
Legislation 189
Fieldwork 189
Food standards ............................... 192
Expert committees .......................... 192
Codex Alimentarius Commission ............... 192
Food enrichment and food technology .......... 194
vii
Page
VIII. ADMINISTRATION. CO-ORDINATION
AND TRAINING " . . . . . . . . . . . . . . . . . . . . . . . . .. 195
Administration 195
Co-ordination ................................. 195.
Training on food and nutrition .................. 198
Basic training .............................. 198
Training for applied nutrition programmes.... 199
Higher-level training .......................... 200
IX. APPLIED NUTRITION AND

INTERNATIONAL AGENCIES 201
Applied nutrition programmes ................ 201
International agencies ........ . . . . . . . . . . . . . . . 202
ANNEXES
I. FOOD COMPOSITION TABLES ................ 206
Introduction .................................. 206

Specific nutrients and related items .............. 207
"Edible portion" (E.P.) and "as purchased" (A.P.) 208
Cooking losses and changes ...................... 209
II. NUTRITIONAL REQUIREMENTS ............. 221
General comment. 221

Energy 222
Protein 227
Vitamin A 240
Vitamin B complex 242
viii
CONTENTS
Page
Ascorbic acid; iron ............................ 244
Calcium ...................................... 246
III. SAMPLE SURVEY FORMS .................... 249
General infant feeding and weaning practices .... " 249

Special feeding practices of mothers and infants ' .. , 252
Household survey ... , ....... , ............... ,.. 256
Community survey .......... , .... , .......... ,. 259
School survey , ... , .................... , .. ,.... 264
Nutrition centre examination form, ....... , .. , . . .. 273
IV. SOME ANTHROPOMETRIC INDICATORS

OF NUTRITIONAL STATUS ... , .... , ...... ". 275
V. MORTALITY DATA IN THE COMPARATIVE

ASSESSMENT OF COMMUNITY
NUTRITIONAL STATUS ,.................... 295
VI. FOOD FOR INFANTS - a sample pamphlet .. , .. , 301
VII. RECIPES .. , .... , ....................... ,.". 309
A. for infants and toddlers . . . . . . . . . . . . . . . . . . . . . 309

B. for schoolchildren ...... , ... ', .......... ,., 321
C. for leafy greens ........................... 338
VIII. SOUTH PACIFIC ISLAND DIETS.............. 342

REFERENCES 356-378
ix
TABLES IN MAIN TEXT
3.1 Principal features of protein-calorie deficiency 42

3.2 Haemoglobin values below which anaemia
can be considered to exist, and associated
haematological values . . . . . . . . . . . . . . . . . . . 79
3.3 Changes in prevalence of dental decay in
areaa of American Samoa ................ 86
4.1 Mean weights of children in the Western
Pacific Region ., . . . . . . . . . . . . . . . . . . . . . . . . 97
4.2 Normal pattern of eruption of primary
dentition .. .. .. . . .. .. .. .. .. .. .. .. .. .. .. . 98
4.3 Normal motor, behavioural and mental
development . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.4 Amounts of foodstuffs required for a
balanced diet ............................ 116
6.1 Feeding of young children in Sierra
Leone village ............................ 133
6.2 Compilation of clinical survey data ... '. . . . . .. 140
6.S Biochemical tests spplicable to nutrition
surveys .......................... . . . . . . 149
7.1 Claesification of food-borne illnesses ........ 180
7.2 Food-borne diseases ...................... 181
8.1 Functions of a nlltrition unit .............. 196
TABLES IN ANNEXES
A.1.1 Data used for calculating energy values of
foods or food groups .................... 211
A.1.2 Factors used for calculating the protein
content from the nitrogen content of the foods 212
A.1.3 Thiamine and ascorbic acid; suggested
percentage l088eB in cooking .............. 212
A.1.4-8 Food composition tables .................. 213-219
x
CONTENTS
A. 1.9 SIIJDIIUIl"Y of nutrients supplied by principal
foods (par 100 g) .........•••........... 220
A.2.1 Recommended calorie allowances .......... 225
, A.2.2 Calorie allowance adjustments for different
activity levels . . . . . . . . . . . . . . . . . . . . . . . . .. 226
A.2.S Calorie allowance adj ustments for age of adults 226
A.2.4 Reference protein requirements of children
and adults .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 228
A.2.5 Comparison of the protein values of some
human diets as determined by rat assay
and as calculated from food tables ..... . . . .. 284
A.2.6 Protein values of some simplified diets in
the Western Pacific Region... ............. 285
A.2.7 Whole egg amino acid pattern... .... .... ... 238
A.2.8 Chemical score and N.P.U. of selected proteins 238
A.2.9 Recommended daily intske of vitamin A
at various ages .......................... 241
A.2.10 Recommended daily intakes of thiamine,
riboflavin and niacin for children and
reference adults ......................... 243
A.2.11 Recommended daily intakes of vitamin B
for adults of different body weight ..... . . . .. 244
A.2.12 Recommended daily intakes of ascorbic
acid. vitamin D. vitamin 812 and folate. " 245
A.2.1S Recommended daily intakes of iron ........ 246
A.2.14 Practical allowances for calcium ............ 246
A.2.15 Summary of recommendfd daily intakes ..... 247
A.4.1-2 Weight for Age .................. 278-279
A.4.3 Length for Age 280
A.4.4 Height for Aile 281
A.4.5 Skinfold Thickness . . . . . . . . 282
A.4.6 Arm Circumference 283
xi
A.4.7 Head and Chest, Circumference 284
A.4.B Conversion of pounds to kilograms 293
A.4.9 Conversion of inches to centimeters 294
A.5.1 Age-specific mortality rates among toddlers
and one-year-olds, based on registered deaths 295
A.5.2 Deaths among toddlers and one-year-olds
as % of all registered deaths .,., ... , ... ,., 296
A.S.3 Vital statistics indices of nutritional
status, 296
A.S.4 Percentage of all in,fant deaths occuring in
monthly age groups ....... , ... ,'......... 297
A.5.5 Deaths among toddlers and one-year-olds as
percentage of all deaths (by mother
interview) .......... ' ........ ,.,... 299
FIGURES IN MAIN TEXT
1.1 Western Pacific Region of the World Health
Organization ... , .... , ....... , .......... , 2
2.1 Proportion of nutrients in lightly milled
rice remaining in highly milled rice ,.. 11
2.2 Protein content of foods - A. Per 100 g 24
B. Per peso ..... 25
2.3 Carotene content of foods ...... ' . . . . . . . . . . . 26 '
4.1 Mild and severe growth retardation', , .. ' , . . 94
4.2 Typical growth curves (body weight) in well
nourished and poorly nourished children 95
4.3 Average weights of children in different
countries in the Western Pacific Region 96
4.4 Simple equipment for grinding cereals
and legumes ................ ,'.......... 106
6.1 Effectiveness of different types of learning
experience 162
6.2 Use of flannelboard and chalkboard 163
6.3 Village nutrition station (A,B,C,D) 175
xii
CONTENTS
FIGURES IN ANNEXES
A.2.1 Prediction of N Dp Cal % ................ 232

A.2.2 Protein allowances in terms of N Dp Cal % 233
A.4.1 Average weights of infants and toddlers of
different socio-economic groups ............ 276
A.4.2 Child's record . . . . . . . . . . . . . . . 235
A.43 Weight in kilograms ..... 286
A.4.4 Schoolboy's weight record . . . . . . . . . . . 287
A.45 Schoolboy's height record . . . . . . . . 288
A.4.6 Schoolchild's record ... 289
PLATES
Plate 1. A malnourished family .................. 43

A. Protein-calorie malnutrition and
vitamin A deficiency
B. Marasmus, xerosis and Birot spot
C. Kwashiorkor without dermatosis
Plate 2. Kwashiorkor 44
Plate 3. Nutritional marasmus 44
Plate 4. A. Depigmented skin, compared with nonnal
child ............................... 44
B. Moonface
Plate 5. A. Bitot's spot .......................... 45
B. Keratomalacia (late. with necrosis of
cornea)
C. Scleral pigmentation
Plate 6. A. Pinguecula 46
B. Pterygium
Plate 7. A. Dyssebacea .. . . . . . . . . . . . . . . . . . . . . . . . 47
B. Conj unctival xerosis
C. Corneal xerosis and early keratomalacia
xiii
Plate 8. A. Keratomalacia involving whole cornea 48
B. Corneal vascularization with angular
palpebritis
C. Angular stomatitis
Plate 9. A. Atrophic papillae .................... 49
B. Fissures of the tongue
C. Early mottling of the teeth
D. Late mottling of the upper incisors
Plate 10. A. Spongy bleeding gums ................ 50
B. Pyorrhoea
C. Acute pellagrous dermatosis on forearms
and hands
D. Chronic pellagrous dermatosis on forearms
Plate 11. A. Cheilosis . .......................... 51
B. Hypertrophic papillae
Plate 12. A. Late mottling of teeth . .. .. .. .. .. ..... 52
B. Dental attrition
c. Enamel hypoplasia
Plate 13. A. Profile photographs illustrating
thyroid gradings . . . . . . . . . . ...... 53
B. Profile silhouettes illustrating
thyroid gradings
(from photographs)
Plate 14. A Follicular hyperkeratosis . ........ 54
B. Pellagrous dermatosis
Plate 15 A. Flaky-paint rash: forearms ........... 55
B. " : backs of legs
C. Bow-legs
Plate 16. A. Epiphyseal enlargement 56
B. Rickety rosary
Plate 17. Degrees of protein-calorie deficiency in early
childhood: Mild protein-calorie malnutrition 57
CHAPTER I
INTRODUCTION
1. SCOPE OF THE MANUAL
Nutrition is the science of food and the nutrients as related to

1..
health. In practical terms, nutrition means supplying the body
with the foods it needs.
This implies a consideration of several phases:
(a) food science: the value of available foods - food compo-
sition, food processing, etc.
(b) nutritional physiology: processes of normal assimilation;
of foods - nutritional requirements, etc.
(c) nutritional pathology and clinical nutrition: abnormalities
resulting from improper food supplies or assimilation
their ecology, aetiology, pathogenesis, treatment and
prevention.
(d) public health nutrition: the proper organization of food
supplies needed for individuals and communities;
nutrition surveys, nutrition education, supplementary
feeding, administration and planning.
This manual has been written because health authorities are
increasingly aware of the inadequate background of many health
workers on the subject of nutrition, more particularly as applied
to local circumstances in the Western Pacific Region of the World
Health Organization, which is shown in Figure 1.1.. This manual
applies mainly to the developing countries of the Region.
The manual is intended mainly for physicians but other health
workers, especially nurses, midwives, and health education
workers may find it useful. Many other professions are involved
in some aspect of nutrition work. These include nutritionists
and dieticians of various kinds, school teachers, home economics
teachers and agricultural extension workers, and community
development workers. The book may be useful to them. Compa-
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INTRODUCTION 3
nion documents on nutrition in maternal and child health and

village-level nutrition are availableJ36e. References to scientific
literature are given to guide those who wish to deepen their
knowledge further. A list of publications is given at the end of this
book. The numbers in the text refer to this list.
The types of nutritional problem encountered and their solu-
tions depend greatly on local circumstances. Ideally, perhaps, a
separate manual should be prepared for each area. The present
one deals in a general way with the common problems and solu-
tions, with illustrations where possible from particular areas in
the Region. The manual might also be applicable and useful be-
yond this Region, especially in some countries of South and East
Asia with similar nutritional problems.
2. PLANNING FOR BETl'ER NUTRI'nON

For rural areas, the way to better nutrition is usually through
improved farming and gardening. Education is vital and needs
to be related to local problems, to help people make the best use
of their resources, especially for the nutritionally vulnerable mem-
bers of their families. These are community problems, best dealt
with by the community education and development techniques
which apply to all aspects of community life and planning. Be-
cause food and nutrition problems involve many phases of com-
munity action, their solution demands inter-ciisciplinary and inter-
agency planning, co-ordination and action.
Likewise in urban areas the problems and their solution in-
volve many disciplines (food hygiene, food technology, control of
food standards and importation, etc.) and several agencies. No
developing countries can afford all the importations they would
like, to meet their food and nutrition needs; planning the best
use of their limited available resources is therefore essential 6ob•
Overall national planning, priorities and policies are needed in
food and nutrition. Within this framework, health workers play
a vital role, especially through established health channels such
as rural health units, and particularly through maternal and child
health services. However, practical nutrition education and
action· is needed at community level, at intermediate levels and
at national level, involving workers in the fields of education,
agriculture, community development, etc., as well as health
workers.
4 THE HEALTH ASPECTS OF FOOD AND NUTRITION
This manual deals mainly with those aspects of nutritional

problems and their solution which are the concern of health
workers. In due course a further manual on the inter-disciplinary
nutrition programmes commonly lmown as applied nutrition
programmes will be prepared. This manual is primarily con-
cerned with public health nutrition, i.e., the accurate definition
of nutritional status in the community, where necessary the cor-
rection and prevention of nutritional deficiencies, and the orga-
nization of an adequate nutrition component in public health ser-
vices. Most countries in the Region are working on national
health and national development plans. It is hoped that this
manual will give useful background information and perspective
for those planners, as well as for those concerned with the teach-
ing of nutrition in universities and other training' institutions,
and for all field workers engageo in nutrition activities.
3. GENERAL FACTORS AFFECTING HUMAN NUTRITION

IN THE REGION58b
3.1 Geographical and agricultural factors
Geographical and agricultural factors have an important

influence on the food and nutrition situation in the Region. Many
of the countries or territories are tropical or subtropical; many of
them are islands, and sea foods are fairly readily available. Most
of them have predominantly rural population and their economies
are usually based on agricultural products. In considerable areas
there is no permanent cultivation of farms, but rather, "shifting
cultivation": newly exploited land rapidly becomes exhausted,
after which the cultivator turns to another plot of forest or grass-
land. Average annual rainfall is usually high, but often there
are sharply alternating wet and dry seasons. Although primary
forest growth is luxuriant, the soil fertility is often low when it
comes to permanent cultivation. Subsistence agriculture is wide-
spread - the people are mostly small-scale farmers who in gene-
ral grow what they eat and eat what they grow. These factors
imply marginal nutrition but not necessarily malnutrition. How-
ever, an unfavourable event in the health, economic or agricul-
tural field can readily push the nutritionally vulnerable groups
(especially young children) across the borderline into malnutri-
tion.
INTRODUCTION
The principal staple food crops are rice, maize (corn) and/or
various tubers. Animal products are usually sold, mainly in
urban markets. They are relatively highly-priced, and are cOn-
sumed in smaller quantities than in occidental countries, and by
limited sectors of the population. Fish is more commonly avail-
able than meat, milk or eggs. Vegetable consumption is variable,
and tends to be more restricted in certain small islands; in some
cities; and in some areas where for instance a rice monoculture
prevails. Difficulties of transportation (especially between islands)
and storage and preservation of food also affect dietary patterns.
In general, local food production patter~ and agricultural factors
have a dominating influence on food availability and consumption.
Natural hazards occasionally playa dramatic part in curtail-
ing food supplies. For instance, prolonged dry spells and drou'lfllt
are common in some areas; heavy flooding of rice-fields and
vegetable gardens is also common; banana, papaya and even
coconut trees are occasionally destroyed by typhoons; and
numerous pests affect the crops. Fish supplies are often
affected by monsoons and the phase of the moon and
tides. Pollution of inland waters can seriously affect the
fish, ducks and other animals dependent on them.
In short, most people in the Region are small-scale farmers
whose livelihood is determined largely by their immediate physi-
cal environment. Nevertheless the human factor plays an impor-
tant part.
3.2 Socio-eeonomic factors

Economic factors are the most obvious ones responsible for
malnutrition. Malnutrition is a serious public health problem
mainly in developing countries where incomes are barely ade-
quate. For instance, in a country where milk is habitually drunk
by virtually all children, malnutrition is much less likely than
in a country where the popUlation is predominantly rural, milk
production is very low, and meat and eggs are too costly for the
regular family budget. Economic circumstances often also re-
quire mothers to work, resulting in difficulties in child feeding.
Such family misfortunes as unemployment, accidents, death or
separation of parents often lead to malnutrition. In such cir-
cumstances or in rural areas when awaiting the harvest, children
often have to go to school without breakfast, and family meals

are more meagre and infrequent than usual.
The standard of living, including food consumption as well
as income and housing, varies widely within most of the coun-
tries. There is a regrettable tendency, both between and with-
in countries, for the rich to get richer and the poor poorer, be-
cause of declining soil fertility, increasing population and land
pressure, excessive migration to urban areas, unemployment and
inflation.
Dietary patterns are also greatly affected by food customs
and traditions. Historical factors including religious affiliation
and the migration of some ethnic groups and the establishment
of trade routes have resulted in wide dissemination of some
distinctive food patterns such as those of the Chinese, Indians,
and various groups of Pacific islanders. Immigrant groups com-
monly adhere to their traditional foods to a greater or lesser
extent, even though these may not be so readily available or so
cheap as local foods; efforts to modify strongly entrenched habits
may therefore be fruitless. But on the other hand, importation
of dietary habits, food plants and processed foods has also some-
times resulted in mixed recipes and diversification of food pat-
terns. The most important beliefs are those which affect the
diets of the vulnerable groups particularly - pregnant and
lactating women, infants and toddlers. These beliefs vary wide-
ly from country to country and even between adjacent localities.
Prestige has a great deal of influence on food preferences.
Some foods have high prestige value, e.g. (commonly) meat and
white rice. Tubers have high prestige in some areas and low
prestige in others. The same is true of certain kinds of fish,
legumes (e.g. soybean, peanut, green gram or mung bean, etc.)
and green leafy vegetables. All of the latter are highly nutritive
but their popularity and acceptance vary widely. Some foods
of much lower nutritive importance have high prestige in many
areas, e.g. pork fat, eggplant, okra, onions and cabbage.
Food patterns are not static however. In many small islands
in the Pacific, for instance where soil fertility is low but coconuts
can be grown and exported, more and more of the foods con-
sumed are imported products - rice, wheat products, sugar,
tinned meat, fish and milk. These may bring both advantages
and disadvantages nutritionally. In most countries, urban deve-
lopment is rapid, with trends towards the use of the types of
INTRODUCTION 7
foods just mentioned. 1ao•140 Urban people with adequate income

may fare well, but those on low incomes, especially if employ-
ment is intermittent, may have very meagre diets with insuffi-
cient staple foods or more commonly, largely devoid of vegetables
rich in vitamins and minerals, especially vitamin A and iron.
The processing of foods, especially cereals, mainly for urban
markets but sometimes also for rural areas, leads in several coun-
tries to drastic lowering of intakes of thiamine, riboflavin, iron
and other nutrients.
4. CONCLUSION
Thus in the Region there are many circumstances - geogra-
phical and agricultural situations, climatic disturbances, national
and family poverty, etc. - which can lead to inadequate consump-
tion of food and poor nutrition. But in spite of the variable
factors involved in their evolution, the immediate causes and
manifestations are commonly similar in most parts of the Region.
The prevalence and severify of different types of malnutrition
varies considerably from place to place, however, depending on
the availability and use of local foods.
CHAPTER II
THE PRINCIPAL FOODS USED

IN THE REGION
From the functional point of view, there are three main food
categories:
A. Sources of energy
1. foods rich in carbohydrates (cereals, tubers, sugars and
starches)
2. foods rich in fat or oil
B. Sources of protein (body-building foods)
1. animal foods: milk, meats, eggs, fish, etc.
2. vegetable foods: grain legumes (pulses) and nuts
C. Sources of minerals and vitamins (protective and regula-
ting foods)
1. vegetables
2. fruits
The cereals contain 7 - 14% protein and 65 - 75% carbo-
hydrate, yielding approximately 360 Calories per 100 g. The
whole grain is a good source of various vitamins, especially vita-
min Bl (thiamine) and minerals, but much of this (and the part
richest in protein) is usually lost in the highly milled products.
Because of the quantities consumed, cereals can also contribute
half or more of the protein in the diet.
The starchy roots, tubers and fruits can provide adequate
calories in the diets, but insufficient protein - much less than
cereal-based diets. The protein differs markedly in value in
different members of the group, as discussed below. They can
also supply half or more of the protein in the diets, because of
the quantities consumed, and an almost adequate amount of most
minerals and vitamins.
The dried legumes (pulses) mostly contain about 20% of
protein, of varying quality. They contain about as much energy
as cereals, but are seldom eaten in sufficient amounts to be
8
THE PRINCIPAL FOODS USED IN THE REGION 9
important as energy sources. They are particularly rich in B

vitamins and contain useful amounts of many minerals, but sel-
dom any vitamin A or C. A qualitative summary of the main
nutrients supplied by the commonest kinds of food is given on
p. 219.
1. FOODS WlUCH ARE PRIMARILY SOURCES OF ENERGY

In most developing countries, one particular food makes up
the bulk of the intake and is referred to as the 8taple food. This
is usually:
<a) a cereal: rice, maize and wheat are the commonest;
(b) a tuber: sweet potato, taro, yam, cassava; or
<c) a starch: sago.
The staple foods are all rich in carbohydrate. Sometimes the
staples alternate through the day, e.g., bread for breakfast, rice
or tubers at other meals. Sometimes they are mixed together
before or after cooking (e.g., rice and maize). And sometimes
the staples used vary with the season, e.g., maize or tubers be-
ing used before the rice is harvested, in areas where there is
insufficient rice. Subsidiary foods sometimes provide a sub-
stantial calorie supplement to a staple, and may even become the
main source of calories in certain places or seasons, e.g., plantains
(cooking bananas), breadfruit. jackfruit, sugar.
Bulk trade in foodstuffs is usually in cereals or cereal products
because of the relative ease of their storage. However, in many
territories, especially in the Pacific islands, substantial trade in
tubers also takes place between villages and between rural and
urban areas.
1.1 IUeeIla
This is the most widely eaten staple food in the Region. Pro-
duction is below requirements in most of the developing coun-
tries. Imports come mainly from Thailand and Burma. In most
countries it has high prestige and in several national languages
and local dialects the word for "to eat" means also ''to eat rice".
Rice usually supplies about 360 Calories and 6-8 g protein per
100 g; thus about 8.3% of its calories are derived from proteins.
Rice is insufficient as sole source of protein for children in the
first three years of life. It is a moderately good source of
B-vitamins but contains no provitamin A or vitamin C. Rice is
low in calcium. Certain high-yielding and high-protein varie-

ties have been bred in the International Rice Research Institute
in the Philippines and are undergoing further selection and test-
ing, and some are being widely distributed in the Region.
In many places where rice is grown it is intensively cultivated
in circumstances where only one crop can be harvested annually.
Therefore, rice often has to be stored for long periods, or else
complemented with other foods (purchased OF grown). Storage
is sometimes efficiently done, either in large commercial grana-
ries, or at the household level in large wooden crates or large
woven baskets, bamboo or similar materials. It is thoroughly
sun-dried and then stored in the hulls or even on the dried stalks.
It is then less vulnerable to attack by insects and moulds. Ade.-
quate sun-drying or machine-drying before storage is essential
to avoid spoiling. Rodents, insects and fungi often cause very
substantial losses in rice which is improperly stored. Lightly-
milled or home-pounded rice deteriorates more rapidly than rice
in the hull or highly-milled rice. This is one reason for the
preference of traders for a highly-milled product. Others are
its attractive appearance, the people's preference for smooth rice,
and the fact that the rice bran can be profitably sold for stock
feed; the higher the degree of polishing, the more rice bran is
obtained. Imported rice is also usually highly-milled because of
its better keeping qualities and because it takes up less shipping
space.
The cereal is traditionally prepared for household use by
pounding or grinding it with wooden or stone implements. The
first stage of such processing leads to detachment of the outer
hull, and the product is known as brown rice. Essentially, "brown
rice" is undermiIled, i.e., not polished smooth, but it is not neces-
sarily brown in colour. Only certain strains of rice have a brown
coating. Whilst brown rice retains most of the nutrients in the
original grain, this is precisely why it does not keep well. There
is a higher concentration of fats as well as of protein, minerals
and vitamins, in the outer layers of the grain; the fat under-
goes chemical change resulting in rancidity, and the fat and other
nutrients attract and nourish' the contaminating organisms. The
losses of various nutrients during milling are shown in Figure 2.1.
Sometimes, on festival occasions, rice may be pounded Clml-
pletely to a fine powder which is made into cakes. This flour
can be used for making porridge or gruel very suitable for in-
fant feeding; but because of its fat content. it cannot be stored

for more than a few days.
Rice mills driven by electrical or other power have made pos-
sible the processing of rice in bulk. Sometimes this rice may
be lightly-milled and gives a product comparable to pounded grain.
Usually. however. machine-milled rice. especially produced by
small travelling mills with steel rollers. is highly milled and the
percentage of broken grains is high. Rollers made of rubber or
other softer material are preferable. The most important nu-
trient lost in highly~milled rice is thiamine. so that diets consist-
ing mainly of this food can lead to the occurrence of beriberi.
Highly-milled rice can be further processed by milling it in
the presence of special powders. The product is known as
polished-rice. Actually. polishing of rice is going out of practice.
but the term polished-rice is often applied to all highly-milled
forms.
FIGURE 2.1
PROPORTION OF NUTRIENTS IN LIGHTLY MILLED RICE

REMAINING IN HIGHLY MILLED RICE
~ Un4.r.llled, hom. po.nded or parboiled ric ••

_ HI,hl, .illed .. (IOIlshlll rice.
When rice is soaked or steamed before pounding or milling,

water-soluble nutrients contained in the outer layers dissolve in
the water entering the grain and seep into the inner part of it.
Even when the outer layer is removed in subsequent milling,
most of the nutrients remain in the final product. The actual
amounts of different nutrients retained in milled grains depend
on the time and temperature of the preliminary soaking; when
too prolonged there is loss of nutrients out of the grain into the
water in which it is soaking. Movement of water-soluble
nutrients into the inner parts of the grain is more rapid at rela-
tively high temperatures (parboiling). Parboiled rice has a par-
ticularly high retention of nutrients after milling. The actual
process of parboiling varies, but a usual process is that the whole
grain (in the hull) is soaked in water for one or two days,
steamed, then dried in the sun or by some other form of heat,
and finally milled. Strong flavours and discolouration of the rice
can occur if the preliminary soaking is not properly controlled.
An improved method has been developed at the Central Food
Research & Technology Institute in India. The rice is soaked in
water at 70-75°C for 3-3! hours, then steamed and dried. This
produces a product with no off-flavour. Machinery for its com-
mercial application has been developed. Parboiled rice contains
two to five times as much thiamine as untreated highly-milled rice.
Parboiling toughens the grain so that less of it is broken during
milling, and parboiled rice is more resistant than untreated rice
to attack by weevils.
In order to try to avoid the occurrence of beriberi and other
nutritional deficienices in rice-eating communities, highly-milled
rice can be enriched by adding to it a certain amount of specially
treated grain, known as "premix". The premix is made by spray-
ing milled rice with a watery solution of vitamins (usually thia-
mine and niacin) and sometimes minerals. It is then dried and
mixed with powdered iron pyrophosphate and sprayed with an
alcoholic solution of zein· and fatty acids which, after drying,
leaves a coating that dissolves in hot, but not cold water. When
riboflavin is one of the nutrients added the premix is coloured
yellow. This has sometimes led to the practice by housewives
of picking out the yellow, enriched grains from the main bulk
of the rice before cooking it.
• The principal protan found in mal ...
THE pRINCIPAL FOODS USED IN THE REGION 13
Rice is usually washed in the kitchen before it is cooked. This

removes dust, grit, small stones and seeds, etc., and also small
particles of starch which if left cause the cooked grains to stick
together. According to the vigour and duration of the washing,
the proportion of broken grains, and the particular kind of grain,
losses of thiamine during kitchen preparation can vary from
about 5 to 50%. Further losses during cooking vary according
to the method used, -the greatest being when the rice is cooked in
a large amount of water, the excess of which is discarded before
the product is consumed. Recommendations to minimize the
losses are given on p. 153.
Where rice is the main food, growth retardation, kwashiorkor,
marasmus, vitamin A deficiency and beriberi are liable to occur
especially where, as is often the case, rice is eaten with only a
little salt and fish paste or other seasoning, and no supplementary
dishes.
1.2 Maize620
This relatively recent introduction from Latin America is be-
ing grown and consumed more widely - sometimes as a snack
or vegetable, sometimes (especially, in drier and less fertile areas)
as the staple food, either alone or mixed with rice, and for part
or all of the year.
Fresh maize supplies about 120 calories, 3-4 g protein and 1 g
oil per 100 gj dried maize, three times these amounts. Yellow
varieties supply significant amounts of carotene (provitamin A).
Maize contains adequate amounts of thiamine but is relatively low
in macln. Its amino acid composition is poorly adjusted to hu-
man requirements, being low in lysine and tryptophane, and
having an excess of iso-leucine over leucine. Its protein quality
is therefore inferior to that of rice, but since its protein content
is higher, the net value is almost the same.
Maize seldom has such high prestige value as rice. However,
in several areas where maize and rice are commonly eaten toge-
ther, the people are said to be stronger than those whose staple
is rice alone. There is some evidence to support this from athle-
tic contests. The reason is not known. In any case, there are
some advantages in mixing these staples. For infants, maize is
usually considered less digestible j they are often given rice as their
first solid food even in predominantly maize areas.
Maize may be cooked fresh on the cob and eaten as whole

grains, or may be dried and stored either on the cob (usually over
the kitchen fire) or as whole grains. Bulk storage presents pro-
blems which are beyond the scope of this manual. The dry grains
are pounded with mortar . and pestle, or ground with a stone
grinder, to remove the outer cellulose coating and to produce a
grain like rice. In this process the germ, which contains the best
protein material in the grain, is separated off as bran. The re-
maining protein material consists mainly of zein, which is very
deficient in several essential amino acids.
Classically, diets based solely on maize, especially if the maize
has been spoiled in storage, lead to pellagra. However, even
where maize dominates the diet, pellagra is rather infrequent, per-
haps because of the interplay of unknown factors. Maize diets
for weanling infants also commonly lead to kwashiorkor which
is probably more common than pellagra.
1.3 Sorghum and millet
These are somewhat similar, agriculturally and nutritionally,
to maize, but millets have more protein and its quality is better.
They do not contain provitamin A. They. are seldom sole staples
in this Region.
1.4 Wheatl8o.1aG
Little wheat is grown in the developing countries in the Re-
gion, but most of them import substantial qu!mtities.
Bread and biscuits are becoming increasingly popular high-
prestige foods, especially in urban areas. They are consumed for "
breakfast, other light meals or snacks. These products or home-
made preparations such as dumplings, etc., are becoming regular
foods in the developing Pacific islands. Usually white flour is
used, because of its better keeping qualities. Like highly-milled
rice, this is relatively low in thiamine, other B-vitamins, and
other nutrients, as shown on p. 212. Wheatmeal or brown or whole-
meal flour (synonyms) contains more B-vitamins, calcium and
iron than does white flour. However, the former also contains
more of certain substances (fibre and phytates, etc.) which inter-
. fere with absorption of several nutrients. White flour products
therefore provide slightly more calories and are about equivalent
in protein value; the chief advantage of brown flour is its higher
vitamin content. Enriched white flour is however quite widely

available.
Wheat protein is of poor quality, but as with maize, the con-
tent is more than in rice, so that the. net result is more or less
equivalent. If supplementary foods are inadequate, excessive
amounts of wheat products could lead to kwashiorkor or
beriberi. However, persons to whom wheat products are avail-
able are usually able to obtain a wider variety of foods, and defi-
ciency diseases have not been directly attributed to over-
dependence on wheat products. Coeliac disease in children, how-
ever, is apparently due to a genetically-determined intolerance to
wheat gluten. The use of refined flour in wheat products, espe-
cially those of sticky nature such as biscuits, is believed to be a
major factor predisposing to dental caries, which is becoming
widely prevalent in the Region.
1.5 Sweet potato 1,8,91,lOO,llO,180,18a,140,168,lU.110,210a,2.1
This is the staple food in substantial parts of New Guinea and

is the sole or a subsidiary staple in parts of other countries such as
China (Taiwan), Philippines, and many Pacific islands, It spread
from Latin America in the last few centuries. It appears to be
growing in importance as a subsistence crop in the Pacific. As with
the cereals, there are hundreds of different varieties or strains,
and they vary quite widely in composition. Average tubers pro-
vide about 100-120 Calories and 1 g crude protein, per 100 g; the
range is from 0.4 to 2.5 g protein per 100 g, The growing con-
ditions also affect the protein content. Apparently a given strain
produces more protein in the highlands than the lowlands, possi-
bly because of slower growth. Only the yellow varieties provide
carotene (purple flesh being due to another pigment), They are
very rich in ascorbic acid and moderately rich in thiamine but
are low in riboflavin and calcium. Even though about half of
the crude protein is non-protein nitrogen, the protein quality is
quite good. However, the concentration is too low for growing
children and even for adults. In some areas, such as the New
Guinea highlands, the sweet potato dominates the diets drastic·
ally. Adults eat about 2 kg (4-5 Ibs) daily and even children
may eat 1 kg or more. The sweet potato commonly supplies 80-
90% of the calories and as much as 40-5010 of the protein in the
diets, despite the low protein content of the tubers, because of
the very low consumption of protein-rich foods. Daily protein

intakes in the New Guinea highlands average about 30 g for men
and 20 g for women.
Sweet potatoes are normally eaten within a few days of
harvesting, in subsistence cultivation. Storage of the tubers on
a commercial scale requires careful harvesting to avoid damage
to tubers. They are packed in boxes which are stacked in columns
allowing air circulation, inside a storage room where temperature
and humidity can be controlled. "Curing" is effected by main-
taining a temperature of about 30-32°C (86-89°F) and a humi-
dity of about 92% for some days, then lowering the temperature
moderately to between 10-15°C (50-60°F). The Maoris in New
Zealand have developed various traditional methods of curing
and storing, using stacks or holes in the ground. Indigenous
methods are also used in mountainous parts of the Philippines.
Another method of storage is by slicing the tubers into thin slices
or pea-sized cubes which are sun dried and can be stored for long
periods. Some commercial-scale storing is practiced in New
Zealand.
1.6 Taro 8.110&.180.138.140.149.110
Probably Colocasia species were the original staple foods in

most parba of the Pacific; they are believed to have originated in
Malaysia. In some Pacific islands the taro is a high-prestige food
even where it is not the main staple, e.g., the New Guinea high-
lands (it is grown more widely in the lowlands than in the high-
lands). Fresh tubers contain about 2% protein. This protein
is said to be relatively rich in the sulphur-containing amino
acids l7O, which are relatively deficient in most subsistence diets
in developing countries, especially where tubers predominate.
The taro supplies moderate amounts of thiamine, some other B-
vitamins, little vitamin C, and no carotene.
The taro is used in numerous food preparations - baked,
boiled in water or sometimes fermented; and often eaten toge-
ther with coconut. There are numerous methods of fermentation
and dishes based on them in Polynesia.
1.7 Yam 8.110&.180.188.140.149.110
Yams probably originated in India, and include various spe-

cies (Dioscorea alata, D. eseulenta, and other wild species). These
tubers are grown in subcoastal parts of New Guinea and some

other Pacific islands. Sometimes they grow to enormous size,
but th~ ·ones are usually grown more for ceremonial than for
food purposes. Yaros are a seasonal crop, and other foods (e.g.,
sago) are commonly eaten during times of shortage. Yams are
often stored for six months or more in dark but airy "yam
houses". Yam cults are an important part of the social life of
these people. It has been found that closer planting of yams
produces smaller tubers but a larger total yield per unit area,
than the more usual wide spacing.
Nutritionally the yam is similar to the taro but with 2-3%
protein in the fresh tuber, and a higher percentage of calories
derived from protein. The protein content of the different
varieties has not been extensively investigated, but is low in
sulphur-containing amino acids.
1.8 Potato (Irish) 218
In the tropical parts of the Region, this is grown at high alti-

tudes (over 2000 metres). The fresh tubers supply about 80 Ca-
lories and 2 g protein per 100 g; they supply therefore less energy
per unit weight but more protein per calorie, than the tropical
tubers. Its protein quality has been more fully investigated than
the others. For maintenance, it is better than most cereal, beans,
etc., and the potato will maintain nitrogen balance over long
periods when it is the sole source of nitrogen. Its protein value
for growth is rather lower, and the percentage of calories from
protein is too low for very young children. It is like the sweet
potato in mineral and vitamin content, but lacks carotene. It is
less fibrous than the other tubers. Its relatively high prestige
derives more from its occidental association than from its nutri-
tional value. As a supplementary food for infants the potato is
not highly -recommended; richer sources of protein should be pre-
ferred.
1.9 Cassava 6a.8.130.156
This was introduced within the last century from Latin Ame-
rica. It is being grown in increasing amounts in many parts of
the Region, especially in drier areas. It is a hardy plant which
can grow where the soil condition is poor. It was grown and
eaten relatively widely during World War II, resulting in wide-
spread nutriti.onal deficiencies - often referred to as beriberi but

probably more often due to protein-calorie deficiency. Its protein
content is very low; and of very poor quality, being very deficient
in several essential amino acids. The protein content of different
varieties has not been studied sufficiently. The mineral and
vitamin content is less than that of sweet potato.
Cassava may be cooked when harvested (fresh) - boiled
whole and sometimes fried, or grated and steamed. Some varie-
ties contain a glycoside which can produce cyanide; these varieties
must be peeled, and sometimes are soaked in running water before
cooking. The local inhabitants are usually well aware of any
such poisonous varieties. In some parts of the Region, the fresh
tubers are fermented by soaking for several days before con-
sumption. Cassava can also be sun-dried, and .then pounded into
flour. This can be eaten as a staple food, cooked like rice, or
made into sweetmeats, etc. Drying destroys the vitamin C con-
tent.
Cassava is usually grown where the soil is too dry or exhausted
for other crops, or where a food reserve is needed. In just these
circumstances, other protective foods, especially protein sources,
are often lacking. Thus cassava is apt to satisfy the hunger but
not the protein needs. As a staple and weaning food it is prone
to lead to kwashiorkor and even nutritional oedema in adults,
especially lactating women.
1.10 Banana and plantain 8.21.91.110.180.140.149.168.170
It is usually the plantains (green bananas, eaten cooked) which

are used as a staple food - sometimes as sole staple in some
Pacific territories; but more often as a subsidiary to other staples.
When it softens and becomes yellowish, it is ready for cooking
in hot-stone ovens·, or by boiling, or baking in ashes. Sweet
bananas are usually grown for sale and are sometimes eaten
as snacks. There are numerous varieties of both plantains and
bananas. Many of them are associated with traditional rites and
some are not allowed for girls, or for women during pregnancy
or lactation.
*Thia is made in a hollow In the wround. or in a drum or hollowed out lo&,. Rounded
stones 8"' heated on an open Are until red. hot. then lifted with tonS's (e.g. bamboo) and
placed in the bottom of the hollo.... or drum. followed by a layer of leave. (e.K. 'ban811a) and
then a layer of fooda: followed by another layer of leava ••tons. leaves and food. Several
such layers are made and then the top I, lealed over with a larae banana leaf. B.fore ...Unl'.
cold water i8 poured in. Thlll oookins fa effected b)" .team under presaUl'e. for about 1 to
1·1/2 .........
Plantains and bananas are rather similar to the sweet potato

in respect of their calorie, protein, mineral and vitamin content.
When ripe, they are less fibrous and apparently more readily
digested by infants (under six months) than most tubers. The
yellow - fleshed varieties contain useful amounts of carote ne ,
and sometimes are the major source of this vitamin for infants.
Although widely favoured as an infant food by many people (and
physicians) in the Region, their protein quality and amino acid
pattern are poorer than those of the sweet potato, and as wean-
ing 'and staple foods they readily lead to kwashiorkor. While
serving as useful sources of calories, minerals and vitamins, they
need supplementation with protein-rich foods.
1.11 Sugar 8.91.180.140,149,156,170
Sugarcane is often eaten as a snack between meals, especially

by farmers working in fields or gardens where it is cultivated.
The juice is sucked directly from the fibrous canes, which are
peeled with the teeth. The juice contains carbohydrates with
practically no protein, vitamins or minerals. This makes it un-
suitable for children.
Refined sugar is pure sucrose, and contains no other nutrients.
A reasonaBle amount of sugar as part of a well-balanced diet
does no harm. If, however, large quantities of sugar are included
in a poor diet, it may, by supplying "empty" calories, reduce to
an undesirable extent the amount of protein, minerals and vita-
mins in relation to the total quantity of the diet. There is also
evidence that a high sugar consumption promotes dental caries.
Unrefined sugar is also made from various kinds of palms.
Allowing for their additional moisture, these palm. sugars, and
also molasses, are similar to cane sugar in calorie content, but
contain in addition useful amounts of iron, calcium and B vita-
mins. Molasses is also rich in potassium salts, useful in the treat-
ment of diarrhoea.
1.12 Sago 8.21,91,140.156,170
This is extracted by washing it out of the trunk of the sago

palm, which grows mainly in swamps along the coast and along
large river valleys in many islands in the Region. It is the chief
staple in parts of Papua and New Guinea, but is more often used
as a subsidiary to other staples, e.g., when tubers are out of sea-
son; the trees form a natural food reserve for emergency use.
The preparation of sago is however a laborious and time-consuming
process.
Sago is almost pure starch - an excellent source of calories,
but almost devoid of protein, minerals and vitamins. It appears
to be well digested by infants. Insofar as fish are commonly
available in these areas, family and infant diets may not be as
bad as the nature of the staple would suggest. Properly dried
sago can be stored for long periods and is a significant item of
trade within and between islands. Bacteria which cause
food poisoning can grow rapidly in cooked sago.
Sago is generally a low-prestige food even where it ill widely
consumed, and the need for supplementary foods seems to be
generally appreciated. But fish are sometimes not given to very
young children, and cultivated vegetables (or other sources of
minerals and vitamins) are apt to be scarce in these swampy
areas. Various leaves, fruits, etc., can and should be gathered
from the forests.
Sago is eaten in a great variety of traditional forms, especial-
ly with coconut milk or flesh, and the nutritional value of the
dishes depends mainly on these other ingredients.
1.13 Coconut 8.21.91.180.140.149.156.170
The coconut is very widely distributed in the Region, mainly

in coastal areas and subcoastal lowlands, and on small islands.
It is an important cash crop. The coconut meat is processed
commercially, or sun-dried and smoked as a subsistence procedure
to yield copra. Copra is exported as such, or processed locally
to extract the coconut oil, leaving a residue (coconut meal) which
is useful for livestock.
The mature coconut meat contains about 4% protein, 3% fibre,
and 34% oil; it supplies about 350 Calories per 100 g. It is a
moderate source of most minerals, but a poorer source of vitamins.
The soft meat of young coconuts contains fewer nutrients. The
clear coconut water contains some minerals but has little vitamin
content except vitamin C (which is present in the water of young
nuts only). Coconut cream (made by grating the mature meat
and then squeezing with a little water) retains some of the pro-
tein, and most of the fat and calories. It is free of fibre. The
B-vitamins are largely lost in the dbroua residue, which is usual-
Iy fed to animals. Coconut milk is the diluted coconut cream, or
the product obtained by repeated washing of the residue after
first expressing the cream.
Coconut milk and cream are widely used in preparing various
palatable dishes. Coconut oil is sometimes made at household
level by primitive extraction methods (which are rather waste-
ful) and is widely used for frying.
It has been claimed that infants can be reared from birth to
six months solely on coconut products. Research is needed on the
amount of coconut meat, cream and milk which can be tolerated
by infants. Coconut meat is too fibrous for feeding in quantity
to infants while coconut cream is too rich in fat. Coconut flour
or coconut protein extract suitable for infants can be manufac-
tured, and research into the amounts tolerated is planned.
In general it may be said that small amounts of coconut cream
and milk are desirable supplements in the infant's diet after six
months. The protein content is significant, and the fat has a
protein-sparing effect. The availability of coconut products may
be one reason why kwashiorkor is much less prevalent in the
coastal parts of New Guinea than in the highlands.
1.14 Breadfruit and jackfruit 8.21.91.180.140.U9.166.170
The breadfruit is eaten in considerable quantity in many

Pacific territories, especially in the lowlands, sometimes copsti-
tuting a staple food in season. In calorie and protein content it
is rather similar to the plantain, but it is more fibrous. It is
prepared in hot-stone ovens, or boiled or smoked (and in this
form it can be preserved for some time).
The jackfruit is rather similar in composition and use. The
seeds of both fruits are relatively rich in protein.
Breadfruit is sometimes processed in the South Pacific into
a dough which can be baked in an oven. The breadfruit is kept
for several months or years in covered pits, where it undergoes
fermentation.
1.15 Oils and fats
Vegetable oils commonly used include coconut oil, maize oil,
peanut oil and soya oil. Except for coconut oil, vegetable oils
are mostly rich in polyunsaturated fatty acids which tend to lower
serum cholesterol levels and may therefore provide some pro-

tection against atherosclerotic arterial and cardiac disease.
Red palm oil is produced in some quantity in Malaysia. It
can be given medicinally to infants (one-half teaspoon daily) in
place of cod-liver oil. It has been effectively used in the treat-
ment of established vitamin A deficiency, by oral dosage. It can
be mixed to the extent of 5% with other cooking oils without
affecting the flavour, and this would materially help to prevent
vitamin A deficiency.
Animal fats, especially pork fat, are highly valued, especially
in the Chinese cuisine and by many Pacific islanders. They tend
to elevate serum cholesterol levels.
Butter contains about 85% fat, a trace of protein and vary-
ing amounts of vitamin A and carotene.
Margarine is mad~ from vegetable oils. Fortification with
vitamins A & D is widely practised.
1.16 Alcohol
Alcoholic drinks are significant as "extras" in human diets .
. Alcohol itself supplies about 7 Calories per gram. The alcoholic
content of beverages such as spirits, wine and beer varies widely
(see p. 213).
They are almost devoid of essential nutrients, but the crude
"beers" and other fermented drinks made in tropical countries
may contain a little protein, some vitamins and sugars. When
alcohol is taken in excess over prolonged periods of time, the re-
sult is chronic gastritis, a reduction in appetite and an inadequate
consumption of food. Hence, habitual heavy drinkers are liable
to suffer from nutritional deficiencies, especially beriberi and pro-
tein deficiency with fatty liver.
2. FOODS WHICH ARE PRIMARILY PROTEIN SOURCES

These include both animal and vegetable foods. Animal pro-
teins are fairly readily digestible and generally have a good amino
acid composition. Vegetable proteins are sometimes less digesti-
ble and some have lower nutritive value because of relatively low
levels of some essential amino acids. However, some are equal
to animal proteins in nutritive value and a proper balance of dif-
ferent vegetable foods can minimize any deficiencies. Often, it
is easier to supply additional vegetable protein in large amount,

than additional animal protein, because of the low availability and
high price of the latter. Nevertheless, it is desirable to add a
little animal protein to a mainly vegetable diet whenever possi-
ble. The relative composition and cost of different sources of
protein as available in a rural area in the Philippines in 1965 are
shown in Figures 2.2 A and B.
Milk could also be grouped with the energy sourees, since it
is actually the staff of life supplying nearly all the energy and
nutrients in the first months of life. However, beyond six months
of life, it serves mainly as an important protein source. Milk is
therefore grouped here together with the other animal products.
2.1 Milk
2.1.1 Human milk 8h.S2.46.47.78a.b.80.10U01.I09.118.114.121.188.168.198.210
Human milk is the ideal natural food for the human body.
Infant feeding practices are considered later but it should be
emphasized that it is the best, cheapest, safest and most readily
available infant food. It also supplies important protective anti-
bodies (in the milk globulin fraction) for the infant, reducing
the incidence of infant diarrhoea, etc. The following remarks
apply mainly to its composition; infant feeding practices are dealt
with on p. 97.
Breastmilk is commonly held to be of rather constant compo-
sition, but the evidence is contrary. Human milk is relatively
high in fat content compared with the milk of other mammals. The
fat content varies widely, from about 2 to 5 g per 100 g, depend-
ing on the amount of fat in the mother's diet and possibly on gene-
tic factors. This affects the calorie content, which may be from
50 to 75 calories per 100 g. The protein content also varies wide-
ly between about 0.8 and 2.0 g/100 g, depending on the mother's
diet and possibly on genetic factors. The evidence suggests that
the protein content is lowered only when dietary protein intakes
are extremely low. 8b•4,.I09 Human milk is however lower than
nearly all animal milks in protein content.
The calcium content also varies with the mother's diet, but
the amount present seems adequate for the infant's needs if the
total amount of milk is adequate. This is usually true for vita-
mins C and D but not necessarily for vitamins A and B. The
FIGURE 2.2
~
PROTEIN CONTENT OF FOODS (88 purchased)
A. Gram. of protein per kilo (as pureha8ed)
il'!Ia
;--
(Approximate values)
=
t:
E;
r-- =
§
~
r.o
o
-
""~
o
t:1
r---f-- ~
Z
r---
~
. ~
524 3'11 360 256 244 126 108
oz
102 101 91 111 84 77 74 1----5-
Orled Soy Skim Peanut
...Orled Orlecl Egg Pork s-
......n,
Brad Maize Evap. F...h Rice SWeet
ShrImp dried Milk Shtilid Fish Cond • dried Fill'" Fish potato
Powder dried Filled Milk (small)
(- Milk
IrIm)
FIGURE 2.2
PROTEIN CONTENT OF FOODS (as purchased)

B. Grams of protein per peso (as purchased)
(Approximate values)
Based on prices at harvest time, January - June 1966, in Bayambang, Philippines
~
l"l
!~
i
e
z
of
::.:
l"l
I
559 287 263
----- ~
213
--
210 123 115 101 77 63 61
L -___
56 . 401 29 I 21 J
Soy Dried Maize Peanut Dried Rice Skim Bread Fresh Dried S_ Evap. Egg Pork S_
mung Shelled Shrimps Milk Fish Fish Condo Filled PotalO
.... ns (small) Powdet' (small) Filled Milk l.:I
(green
gram)
Milk en
FIGURE 2.3
CAROTENE CONTENT OF FOODS

r.:I
CD
Approximate Provitamin A Content of Some Leafy and Yellow Vegetables and Fruits
International Units per 100 Grams (as purchased)
(Rounded average figures, based on the Philippine food composition tables. o-:l
There is considerable variation between different specimens of anyone kind.
These figures are merely to give an idea of the relative value; not for memorization.)
==
l"l
f-- ==
~
~
~
~
t----- ~
!'Il
o
.."
.."
o
o
o
I--t-r- ~
Z
d
o-:l
...
:0
...o-:l
o
Z
15000
Carrol Ta", Sweet Petsay Swamp Sweet Pump- Papaya
leaves pepper (Chinese cabbage potato kin Ripe
leans cabbage) (Ka"'l tops (squash)
kong
leaves)
vitamin B-complex content of the milk depends rather closely on

the amount in the mother's diet. The vitamin A content is also
influenced, but only by relatively larger variations in the maternal
diet. The iron content of breastmilk is always low and there-
fore needs supplementation at latest by six months.
The composition of the milk tends to be rather constant for a
given mother throughout lactation, except in the early days after
parturition 136.
2.1.2 Cow's milk 228b.282c.h.
The use of dairy products is not traditional in most develop-

ing countries of this Region, but has increased greatly in recent
decades, especially in urban areas and through milk distribution
schemes. The availability of fresh milk is very limited and the
price is usually prohibitive for those in need of improved nutri-
tion. Expansion of dairy production is fraught with difficulties
in the tropics. Fresh cow's milk contains about 65 Calories and
3-4 g protein per 100 g.
If milk is produced in villages it is advisable that the milk be
brought to the boil' momentarily, immediately after collection, and
used immediately when it is cool enough; this can be hastened
by standing the container in a
larger bucket of cold water. If
not boiled, tuberculosis, brucellosis and other infections can be
transmitted. If allowed to stand, the milk rapidly breeds bacteria
which can cause severe diarrhoeal and other diseases, even though
the milk may be boiled before or after standing.
Powdered milk is available in three main forms:
(a) whole milk,
(b) skimmed milk,
(c) acidified milk.
In skimming, the cream is separated from the milk and the
fat-soluble vitamins are thus removed. However, most skimmed
milk is now fortified with vitamins A & D, and is lacking only in
fat. Skimmed milk powder is commonly priced at one-third to
one-half of whole milk powder, but its availability in the world
market for free distribution schemes has declined recently. In
acidified milk, the protein is partially pre-digested in order to
promote its digestion by infants; but this seems to be unneces-
sary for most infants and makes the cost much higher. Once a
tin of powdered milk is opened, contamination can easily occur.
Only clean utensils should enter the container which should be
quickly closed and kept firmly closed at all other times. For
skimmed milk, the strength used is four to five level tablespoons
(large) per 1/2 liter (500 ml) of water (boiled).
Preserved liquid milk is also available in three main forms:
(a) evaporated milk (also known as ideal milk) ;
(b) condensed milk (sweetened);
(c) filled milk (evaporated or condensed).
Evaporated whole milk retains the proportions of the original
milk and is the recommended form. It is diluted with an equal
quantity of boiled water for use. However, it is also the most
expensive form, because of the amount of water retained. Once
the can is opened the milk must be kept cool and used quickly;
it has the same keeping properties as fresh milk.
Condensed milk is strongly sweetened, so that the milk can
be kept for a long period after opening the can. Bacterial con-
tamination can nevertheless occur. One part should be diluted
with only 7 parts of boiled water.. Commonly, it is diluted much
more than this, because it is so sweet and the fluid still looks milky
enough. In the circumstances in which it is commonly used, as
a supplement to a rice diet, the milk proves to be too low in protein
to prevent kwashiorkor and its use is therefore not recommended.
In filled milk, skimmed milk is reconstituted in liquid form to-
gether with locally available vegetable oils to produce filled eva-
porated or filled condensed milk. In these milks, milk fat is
simply replaced by an equal amount of vegetable oil. However,
the fatty acid composition is different. Studies of infants fed
with these milks indicate that for the short-term they may be
satisfactory, but not for longer-term feeding. The aim is to pro-
duce milk of equivalent nutritional value at significantly reduced
cost, but neither objective is adequately attained. The retail cost
is approximately two-thirds of the equivalent evaporated or con-
densed milk.
In addition to the lack of iron common to all milks, tinned
milks (liquid and powdered) lack ascorbic acid. More important
is the fact that any form of tinned milk can be diluted with too
THE PRINCIPAL roODS USED IN THE REGION 29
much water. This is the principal hazard, especially in poor

communities and those where literacy is low. It is often wiser
to give milk powder sprinkled over solid food, or mixed in with
it, rather than in fluid form, which may be disliked or spilled or set
aside and used later, when already contaminated. Alternatively,
many infants and toddlers like skimmed milk when it is moistened
with a little water (previously boiled) on a plate or banana leaf,
and made into a firm ball which is eaten piece by piece.
The virtues of milk preparations are well-known, but the
hazards, especially in the circumstances of many households in
developing countries, are not adequately realized, in terms of:
<a) cost to the family budget;
(b) over-dilution and unhygienic preparation.
2.1.3. Other milks and milk products62ba

Occasionally cow's milk causes allergic manifestations, e.g.,
skin reactions, gastro-intestinal intolerance (although this is more
often due to faulty preparation). For such children, goat's milk,
carabao's milk or soy milk may be useful.
Goat's milk is very similar to cow's milk in composition. The
physician needs to check lest anaemia develops and to ensure that
the milk is b:r:ought to the boil to avoid possible brucellosis.
Carabao's milk is extremely rich in fat and energy. Toned milk
is manufactured in some countries outside this Region. The milk
is diluted by approximately half, to reduce the fat content to about
the same level as cow's milk, and the protein content is restored
by adding skimmed milk powder. Carabaos are commonly used
in several countries of the Region as draught animals. Their
milk yield is seldom high, but could be improved by selection,
• disease control and more adequate feeding, to supply enough milk
for human consumption as well as the offspring. The milk is
usually diluted to half strength and brought to the boil, before
use. In some localities it is available commercially and its com-
position should be checked before recommending dilution, since it
may already have been diluted before retailing.
Cheeses are rich sources of both fat and protein and also
minerals (except iron) and vitamins. They are made· from milk
curds. Cottage cheeses are made as home industries in some of
the developing countries but are expensive. Cottage cheese and
yoghurt can be made from skimmed milk powder.
2.2 Meat 62b,,,,212m
Pork is the most widely available form but is prohibited in

Muslim communities. However, insofar as meat is a luxury food
in these countries anyway, this prohibition is not of great impor-
tance nutritionally. Goat, beef and poultry are the principal al-
ternatives. Meat is usually reserved for sale in the urban markets
or for consumption at small or large festivals, because of its high
prestige and price. Hygiene is often faulty, resulting in para-
sitic infection or food poisoning, especially where festivals are
prolonged. An important form of this is a gangrenous enteritis
(enteritis necroticans) which occurs in the New Guinea highlands.
Fresh meat should only be given to infants if it is freshly
slaughtered and immediately prepared in a suitable form and
consumed.
Preservation of meat by smoking for several days (in smoking
houses) or by salting is feasible, but hygienic precautions are
essential.
Meat contains usually about 189'0 protein and varying amounts
of fat. Red meat is a good source of iron. Pork is notably rich
in thiamine. Liver" is extremely rich in many nutrients - espe-
cially vitamins A and B (including vitamin B12) and iron, besides
protein. Although not so readily available, it is highly desirable
to give some of this to an infant when possible, provided it is
fresh.
Tinned meat should have a similar protein composition, but
is sometimes mixed with cereal, which reduces the protein content
to about 12%, Supervision of hygiene during "manufacture is
essential. . Subject to this, tinned meat is probably preferable
to fresh meat of uncertain hygienic quality for infants, and is
usually available in a suitably digestible form. This is much more
expensive than skimmed milk However, it does contain some
nutrients (notably iron) lacking in milk and may stimulate the
appetite of a malnourished child better than milk.
2.3 Eggs SIb, ..
Village hens rarely produce a good supply of eggs, partly be-

cause of poor stock and partly because of deficient feeding; and
the eggs are often sold or used for breeding. Eggs are widely
available in the market, but are usually the most expensive form
of animal protein. In some communities, they are well accepted
as foods, suitable even for infants, but in otbers they are denied
to infants or only given during sickness. Hard-boned or scram-
bled eggs have particular value in rehabilitating malnourished
children who have finicky appetites.
An egg contains about 4-6 g of protein of the highest quality,
and useful amounts of vitamins A & D, iron and practically all
other nutrients. Eggs are specially recommended for infants and
toddlers when available.
Ducks can often be more easily reared in village conditions
than hens, because of the wider range of suitable foods (including
snails) for which they can forage. Duck eggs are of similar
nutritional value to hen eggs, but are prone to become wet
and soiled when laid, and contamination with salmonellae is said
to be more prone to occur; duck eggs should therefore be tho-
roughly cooked.
2.4 Fi8h 82b.ka.130.140.160.168.209
Fish is obtained in great quantities along sea coasts and in

inland waters (rivers and lakes) in nearly all parts of the Region,
and cultivation in fishponds and ricetields is practised in some
areas. Certain fish are poisonous - these varieties are usually
well known to local inhabitants. In many marine and inland
waters there are dangers of depleting the stocks by over-fishing.
Tb,e advice of experts must be sought on any projects to increase
fish supply. The prospects for increasing regional and world
supplies of protein are probably greater with fish than with other
animal products, but the problems are complex.
In any case fish are the mostly widely available and reasonably
cheap form of animal protein. Nevertheless fish are often denied
to young children, e.g., in several countries they are thought to
cause worms in infants and toddlers. Small soft fish eaten whole
and small dried shrimps are often the cheapest and most nutri-
tious forms available, supplying vitamin A and calcium as well
as protein. The increased use of crustaceans, shellfish and other
aquatic life is also recommended.
Fish can be preserved by simply drying; by salting; by
smoking; and by fermentation, using anaerobic autolysis with
excess salt, in sealed containers.
Fermentation of small fish and shrimps is used in the prepa-
ration of fish pastes of somewhat similar kind in several countries
in the Region. The ingredients may not always be cooked during

the preparation and the pastes may not be completely safe bacte-
riologically, but in practice they do not seem to cause trouble.
They are highly salted, and are usually consumed by adults and
only in small quantities, mainly as flavouring with rice or other
staple foods. They can serve a useful purpose in enhancing the
appetite, especially for children, and in improving the protein
quality of vegetable dishes, but should be cooked before consump-
tion by infants. Examples are Nuoc-Nam (Viet-Nam), Bagoong
(Philippines), Blachan (Malaysia). Clear liquid fish sauces con-
tain much less protein and are mainly useful as flavouring.
2.5 Other animals
Foods which are unorthodox for sophisticated people may be
quite popular and common in some localities, and may supply
useful amounts of protein - which may be overlooked by dietary
surveyors. Such foods include hunted game such as birds, pos-
sums, foxes, and rats, etc., bird's eggs, reptiles (lizards, snakes,
turtles, etc.), frogs, insects (caterpillars, grasshoppers, crickets,
beetles, ants, various larvae such as the sago grubs) and various
kinds of snail and crustaceans. Often these cease to be used as
sophistication spreads in primitive areas; this may significantly
impair the diets. Poisonous species of these animals are usually
well known to local people.
2.6 Soybean 62b.188a.I76.Z06a
This is one of the most widely available and cheapest sources

of vegetable protein in the Region, and is extensively used in
China, Japan, and Southeast Asia. The dried beans contain
about 35% protein of relatively high nutritive value. It grows
better in temperate or subtropical climates than in the tropics;
where it grows better at higher altitudes than at sea level. Cer-
tain varieties have been selected for their improved yield, re-
Idstance to diseases and palatability.
One problem with soy is that it is not widely acceptable with-
out special methods of preparation. Most varieties have· a some-
what bitter flavour and also a hard indigestible seedcoat (cellu-
lose). The seeds usually have to be soaked overnight, the seed-
eoats removed by hand and the beans boiled for one to two hours
before making into various recipes. In China and Japan, tradi-
THE PRINCIPAL FOODS USED. IN THE REGION 33
tional . fermentation processes are employed. Natto is made

in J3pan by soaking the beans overnight, boiling, inoculating with
a culture of Bacillus subtilis, and wrapping in straw or thin sheets
of pinewood. In about two days an adhesive grey mass is formed
which is high in protein content and some vitamins. Soybean
curd (tofU) is obtained usually by grinding the soaked beans by
a wet process to form a paste. This is heated, and water added.
The white liquid is filtered through a fine cloth and a solution of
gypsum added. A curd is formed which is moulded into cakes.
The fresh curd keeps only for about one day, but can be preserved
by drying, smoking or fermentation.
Another problem with soybean is the need to destroy the tryp-
sin inhibitor which is present in the raw soybeans. The trypsin
inhibitor interferes with the intestinal digestion of protein by
trypsin in animals, but its influence in the human has not been
clearly established. The beans should be boiled for one to two
hours, or else pressure-cooked for about 10 minutes. Grinding
into flour and cooking for a few minutes, as can be done with
other beans, cannot be recommended with certainty.
For infants, natto and tofu and a soy flour (kinaka) made by
household methods were tested with good short-term results in
Japan. La!
The soybean is also acceptable and useful for school feedings.
Sprouted soybeans are also popular in some areas. After soak-
ing, for a couple of days. they are allowed to germinate in a
covered vessel, or else in a damp cloth. The sprouts reach about
5 cm in three or four days. In sprouting, the seed is partially
broken down with the formation of sugars, amino acids and
Vitamin C. The sprouts are much more bulky than the original
seed, so the total quantity of protein consumed may be less.
Soybeans contain considerable amounts of oil, for which they
are often grown commercially, the residue being used for livestock
feeding. None of the countries in the Region can meet its own
demand for soybeans.
2.7 Green gram or mungbean 62k.1688
This pulse is very popular in ·several countries in the Region.

There are actually green and yellow varieties and some similar
species which are black or red (all known in India as dhalls).
They are fairly widely grown in the Region but their yields are
usually not high. Small amounts are uaually kept and eaten at
harvest time. It would be desirable to store larger amounts in
sealed containers such 88 kerosene tins. The main problem is
to increase production. They all have similar culinary uses, and
a protein content of about 22-24%.
There arenumeroua traditional dishes in which they are incor-
porated after boiling for 30-60 minutes. Soaking overnight re-
duces the time required for boiling, but entails considerable losses
of B-vitamins into the water. Therefore, it is recommended to
cook them in the water in which they were soaked or to place the
cleaned beans directly into boiling water.
Although quite widely available, their value as protein source
is often not wen-known. They are rich in thiamine and have
been rightly popularized in some countries 88 a beriberi-preven-
tive, especially during pregnancy.
Sometimes they are preferred in sprouted form. Sprouting
is done as described for soybeans. Because of their bulk, the
total protein consumed maybe less, and the sprouts contain only
about 2.5% protein.
2.8 Peanut or groundn"1 6b.82k.168a.
Peanuts are widely grown in the Region, although mainly

as a cash crop for extraction of' oil; the residue is utilized for
livestock. However, they can be easily stored in the home at
harvest time (by hanging them in the shell and usually still on
the stalks, over the kitchen fire). They can be easily processed,
by lightly baking and then pounding or grinding into a smooth
paste which, alone or when mixed with mashed banana, is useful
for infants. 8b These recipes supply valuable extra calories, vita-
min B complex, iron and calcium, as well 88 protein. However,
only matured peanuts which have been freshly harvested and
sun-dried, or properly stored and free of moulds, should be used.
Aflatoxin can be generated on mouldy peanuts and is toxic (some-
times carcinogenic) to some animals. Its possible toxicity to
humans is under study. 1'111
2.9 Other dried beans and peas 62k.168a.
There are numeroua varieties, mostly with a protein content

of about 20 %: peas, pigeon peas, winged beans, hyacinth beans,
lima beans, kidney beans, lentils, etc.
These can be ground into flour which can be added to soups

or porridge for infants.1Ik. I3Ie
Some of these beans however contain factors which may be
toxic l68a under certain conditions or to certain individuals, e.g.
broad beans. These and some kinds of kidney beans and hyacinth
beans can slow down the growth of rats when used as the sole
protein source, and cannot be recommended for use in large quan-
tities. Some lima beans (Phaseolus lunatus), either white or
coloured varieties, and some other Phaseolus species, contain
cyanogenetic glueosides in considerable quantities and are highly
toxic. The local inhabitants usually are well aware of these.
They can be rendered harmless by repeated boiling, discarding
the water between boiling. Only known safe varieties should be
recommended for use. Safe varieties cannot be judged by colour
or other appearances, but in case of doubt, their toxicity will be
apparent by feeding them to a domestic imimal, e.g. a chicken.
Many of these beans are more commonly eaten as young imma-
ture pods; or when mature, as fresh beans in the whole pod, or
after shelling out of the pod. Eating the imInature beans is
wasteful, because the seeds have not yet accumulated their pro-
tein store. Fully Inatured beans in the pod contain their full
quota of protein in the beans. The whole bean pod is usually
about 3-4% protein. The mature seed (moist) excluding the pod
is usually about 6-7 % protein. To obtain the best protein value.
either the dried seeds should be used, or the Inature seeds shelled
out of the pod when harvested. If the whole pod is edible, it
would be desirable to shell out the seeds and give them to the
youngest member of the family, whose needs are relatively
greatest.
2.10 Nub 8.V1.188
Many different species are grown in different localities, e.g.,

species of Macaranga, Canarium, Terminalia and others. The
nuts of the tulip tree (Gnetum gnemon) are quite popular in
some areas. Some Pandanus species have nuts which are highly
prized. Nuts generally have a protein content of 10-12% and a
high fat content. If not too fibrous, they can be ground for in-
fants, as described for peanuts.
Some other oil seeds and nuts grown in the Region which may
have potential value as sources of protein are palm nuts, sun-
flower seeds, cotton seed and sesame seed.
3. FOODS WmCH ARE PRIMARILY SOURCES OF

MINERALS AND VITA..'WNS
Vegetables other than the pulses and nuts already mentioned

can be classified as:
(a) Leaves, e.g., spinach, cabbage, swamp cabbage, drumstick
leaves.
(b) Roots, e.g., onions, carrots.
(c) Vegetable fruits, e.g., pumpkin (squash), eggplant, okra,
tomatoes.
(d) Stalks, e.g., celery, asparagus, setaria hearts, ferns.
(e) Flowers, e.g., banana flower, sesbania flower.
(f) Seaweeds.
All these vegetables have a high water content and are rather
bulky and fibrous. The fibre is cellulose and other indigestible
complex carbohydrates. These vegetables have a low calorie con-
tent (usually 10-20 calories per 100 g). Their protein content
is often low, but the percentage of calories derived from protein,
on the other hand, is sometimes very high; their limitation as
protein sources is therefore due to bulk or price and availability.
Some of them are expensive as purchased in the market. Others
such as leaves gathered in the forest or fields are free for the
picking. They are important to add flavour and variety to the
diet, and as sources of many nutrients: principally iron and cal-
cium, vitamins A, B, C, D, E and K, but also many other micro-
nutrients not mentioned specifically in this manual.
It should be repeated that fresh beans in the pod are not
especially rich as protein sources and should rather be classed as
vegetable fruits; they supply some water-soluble vitamins
(especially riboflavin) and some minerals (especially iron).
Mostly the indigenous vegetables are considerably richer in
nutrients than introduced ones. 1a• 1M This is particularly true
of green leafy vegetables, which are usually better than cabbq.ge,
lettuce and the like, although the latter commonly have more
prestige. The indigenous ones are also commonly more adapt-
able to local agricultural conditions and less sensitive to the pre-
valent plant diseases and pests. and are therefore, easier to pro-
duce in home gardens.
3.1 Green leafy vegetables 168.196.2850
These are usually plentiful in rural areas, but may be in short

supply in towns. Some varieties are available only during a
limited wet season or during summer months. They contain only
3-5% protein, but up to 30% of the dry weight may be protein,
and up to 40% of the calories may be derived from protein. They
are mostly high in fibre content however. Their principal value
is as sources of carotene (see Figure 2.3), iron, and sometimes
calcium, B-vitamins (including folic acid) and ascorbic acid.
However, the utilization of the carotenes present in these foods is
quite variable, and inadequately known.Z82A The charts give only
some impression of their relative vitamin A potency.
Many of the most nutritive varieties grow wild in forests,
fields and gardens (as weeds!). But some are cultivated, e.g.,
Chinese cabbage and mustard. Some plants produce edible and
highly nutritious leaves as well as fruits or other vegetable
portions, e.g., beantops, bitter melon leaves, sweet potato tops,
cassava leaves, pumpkin tips, etc., and the leaves are usually the
more nutritious portion. For these vegetables it is usually
advisable to have separate plots under cultivation, one for the
leaves and one for the fruit or root, because if many leaves are
picked, the fruit or root production will be impaired. The leaves
should be picked when the stems are still short and the leaves
relatively young and tender; this helps to keep the plant free of
pests also.
Indigenous leafy vegetables often have relatively low prestige
value, being considered in many countries as "poor man's food".
But this is fortunately not so with the Chinese, and in many parts
of the Pacific. Furthermore, it is usually the dark green leaves
which have the greatest nutritive value (especially for carotene
and iron), whereas it is often the pale leaves which have the
higher prestige (e.g., pale lettuce, cabbage and Chinese cabbage).
With intensive nutrition education it should be possible to reverse
these misconceptions.
Some of the most hardy and easily cultivated leafy greens in
the Region are:
Horse-radish-tree or drumstick leaves (Moringa oleifera)
(malunggay in the' Philippines, Malaysia)
Abelmoschus manihot (Aibika in New Guinea, Bele in

Polynesia)
Sweet potato tops (Ipomoea batatas)
Swamp cabbage or spinach (Ipomoea aquatica) (Kangkong
in Malaysia, Philippines)
Native spinach - (a) Amaranthus species
(b) Talinum (Philippine spinach)
Taro leaves (certain Colocasia spp.)
Chinese cabbage (Brassica sinensis)
Sauropus androgynus (Chekur mania in Malaysia)
Some of these need special knowledge for their preparation,
e.g., the taro leaves suitable for eating are those with purple stems;
the leaves may need to be partially sun-dried before cooking with
coconut milk. This eliminates the itchy sensation which is other-
wise liable to be felt in the throat. Many of these leafy greens
can be very appetizing if properly prepared. lsSe
An important part of the educational campaign is to promote
the understanding of the great value of these vegetables; to
encourage their production, with the co-operation of agricultural
agencies; to develop and popularize recipes including both the
locally available ones and newly-introduced ones; and to show
by example, in one's own home garden and in market purchases,
how one values them. The local people are only likely to follow
the lead if the educators practise what ·they preach.
3.2 Roots
Carrots are outstandingly rich in carotene - an exception to
the rule that local varieties are usually superior. Onions and
other roots (except sweet potatoes, taro, yam, cassava and pota-
toes), have not much nutritional contribution. Arrowroot used to
be considered a fine infant food, but is mostly starch. Radishes
contain vitamin C.
3.3 Vegetable fruits
The pumpkin or squash (yellow varieties) is a useful source
of carotene and can be readily used for infant feeding. Other
varieties of marrow, gourd and squash have almost no nutritional
value, and likewise cucumber.
Tomatoes are a useful plant introduction because of their

many uses in the cuisine, and their moderate carotene content
as well as other vitamins and minerals.
Eggplant and okra have high prestige in many countries of
the Region. They are unfortunately not highly nutritive, but are
moderately good sources of riboflavin and iron.
3.4 Stalks
These have relatively little value. When using sweet potato
tops, for inatance, it is better to discard the stalks, since more
leaves can then be eaten.
3.5 Flowers
These are seldom consumed in quantity and are not important
sources of nutrients, but yellow squash ftowers do contain caro-
tene.
3.6 Seaweeds
These are used extensively in many parts of the Region.
There are hundreds of varieties. They are important sources of
iodine in the diet, some other minerals, and carotene and vitamin
C. Agar is made from some types of seaweed. They contain
some protein but it is almost entirely in the form of non-essential
amino acids. If grown in polluted water they should not be eaten
raw.
3.7 Fruits
A great variety of these is grown in the Region. Mostly they
are of similar nutritive value to vegetables, but contain more
simple sugars rather than starches.. They are mostly eaten raw,
and their vitamin C content is therefore not lost in cooking. Some
yellow ones have additional value as sources of carotene, notably
the mango, papaya, bananas with yellow core, cantaloupe (Cucu-
mis melo) , persimmon (Diospyros kald), tiesa (Lucuma nervo-
sa), apricots and yellow peaches. Green mangoes and papayas,
other kinds of melon and pineapples do not contain significant
amounts of carotene. Most fruits also contain some iron and
small amounts of other nutrients. Avocadoes are relatively rich
in fat and riboflavin.
Citrus fruits are noted for their vitamin C content. Most

countries have several varieties of citrus including small ones with
a moderately good vitamin C content. However, they are rather
sour, and not so readily taken by infants, who usually find papaya,
banana, mango and tomatoes more acceptable.
4. EXTRAS
Certain substances are taken in food or drink that have little
·or no nutrient value but are nevertheless necessary because they
add flavour and so help to ensure an adequate intake. They in-
clude the many condiments, herbs and spices which frequently
contain vitamins and minerals, but are seldom taken in sufficient
quantity to add appreciably to the vitamin content of the meal.
Another group of substances which have little nutrient value
but are greatly relished in human diets, are the mild stimulants
used in beverages. The most important of these are tea, coffee
and cocoa which contain caffeine. Tea is a source of lluorine.
A nutritious coffee can be made from roasted soybeans I
CHAPTER III
THE PRINCIPAL NUTRITIONAL DISORDERS

IN THE REGION
Undernutrition and malnutrition occur in many parts of the

Region. "Undernutrition" means the pathological sta1;j! resulting
from the consumption of an inadequate quantity of food over an
extended period of time. In "malnutrition" the quality rather
than the quantity of the food is inadequate, resulting in a relative
or absolute deficiency of certain essential nutrients. However,
commorily there is an insufficiency of several nutrients, resulting
in multiple deficiency symptoms and signs and mixed clinical
syndromes. The principal clinical entities are protein-calorie
and vitamin A deficiencies, beriberi, riboflavin deficiency, pellagra,
scurvy, rickets, nutritional anaemias, endemic goitre, and fluorine
deficiency; The diagnostic features, aetiology and epidemiology
are outlined below, but for further details and illustrations, espe-
cially on the clinical signs and diagnostic criteria, the reader should
consult J elliffe103c and other references. 166• 200
1. PROTEIN-CALORIE DEFICIENCY AND

GROWTH RETARDATION
1.1 Introduction
Protein-calorie deficiency and growth retardation are probably
the most widespread nutritional disorders in the Region. The
calorie and protein requirements of young children are larger,
relative to their size, than in older children and adults. Protein-
calorie deficiency is therefore seen more commonly among these
groups and sometimes among women during pregnancy and lacta-
tion. These are known as the nutritionally vulnerable groups
(see Plate 1) and of these, infants (0-11 months) and toddlers
(1-4 years) are the most commonly affected.
41
42
TABLE 3.1
PRINCIPAL FEATURES OF PROTEIN-CALORIE DEFICIENCY
Mar......... Kwashiorkor
A. Usual age 0-2 years 1-3 years
B. Essential features
1. Oedema None *Lower legs, sometimes
face or generalized.
2. Wasting ·Gross loss of Sometimes hidden;
subcutaneous fat sometimes fat,
"all skin and bone" blubbery
3. Muscle wasting Obvious Sometimes hidden
4. Growth retardation Obvious Sometimes hidden
6. Mental changes Usually apathetic, Usually irritable,
quiet moaning; also
apathetic
C. Variable features
1. Appetite Usually good Usually poor
2. Diarrhoea Often (past or Often (past or
present) present)
3. Skin changes Seldom Often - diffuse
depigmentation
Occasional - 'flaky-paint
or enamel dermatosis
4. Hair changes Seldom Often - sparse,
straight, silky;
dyspigmentation:
greyish or reddish
6. Moonface Seldom Often
6. Hepatic enlarge- Seldom Always
ment
D. Bio.hemistry/pathology
1. Serum albumin Usually normal
(or low) 'Low
2. Urinary urea per g Usually normal
creatinine (or low) ·Low
8. Urinary hydroxy-
proline per g
creatinine ·Low • Low
4. Serum easential
amino acid index Normal • Low
6. Anaemia Uncommon Common; sometimes
megaloblastic;
sometimes iron-
deficiency
8. Liver biopsy ·Normal or atrophic ·Fatty change
*The.e are the most characteristic or useful distingui.hinw features.
PLATE I 43
A Malnourished Family
A. Protein-calorie Malnutrition and Vitamin A Deficiency
B. Marasmus, Xerosis and Bitot spot C. Kwashiorkor: Protein Deficiency

(Protein-calorie and Vitamin A (without dermatosis)
Deficiency) Oedema, Moonface.
Parotid and Liver Enlargement
MOTHER is tired, weak and thin. (Father is working in the big city).
BABY is bawling, famished and wasted, and has primary tuberculosis.
The TODDLERS are listless, apathetic and inactive; they have pot bellies
and flabby muscles; sometimes they grope and stumble in the dark.
As future SCHOOL CHILDREN they might be dull, drowsy and lazy; they
will be thin and small for their age. Many of such toddlers will
die before reaching school age, because of poor nutrition.
44 PLATE 2 PLATE 3
Kwashi orkor
Nutritio nal Marasm us
PLATE 4
A. Depigm ented skin, compar ed with

B. Moon-f ace
normal child
THE PRINCIPAL NUTRITIONAL DISORDERS IN THE REGION 45
PLATE 5
A. Bitot's spot
B. Keratomalacia (late, with

necrosis of cornea
C. Scleral pigmenta-
tien
46 PLATE 6
A. Pingneculum
B. Pterygium
PLATE 7
47
A. Dyssebacea
B. Conjunctival xerosis
C. Corneal xerosis and early keratomalacia

PLATE 8
48
A. Keratomalacia involving whole cornea
B. Corneal vascularization with angular

paipebritis
C. Angular stomatitis
PLATE 9
A. Atrophic papillae B. Fissures of the tongue
C. Early mottling of the teeth (white D. Late mottling of the upper incisors
patches) ~
PLATE 10
50
A. Spongy bleeding gums
B. Pyorrhoea
C. Acute pellagrous dennatosis on D. Chronic pellagrous dermatosis on fore-

foreanns and hands anns
PLATE 11
A. Cheilosis
B. Hypertr')phic papillae
52 PLATE 12
A. Late mottling
B. Dental attrition
c. Enamel hypopla sia

53
PLATE 13 A. PROFILE PHOTOGRAPHS ILLUSTRATING THYRO
ID GRADINGS
GRAO£ 0 GAAOE2A
.""'" 4
B. PROF ILE SILHO UETT ES ILLUS TRAT ING THYR

OID GRAD INGS
(FROM PHOT OGRA PHS)
54 PLATE 14
A. Follicular hyperkeratosis
B. & C. Pellagrous dermatosis
(a) Both forearms and .bands (b) Face and neck (Casal's
necklace)
PLATE 16
A. Flaky-paint rash: Forearms
B. Flaky-paint rash: back of legs C. Bow-legs

PLATE 16
A. Epiphyseal enlargement
B. Rickety rosary
e
PLATE 17
Degrees of protein-calorie deficiency in early childhood: Mild protein-calo-

rie malnutrition.
The child on the left is 18 months old and weighs the same as the 6-month
, baby on the right.

The two principal entities are kwashiorkor'9. '99 (mainly due to

protein deficiency: Plates Ie and 2) and nutritional marasmus
(mainly due to calorie deficiency: Plate 1 Band 3). The main fea-
tures are set out in Table 3.1. However, in practice there is a con-
tinuous spectrum from grossly oedematous kwashiorkor, through
varying degrees of malnutrition associated with minimal oedema,
to marasmus and cachexia. The separation of kwashiorkor is prin-
cipally on the presence of oedema. A comprehensive system of
separation, grading and scoring based on multiple criteria has
been put forward 132•
Besides these specific syndromes, protein-calorie deficiency
impairs resistance to infection and is consequently associated with
high morbidity and mortality rates, especially among toddlers in
poorly nourished communities.
Mild degrees of protein-calorie deficiency lead to growth re-
tardation rather than frank malnutrition; this is associated with
some degree of retardation in mental development.
1.2 Clinical features

Oedema usually occurs first above the ankles and is detected
by pressing firmly over the lower third of the medial surface of
the tibia. Sometimes a puffiness of the dorsum of the feet or
round the eyes occurs even earlier. In later stages, the whole
face, hands and body may be oedematous, but ascites is rarely
due to kwashiorkor alone. The oedema is mainly due to tissue
wasting, together with the low plasma osmotic pressure caused
by low serum albumin levels.
The child is miserable and resents disturbance; his moaning
cry is characteristic.
Muscle wasting is best seen and felt in the buttocks, thighs,
scapular region and upper arms. Loose folds in the buttocks
can be seen when the child is lifted by the armpits. Muscle wast-
ing may not become evident until oedema disappears during treat-
ment. "Pot-belly" and "winged scapulae" also indicate muscle
weakness.
Growth retardation usually becomes more evident, on the basis
of body weight, when the child loses oedema during treatment.
The skin changes, especially the flaky-paint or enamel derma-

tosis (Plate 2), are dramatic. but only present in a minority
of subjects in this Region. Patches of skin turn reddish then
purple (macules and vesicles) and then dark brown patches form,
which become dry and peel off, sometimes leaving raw weeping
areas like burns. These changes are seen mostly in the· covered
parts of the body - buttocks and groins and the trunk, but some-
times extend to the face and limbs. They respond to treatment
with high-protein or even amino-aeid diets.
The hair changes are not dramatic in most Asian subjects,
but are more so in the Pacific islanders. The dyspigmentation
may be greyish-white or reddish brown. However, hair dyes are
rather frequently used in the South Pacific, and in New Guinea
there is an occasional genetic variant causing red hair and skin.
The biochemical changes are diScussed in detail elsewhere .S •••
103e. 225. 226. The serum albumin level is usually below 3 g per
100 ml. The ratio of essential to non-essential amino acids in
serum is reduced to less than 2.0, normal levels being 3.0 -
6.0. 226 • 228 This ratio is not lowered in marasmus. Urinary urea
per g creatinine is lowered. The urinary hydroxyproline per g
creatinine is lowered in both kwashiorkor and marasmus 226 ; this
is a sensitive early indicator of any form of protein-calorie defi-
ciency. These four tests give a good basis for the diagnosis and
separation of kwashiorkor and marasmus.
The anaemia is sometimes of iron-deficiency type (microcytic,
hypochromic); sGmetimes normochromic, normocytic; and some-
times macrocytic or associated with megaloblastic bone marrow
changes. Deficiency of iron, protein, riboflavin, vitamin B12,
folate and possibly other minerals and vitamins and also endocrine
changes, all may contribute to this anaemia. Response to treat-
ment with iron, folic acid, vitamin BI2 and a high-protein diet
is usually slow, and transfusion is beneficial.
Kwashiorkor develops because of a low protein intake. This
causes diminished secretion of intestinal and pancreatic enzymes,
and hence a vicious circle of protein deficiency because of the now
impaired absorption of protein. Fatty change in the liver is the
characteristic result. There is also impaired skeletal develop-
ment, and sometimes there are cardiac disorders. Mental dev-
elopment is also retarded to a varying degree. and there may be

changes in the electroencephalogram. Body temperature may be
far below normal.
Most of these changes are reversible up to a point. However.
some permanent impairment of physical and probably mental
growth results if the malnutrition is severe and occurs early
enough in life. especially before six months of age.
Marasmus. although often less dramatic. is often more serious
clinically. with less fatty change but gross depletion of liver
substance.
Recovery of kwashiorkor and marasmus can be initiated in
two to three weeks treatment with a high-calorie. high-protein
diet. Hospitalization is very desirable for one to three months,
but several more months are required to approach reasonably full
recovery. Initially. weight loss usually occurs for a few days
while oedema fluid is being lost. Early signs of a good response
are the return of appetite and interest in the surroundings, will-
ingness to smile. and rapid weight gains. The essence of dietary
management is to give the child a high-calorie, high-protein diet
consisting of soft foods such as those suitable for infants, and
in a way which will stimulate his appetite. If milk is not well
accepted, fish, meat or egg (boiled or scrambled) may be better
accepted, and vegetable protein resources should be exploited to
the full (soy, peanut, dried beans of various kinds). The mother
should be taught various ways in which to prepare these.
With poor treatment, mortality may exceed 50ro, but even
with thorough treatment a mortality of about 10% may still occur.
This may be due to sudden endocrine failure, electrolyte imbalance,
hypoglycaemia. etc. The first forty-eight hours after admission
are the critical ones. but death may occur suddenly at any time
later on. in or out of the hospital.
Infections, especially of the respiratory and gastrointestinal
tract, may be predisposing causes of the malnutrition, and may
have few clinical manifestations in severely malnourished chil-
dren. Measles is a not uncommon preceding illness; tuberculosis
and amoebiasis need to be considered and carefully looked for.
Intestinal parasitoses - ascariasis, hookworm, giardia, etc., -
are commonly present but are not always important contributing
causes. Treatment should be undertaken when the child is al-

ready on the road to recovery. Preceding diarrhoea may be a
direct manifestation of malnutrition or may be due to an infection.
It often causes severe potassium depletion and sometimes other
electrolyte disturbances (e.g. of magnesium, calcium). If diar-
rhoea has been chronic or severe and acute, the advice of a
paediatrician should be sought, as to the best means of intravenous
or oral electrolyte therapy. The oral replacement of potassium
is especially important.
1.3 Call8eS, epidemiology and prevention

Kwashiorkor, being mainly due to protein deficiency, develops
after six months and commonly between one to four years of age,
when breastmilk production is usually declining and is anyway
insufficient for the growing child's protein needs. It is more
common in places where starchy foods are the main staples, in-
adequately supplemented by protein-rich foods of animal or
vegetable origin. Weaning diets based on the tubers (especially
cassava), bananas and sago are especially prone to lead to
kwashiorkor. Rice and maize also contain insufficient protein in
relation to the calories supplied, for growth of the young child.
All staples therefore need supplementation with protein-rich
foods. The principal reasons for lack of these are poverty and
limited availability, but sometimes they are not given to young
children even when available, e.g. fish and legumes. Prevention
is by improved supplementary feeding for infants. Sweetened
condensed milk, when used too dilute and together with an excess
of rice, tends to cause kwashiorkor. Kwashiorkor can also arise
in older toddlers who are still being breast-fed, if the amount of
milk is small and the child is eating an excess of starchy staple.
Marasmus can develop in the first months of life, and will
result if the mother's milk supply is insufficient and little or no
other food is given. Consequently, this is the commonest form
of malnutrition below one· year. The common causes of inade-
quate lactation are: maternal illness (especially malaria, hae-
morrhage, anaemia, puerperal sepsis, breast abscess, etc.) or
maternal stress due to absence of the father, necessity to work,
psychological factors, etc. Twins also commonly have a low birth
weight and the breastmilk supply is often inadequate for both.
Sometimes lactation fails in mothers who have already borne and

breast-fed several children. Among bottle-fed infants, especially
orphans, marasmus is liable to develop because of a too dilute
mixture, unhygienic preparation with resulting diarrhoea, and
the use of an imperfectly perforated nipple, which leads to star-
vation. Marasmus also commonly arises as a result of successive
attacks of diarrhoeal or respiratory diseases, during which the
child has a poor appetite and often also suffers from ill-advised
dietary restrictions.
Estimates of the prevalence of frank malnutrition and under-
nutrition in different areas are seldom available and vary accord-
ing to criteria. Severe forms may affect from 0 to 20% of
infants and toddlers, but the range is usually about 1_3%.6b.42e.l038
However, milder protein-calorie deficiency, as estimated by refe-
rence to international standards of body weight such as given
in Annex IV, may commonly affect about 30% of toddlers. It is
believed that a degree of mental retardation, amounting to per-
haps One year below school age and two years during the school
age, may be associated with this physical retardation,S8 but
there is no actual evidence on this point from studies within the
Region. It is likely that marasmus outnumbers kwashiorkor by
severa:! times to one, in most countries in the Region. Marasmus
among infants, due to the increase of bottle feeding, is increasing
in probably all urban areas.
PJ.oevention i. by:
(a) adequate breastfeeding (and complementary feeding where
necessary) of young infants:
(b) early and adequate supplementary feeding of older
infants: ..
(c) full diets for toddlers including extra protective foods;
(d) prevention and control of infectious diseases:
(e) proper diet during illness.
1.4 Treatment is summarized in the following pages.

THE PRINClPAL NUTRITIONAL DISORDERS IN THE REGION 68
Guide for Treatment of Malnourished Children in Hospital

and Health Centres
1. PRINCIPLES
1. Avoid delay - aevere malnntrltion fa a medical emergency

2. Feed a high-energy, high-protein diet.
Aim at 100-200 Calories
4-8 grams protein) per kilogram of body weight per day.
3. Use soft diets first, such as those Buitable for no. mill infants aged 4-6
months (Annex VII A).
Later, use recipes for toddlers or IIChoolchiidren (Annex VII B).
4. Fooa.: (a) rice, maize, sweet potato, bananas - for calories
(b) skimmed milk, egg, fish, meat, dried legume. - for protein
(c) dark green leafy vegetables)
yellow vegetables ) for vitamins/minerals
yellow fruits )
Ii. Feed frequently (4-6 times daily).
2. FOODS
A. Milk·
1. Four level tablespoons skimmed milk powder per pint (480 mI) of
boiled water.
2. Mix powder into water by beating with fork.
3. Use immediately; do not store. (It breeds bacteria.)
4. Evaporated whole milk is suitable. Sweetened condensed milk is not,
and filled milk is doubtful.
6. Use a cup, if possible.
6. If a bottle is used, sterilize it. Strain the milk if powdered milk is
used. Perforate the nipple adequately with a heated needle (candle-
Ilame). Milk should drip out drop by drop when bottle is inverted. Too
much or too little interferes with feeding.
7. Quantity
Offer i cup (4 oz. or 120 cc) per kg body weight daily, or say 1 cup
3 times in one day, for 6 kg child.
8. Milk powder may also be used by simply mixing with solid foods
(cooked rice, mashed banarla, etc.); (1 level tablespoon per kg body
weight daily).
·CSM ma.y be uted. and baa the ume CGlorM ecmte'Jlt; but to reach the aame jWoteift
Jeve~ double the """"tlty IPecifted m1llt be a..t. (CSII - eo.... / ...F/m11k _ r e I .
GUIDE for Treatment . . . (Continued)

B. Rice
1. Rice gruel 1 cup 4 times daily - thin at tirst, then thicker.
2. Cooked rice i cup 4 times daily for 5 kg child (with supplements).

Vary the diet with ground maize gruel, banana, sweet potato, oatmeal,
etc. (Raw weights: one cup raw rice makes a little more than 2 cups
cooked.) Bananas and sweet putato may be whole or mashed. For
severe malnutrition, mashed ripe bananas are best; later, cooking bana-
nas are satiafactory. Use nearly twice as many cups of these foods
as of cooked rice.
3. The ehild may take only half these quantities at first. Recovery should
still occur but will be slower.
C. Other 'IIUpplementB
1. Egg: boiled or scrambled
1 egg =6 grams protein _' approx. 5 oz. milk
2. Fish: boiled or steamed, or canned

For severely malnourished children, pa88 through grinder be-
fore cooking with rice. (Shrimps likewise; peel off the shells
if large.)
3. M6Gt: as stew, or dried meat, ground, then cooked with rice; or

canned.
4. Vegetable protBina (dried beans·, peanut, soybean):

(a) Use Recipes for Infants (Annex VII A).
(Especiany recipes I, 5, 10, 11, 12)
(b) Start with bean/rice porridge.
(e) Proper grinding with cereal grinder, or fine pounding, is essential,
to make the legumes digestible.
(d) Use l - 1 tablespoon of dried bean per kg body weight.
6. lAa.I1I l/f'e6nB, 1IeUow 1J6getablu/lf'Uit:

Include frequently, especially:
(a) dark green leafy vegetables··
(b) carrot, yellow _eet potato, pumpkin (aquash)
(e) ripe mauggo, papaya, yellow-eored bananas.
• 8aoh u: areen ..ram or mung bean. (PhaMolua aureu)
lima beans (PhaaeoIwI lUDatua.~ if known to be Don~polaonou variety
hyacinth beano (Dolicboo Iablab)
..I~ beaD. (Poophoearp... _ftOlobllO)
pl~n peaa (Cajanu cajan)
peg (Pieum aativum)
00_ _ (Vipa ain.... )
"8Doh u: hoJ'Mooradiala.tree leava (MoriD. . oIelfen.) (dram8tiek)
aJDaJ1UI,tbu .peciea
_ p cabbqe (1 _ _tlca)
taro leav.. (Co_I. oPP.)
_07._ CbID_
_ topecabbqe (8 ....1ca dlID"") dark ....- yr.rletl.
.-... ........ (__ au....,......,
_ (1_ batatu)
(lIaIao'aIo)
3. ROUTINE FOR HOSPITAL

A. Feeth
Frequent small feeds at first.
Gavage-feeding with milk if refuses to feed; 30 ml (1 oz.) hourly at first,
later increase.
Soft (infant) recipes for first few days.
During recovery, continue feeds 4 times daily.
B. Anaemia (Hb below 10 1'/100 ml)

Colloidal iron l tsp. daily or 1 tsp. Ferri et Ammon. Cit., 3 times daily
Vitamin B12 if megaloblastic anaemia.
Transfuse if Hb below 8 1'/100 ml.
C. Vitamim
U Bually unnecessary.
Vitamin A/D capsules twice daily if dryness of conjunctiva, or Bitot's spots
are present.·
Dryness or ulceration of cornea (xerophthalmia, keratomalacia) Vitamin A
palmitate (oily solution) 50000 I.U. per kg body weight intramuscular-
ly, on admission (urgent).
D. Infections (RespiNLtory tract, Otitis Media, Diarrhoea, etc.) Treat with

antibiotics, as directed by paediatrician, where possible.
E. Diarrhoea
Sugar/ Saline: Sugar - 2 heaped tbsp.
Salt - 1 level tap.
Potassium salt ! tsp.
(citrate, chloride or other)
Water 1 pint
Boil the mixture
Mow..s.a/Saline: Molasses 2 tbsp.
Salt 1 tsp.
Water 1 pint
Boil the mixture
(a) Mild diarrhoea
Give milk and also sugar/saline (or molasses/saline), ~ cup (4 oz.)
of each per kg body weight daily. Use gavage (slowly) if necessary.
Introduce solid foods on second day; discontinue sugar/saline or molasses/
saline.
(b) Severe diarrhoea with vomiting and/or dehydration
Intravenous fluid is necessary. For small children about 100 ml/kg
body weight daily, i N saline in 5% glucose. (Or other regime as
directed by paediatrician.) Begin oral rehabilitation within 24 hours,
as soon as vomiting is controlled.
-All uv.,.. eases of kwash.iorkor without signs in the eyes .should nevertheless reeeive 10
capsules of vitamin A /D immediately as preventive mealJUre.
ROUTINE FOR HOSPITAL ... (Continued)
F. Reco1JBrIJ
1. Weigh child on admission and once or twice weekly thereafter.
2. Loss of oedema may cause initial loss of weight or stationary weight.
3. Thereafter expected gain is 100-200 g weekly (31-7 oz.).
4. Early progress is indicated by improved appetite, smiling and better

humour, loss of apathy.
5. Keep in hospital 2-3 months if possible and advisable at least until

weight gain is more than 1 kg (2! Ibs.). If the child loses oedema,
measure weight gain from the minimum weight recorded.
4. OUTPATIENT ROUTINE
For a child unable to b, admitted:
1. E.:amine and weigh. Insist on return visit after 2-3 days, then once
weekly for review. Give advice on cause and nature of illness. Look for
signs of vitamin A deficiency especially, and treat this if necessary, as
well as protein-calorie deficiency.
2. Feeding. If available, give the mother skimmed milk powder (i kg or

1 Ib per week, for 5 kg child). Give advice on preparation of milk; demons-
tration and practice. Advise on use of other animal foods, legumes, leafy /
yellow vegetables. Encourage mother to bring dried legumes for grinding.
Dried beans should be lightly toasted before grinding, and stored in air-
tight jar. Give recipes as a handout to mothers who can follow them.
3. Follow-up
Malnutrition case register.
House-visit during following week.
Check progress and weigh each week for first month, then every 2 or
4 weeks.
Encourage mother to continue bringing legumes for grinding.
2. VITAMIN A DEFICIENCY 181a. 161. 162. 204
2.1 Qinical features

The principal clinical manifestations of this deficiency are in
the eye. Possibly growth, bone development and resistance to
infection may also be impaired. An early symptom is an inability
to see in dim li~ht, especially after leaving bright daylight. This is
commonly noticed in the late afternoon twilight and is called night-
blindness (nyctalopia, sometimes miscalled hemeralopia). This
is usually, but not always, due to vitamin A deficiency. It is
commonest among children below school age and may easily be
overlooked. However, parents may notice that the child stumbles
in the late afternoon, or gropes for objects in a dim light. This
symptom is often recognized in the vernacular, e.g; matang manok
(Philippines), mata ayam (Malaysia), ya meung (Korea), yeh
maung (Hong Kong), khwak moan (Cambodia).162
Later there is inability 14 withstand bright light (photopho-
bia). The eyelids are kept firmly closed, and sensations of irrita-
tion and pricking may be felt. Later on, the eyes become insensi-
tive to pain.
The first clinical sign is xerosis conjunctivae: the conjunctiva
becomes non-wettable, glazed, greasy-looking and slightly opaque,
(Plate 7B) instead of clear and transparent like the glass of a
mirror. The membrane forms vertical crescentic wrinkles in
the corners of the eye. The dryness may be patchy. Sometimes
the conjunctiva is reddened. At any stage Bitot's spots may
form. These are white foam-like patches, usually triangular in
shape and situated just lateral to the cornea, on the surfa1;le of
. the conjunctiva (Plate 5). These spots are usually seen in chil-
dren of preschool or school age. They are not specific for vita-
min A deficiency, and may be .seen without any xerosis, but a high
prevalence in a community does suggest 'a vi~min A problem.
The next stage is xerophthalmia: the cornea as well as the
conjunctiva is .dry and becomes hazy, like ground glass. A source
of light shining on the eye gives a blurred reflection (Plate 7C).
Later, corneal ulcers may develop: small erosions form on the
cornea, with opaque haloes. These may perforate, the iris usual-
ly plugging the hole as the aqueous humour of the eye escapes.
Sometimes the lens slips out through a large perforation. When

the whole cornea is a soft jelly-like mass, the condition is known
'as keratomalacia (Plate 8A~This may develop very suddenly.
Severe protein-calorie deficiency is commonly present at the
same time and is quite often present in earlier stages (e.g. xero-
phthalmia) also. The mortality in keratomalacia is very high,
either from general malnutrition or from concurrent infections.
Blindness may result from opacities affecting the whole cornea,
or there may be opaque patChes corresponding to ulcers, which
are commonly located in the lower half of the cornea. Perfo-
ration of the cornea results in collapse of the eyeball with total
blindness.
The two eyes can be unequally affected by vitamin A deficien-
cy; when recovery takes place, only one eye may be completely
blind, but the other usually has some corneal opacity and defective
vision.
It should be emphasized that keratomalacia is a grave medical
emergency. The need for treatment is urgent. Examination of
the eye m1,lst be made with the utmost care. Pushing on the
eyelids may cause perforation. To examine the eye, the child's
attention should be caught with a coloured object moved to and
fro in front of his face. Trying to handle his eyelids causes him
to shut them tighter. A good view of the eye can nearly always
be obtained by voluntary co-operation.
The foilowing lesions need to be distinguished from Bitot's
spots and are not of nutritional significance 51 (See Plate 6):
phlyctens - raised white discs surrounded by a red flare,
set in an inflamed conjunctiva (often in-
dicating tuberculosis or other allergy)
pingueculum - yellowish discs situated deeper in a normal
conjunctiva
pterygium - elongated triangular folds in the deeper layers
of the conjunctiva extending from the medial
angle of a chronically inflamed eye, to the
cornea
pigmentation - dark brown irregular spots in the deeper
layers of the bulbar conjunctiva.
Keratomalacia is usually found in children who are very ill

with protein-calorie malnutrition and/or diarrhoea, measles, etc.
Diarrhoea itself may be a manifestation of vitamin A deficiency;
it can sometimes respond to vitamin A therapy. But acute illness
can lead to excessive loss of vitamin A from the body and so to
keratomalacia.
Two vital rules for clinicians and health workers are:
(1) Any evidence of the occurrence of night-blindness, photo-
phobia or conjunctival changes should lead to a careful investi-
gation of the diet of the community concerned.
(2) Every child who is sick must have a careful examination
of the eyes, whatever the sickness happens to be. The eye is
clinically a window which reveals the child's nutritional state.
When any defects suggestive of vitamin A deficiency are found,
especially in the cornea, large oral doses of vitamin A must be
given immediately. This treatment cannot be delayed without
risk of losing or impairing the child's sight.
Therefore, all those likely to encounter signs of vitamin A
deficiency such as staff of health centres, home visitors ·and nutri-
tion survey workers should have supplies of vitamin A ready for
administration. Children with severe kwashiorkor should be
given large doses of vitamin A even in the absence of eye signs.
Detailed discussions of all aspects of vitamin A deficiency in
the eye are given by McLaren131a and by Oomen161 •
Certain skin lesions (follicular keratitis or phrynoderma)
were formerly attributed to vitamin A deficiency, but are now
believed to' be due mainly to deficiency of certain fatty acids and/
or vitamin B complex or other factors.
2.2 Causes, epidemiology and p"evenlion
Vitamin A is found in animal foods (notably the liver of
animals including fish; and also in eggs, butter and whole milk or
fortified skimmed milk). Provitamin A (beta-carotene) is a
precursor found in vegetable foods, particularly the dark green
leafy vegetables, and yellow vegetables and yellow fruits. Bar
charts showing their approximate relative value are shown on
p.26.
All the factors leading to severe vitamin A deficiency in the

eye are not fully known. Carotene can be changed into vita-
min A in the process of absorption through the wall of the
intestinal canal. There is some evidence that signs of vitamin A
deficiency in the eye can occur even when the amount of provi-
tamin A in the diet is reasonably high. This suggests that the
primary fault may not always be in the diet but sometimes is in
the absorption of provitamin A from the intestine or its conver-
sion to vitamin A. The diets are commonly low in protein and
their content of fat in communities where keratomalacia occurs.
The low fat content in the diet may impair the absorption of
carotene. However, nowadays adequate dietary protein is con-
sidered more important than fat.2sZA
By far the greater part of vitamin A intake in most develop-
ing countries in the Region is in the form of provitamin A, and
some populations on extremely low fat diets take chiefly the
provitamin (as green leafy vegetables) and have no vitamin A
problem. The above remarks should not therefore detract from
efforts to proll\ote the consumption of green leafy vegetables and
yellow vegetables/fruit, which are usually the most readily avail-
able or producible low-cost preventives of vitamin A deficiency.
Vitamin A deficiency is in fact more common precisely where
consumption of this food group is very limited. 162 Leafy vege-
tables are highly regarded by some ethnic groups and neglected
by others, even within a given country. Areas where rice is
almost the sole crop grown are those most likely to produce
vitamin A deficiency, but it also tends to be more common among
low-income groups in urban centres. A detailed study of the
epidemiology in Korea, Hong Kong, Cambodia, Viet-Nam and
Philippines, was made by Oomen. 162 There are other reports from
Malaysia197 and Cambodia. 204
Besides general measures to prevent vitamin A deficiency by
improved family diets, it has been shown 78C that a daily dosage
of vitamin A or provitamin A (10 000 I.U.) during the last
month of pregnancy will increase the vitamin A storage in the
liver of the foetus and newborn. Health workers could do a
great deal to eliminate vitamin A deficiencies by promoting such
dietary or medicinal measures in the last month of pregnancy.
Fortification of certain foods with vitamin A may be extreme-

ly important. In one country, fortification of margarine is com-
pulsory, and surveys have shown that this is the major source
of dietary vitamin A in the principal town; no vitamin A problem
occurred until recently. In another country, vitamin A deficiency
was a significant problem until the enforcement of fortification
of condensed milk with vitamin A. Such measures should be
considered in other countries where there is adequate government
control of food importations or local manufacturers.
With growing urbanization in the Region and rapid changes
in dietary patterns, the sources of vitamin A are likely to be
seriously neglected in future decades. It is timely now to take
preventive action in terms of food fortification, nutrition education
and home gardening! This applies to all developing countries
in the Region.
2.3 Treatment: see p 65.

3. BERIBERI
3.1 Introduction
Beriberi is due to deficiency of thiamine (vitamin BI), and
is commonest in areas where rice is the staple food. 62a During
the pre-war, war and immediate post-war years, many people.
especially in war-cievastated areas, suffered from beriberi or other
nutritional diseases with oedema. It is now realised that some
instances supposed then - or even now - to be beriberi were
in fact due to protein-calorie deficiency among adults and tod-
dlers or to other unrelated conditions. "Beriberi" in several
languages in the Region means "swelling" and refers to various
entities with dependent oedema including kwashiorkor, ascites/
cirrhosis, nephritis, and anaemia with oedema. Nevertheless,
vitamin B deficiency does occur in several distinct clinical
forms98d. 101., 106. 16•• 100.
Losses of thiamine from rice would not be so critical if the
diets were supplemented by other foods. Unfortunately, the
greater availability of highly-milled rice has not always been
accompanied equally by that of additional foods rich in the
vitamin. Furthermore, in some communities, during pregnancy,
many women still adhere to the traditional practice of restricting
their diet to rice alone.. When the cereal is highly milled, some
degree of thiamine deficiency seems inevitable in these circums-
tances.
3.2 Clinical features and epidemiology
(a) Wet beriberi (oedematous)
The heart muscle is weakened. Left ventricular failure
develops with breathlessness and weakness, cardiac enlargement,
triple rhythm, rapid pulse, wide pulse pressure, crepitations at
the lung bases (especially left side), venous congestion, hepatic
enlargement and dependent oedema. This may have an acute
onset in an apparently healthy man doing heavy work.
(b) Dry beriberi
Peripheral nervous function is impaired, causing numbness,
tingling, sensory loss, calf tenderness, absent reflexes (knee and
ankle) and impaired motor power (impaired squatting test, and
later, foot-drop). Milder deficiency may cause merely weakness,
tenderness and some mental symptoms, e.g., irritability.
Both these types are liable to occur mainly among women
before and after parturition where rice is the main food eaten,
and among alcoholics in affluent countries. The onset may be
acute, with dramatic collapse, weakness, dyspnoea, oedema, abdo-
minal pain and/or muscular paralysis, but is usually insidious.
Treatment with thiamine by injection is urgently needed and
rapidly effective. Initially 25 mg is given intravenously, and a
similar dose is given intramuscularly at the same time and is
repeated twice daily for several days, followed by oral treatment
(same dosage). If the rf:sponse to treatment in acute cases is
not rapidly effective (within a matter of minutes or hours), an-
other diagnosis is probable.
Beriberi in the last trimester of pregnancy and the puerperium
has been reported in the past in Malaysia, Singapore and the
Philippines, but appears to be rare in these countries nowadays,
and anyway less prevalent than reports from Thailand, Indonesia
and Burma l74 would indicate.
(c) Infantile beriberi 8•14
This classically affects breastfed infants aged 3-5 months who
THE PRINCIPAL NUTRITIONAL DISORDERS IJIf THE REGION 73
look healthy but whose mothers show signs of beriberi and give
a history indicating low thiamine intakes. There are three main
varieties: (i) cardlOrespiratory, in which dyspnoea and cardiac
failure with palIor or cyanosis dominate the picture; (ii) gastro-
intestinal, with vomiting, but usually constipation rather than
diarrhoea; green diarrhoea is not a sign of beriberi; (iii) neuro-
logical - with hoarse crying (aphonia), restlessness, sometimes
rigidity, connlsions, coma, neck stiffness, etc.
Classically, thete are recurring attacks or spasms during which
the infant screams and stretches; aphonia is the most character-
istic sign. Treatment is urgent and rapidly effective; it is the
same as given above.
Infantile beriberi is recorded among the major causes of death
in some countries in the Region. Usually these deaths are not
preceded or followed by a medical examination. Many illnesses
may be recorded as beriberi. Before this diagnosis is accepted,
especially in a child not aged 3-5 months, the parents should be
interviewed by a doctor using a questionnaire such as the one shown
overleaf. This also indicates other diseases which may resemble
beriberi. A peak of mortality among infants beyond 2 months is
suggestive of beriberi (see Annex V).
3.3 Prevention
The factors which could help to eliminate beriberi and are
, already being partly promoted in the Region are:
(a) The rice: Improved milling and cooking practices (pp. 10-
13, 1.53) and where possible, parboiling and/or enriched rice
(which is available in at least four countries).
(b) The mother: Regular pre- and post-natal care including:
- when necessary, vitamin B complex tablets;
- dietary advice, especially the use of foods rich in
thiamine (pulses/nuts, whole-grain cereals, pork).
(c) The infant:
- Give him the rice-water if excess water is ever used
in cooking;
- Give him rice-bran extract (tiki-tiki) or multivitamin
drops;
- Start him on semi-solid feeding by 3-4 months, including
pulses.
FOlLOW-UP QUESTIONNAIRE ON SUSPECTED

INFANTILE BERlBERI*
A. SuggeBtifJe features
(a) At what age in months or weeks or days did the infant die?
(2) Was he breastfed - completely?
(3) Was he often crying?
(4) Was his cJ;ying very difficult to hear (hoarse)?
(5) Was he restless?
(6) Did he vomit?
(7) Was there swelling - (i) generalized
(ii) face
(iii) abdomen
(iv) legs
(8) Was he rigid or stiff in the neck?
(9) Was he breathless?
(10) Does the mother have -
(i) breathlessness
(ii) obvious weakness in the legs
(iii) absent knee and ankle jerks
(iv) abnormal sensations in, the legs
(v) signs of heart failure - enlarged heart, beating rapidly
- crepitations audible at lung bases with
stethoscope
- enlarged tender liver
- raised venous pressure
- oedema of the legs
(11) Was the mother's diet characterized by -
(i) highly polished rice? (examine a sample)
(ii) rice washed vigorously several times?
(iii) cooking of rice in excess water which is discarded?
(iv) low consumption of pork?
(v) low consumption of dried beans?
If the answer to most of these questions is yes, this suggests infantile beri-
beri. Hoarse crying is the most characteristic sign; besides this there is
usually vomiting, or breathlessness, or meningismus.
B. Were there signs of other illnesses simulating beriberi, such as:
(1) diarrhoea (gastroenteritis, dysentery?)
(2) fever with convulsion (malaria, meningitis, encephalitis)
(3) cough (pneumonia)
(4) throat swelling, obstructed breathing, croupy cough (tonsillitis,
diphtheria, laryngotracheobronchitis)
(5) fever, breathlessness, weakness (viral myocarditis, diphtheria)
(6) other siblings with oedema (kwashiorkor, nephritis, anaemia, hepatic
cirrhosis) or grossly underweight (marasmus).
-=--
*This is a summary and sample form which may need adaptation to local circumatancee.
For field use, some workens will need considerable briefing to flll It in: others will need a
more expanded form of which a sample may be obtained from WHO, Manila.
4. OTHER VITAMIN DEFICIENCIES
There are various suggestive clinical signsl03c• 106. 180. 200 but they
are not specific; biochemical tests are more specific but rather
complicated. 98d
4.1 Riboflavin (Vitamin B2)
This is a water-soluble vitamin found chiefly in animal foods
(especially milk, eggs and liver) and pulses, and also in whole-
grain cereals and many vegetables and fruits.
Signs suggestive but not specific for ribo1lavin deficiency
include:
nasolabial seborrhoea
angular lesions and scars (angular stomatitis)( Plate 8C)
cheilosis (Plate 11)
scrotal dermatitis
vascularization of the cornea (Plate 8B)
Riboflavin intakes are quite low according to dietary data, in
areas where either cereals or tubers are the staple. This may
be a factor in growth retardation and anaemia, besides influencing
the above-listed signs. '
Riboflavin is not so easily destroyed by heat as thiamine. The
principal losses to be avoided are due to the action of sunlight
(e.g. exposure of milk) and discarding excess water in which
rice or vegetables are cooked. With careful conservation probably
about 90% of the original riboflavin content can be retained.
Prevention: Since the B-complex vitamins are mostly associated
with animal proteins, pulses and/or whole~grain cereals in their
natural distribution, the recommendations for protein-rich foods,
and the measures to prevent losses in cooking, p. 153, cover the
essential points.
4.2 Pellagra
Pellagra is a clinical disorder caused by diets low in nIacm
and/or tryptophane, or possibly with an amino acid imbalance. s1
It is uSually seen among people subsisting almost entirely on
maize, especially maize which has been stored for some time; or
where sorghum is the staple. The exact aetiology is not clear.
It has been found in some maize-growing areas in the Region.
Niacin is found in animal foods, whole cereals and pulses.

Rice diets usually are not too low in niacin.
The classical picture in pellagra is the triad of di'3Xrhoea, der-
matitis and dementia. The dermatitis is characterized by pig-
mentation and drying (and later desquamation) of the parts of
the skin exposed to sunlight, especially the backs of the hands,
lower legs, face and neck (collar distribution) (Plate lOC,10D,14).
There may be a painful raw red tongue. Mental changes include
depression and irritability. In toddlers, it may be difficult to
distinguish between pellagra and kwashiorkor or marasmus.
Treatment with niacin and a balanced diet may have to be
prolonged.
Prevention is by adequate intakes of B-complex vitamins and
avoiding total dependence on maize or sorghum as staples.
4.3 Scurvy
This is due to deficiency of ascorbic acid (vitamin C).
Vitamin C is found in the following foods:
- most fruits
_. most green leafy vegetables and some other vegetables
- fresh tubers.
It is absent from cereals, most animal products and tinned
milk.
The classical features of scurvy in adults are anaemia, gum
changes, petechial haemorrhages in the skin and sometimes in-
ternal haemorrhages. Biochemical assessment is discussed by
Jelliffe 108c•
The papillae of the gums are swollen, elongated, congested and
purplish in colour; the changes are generalized, not localized to
only a few papillae (PlatelOA). The gums bleed easily on pressure.
Chronic gingivitis and pyorrhoea also cause swollen and inflamed
gums (Plate lOB) which bleed easily, but there is associated pus,
and these IF!sions respond to adequate tooth-brushing but not to
ascorbic acid therapy.
True scurvy is seldom seen in the Region. However, it does
occur among bottlefed babies, even in affluent countries, if the
administration of fruit juice, ascorbic acid or multivitamin pre-
parations is neglected. Infantile scurvy presents a different
picture. The infant is usually between six and twelve months
old. The presenting feature is usually a painful immobile leg;
the child screams when it is touched, and a fracture or paralysis

may be susyected. The pain is due to subperiosteal haemorrhage
which may be extensive with elevation of the periosteum visible
in X-rays. There is also abnormal growth of the bone meta-
physes, best seen as a beading of the costochondral junctions
(distinguishable radiologically from rickets).
Other effects of vitamin C include the promotion of satisfactory
wound healing. Inadequate vitamin C intakes may impair mental
development.
Fortunately, breastfed babies seldom if ever suffer from
scurvy. This may be due to the formation of vitamin C by
bacteria in the intestines of breastfed babies.
There has probably been an over-emphasis in the past on
vitamin C deficiency. The foods recommended for vitamin A
are mostly also good sources of ascorbic acid. However, ascorbic
acid, like thiamine, is easily destroyed by heat; losses may be
up to 50% or even more if special care is not taken. Recom-
mendations for cooking are given on p. 153. The fruits which
are consumed raw have the advantage of avoiding cooking losses,
but many of the vegetables contain much more vitamin C.
Among the fruits, papaya (papaw) is richer than citrus fruits.
Both papaya and small citrus are fairly widespread in the Region
and can be used for infants from the second month onwards.
4.4 Rickets
Rickets is due to a lack of vitamin D (found in animal foods)
but can also be prevented by adequate exposure of children to
sunlight. Vitamin D is generated in t.he skin from the action
of sunlight on 7-dehydrocholesterol. Clinical examination shows
bone changes such as broadening of the end of the radius at the
wrist and beading of the ends of the ribs where they meet the
cartilages in the side of the chest. In young babies rickets pro-
duces abnQrmality of the bones of the skull, which can be dented
by gentle pressure. The full picture includes muscular weakness,
pot-belly, constipation, late walking and delayed closure of the
fontanelle, and delayed teething. Older children develop bowlegs.
Rickets can only develop when the child is growing. Therefore
poor states of nutrition leading to inhibition of growth are not
associated with this condition.
Biochemical evidence of vitamin D deficiency is provided by
abnormally high concentration of the enzyme, alkaline phospha-

tase, in the serum. Radiography of the bones, especially the
costochondral junctions, may also be useful in detecting early
rickets.
Diagnosis of rickets at an early stage is particularly important
in girls. Unless the condition is remedied at this time, permanent
deformity of the pelvis may be caused and this could hinder child-
bearing later in life. Capsules containing vitamin A and D are
usually available in health centres. However, exposure of the
child to sunlight for ten minutes daily should suffice.
Rickets has been reported occasionally from most countries of
the Region. In Korea, children born in the autumn may be kept
indoors for six months because of the cold weather. In sago-
swamp areas and in Muslim homes, mothers are prone to keep
infants indoors for a long time after birth. lSI
4.5 Vitamin K
This is a factor essential for blood-clotting and for making
prothrombin in the liver. It is plentiful in most leafy vegetables.
The livers of newborn infants and especially of premature
infants contain relatively little prothrombin. Bleeding may there-
fore occur into the intestines (causing black stools), internal or-
gans, muscles, skin or nervous system. Vitamin K injections at
birth (1 mil' intramuscularly), and for the mother during labour,
help to prevent such bleeding.
5. ANAEMIA 70.211
Anaemia means a low concentration of haemoglobin in the
blood. Its presence can be suspected by examination of the con-
junctiva and mucosae, especially the lips, and nailbeds. Accurate
measurements of haemoglobin are difficult to make during routine
work in the field. For surveys and for anaemias suspected clinical-
ly, reference to a laboratory is advisable. Haemoglobin levels
below which anaemia can be considered are given in Table 3.2.
A description of one accurate and reliable method for haemoglO:-
bin, using the MRC Grey Wedge Photometer and an oxyhaemoglo-
bin method. is obtainable from the WHO Regional Office on re-
quest. Alternative methods are by cyanmethaemogiobin method
(accurate) or by acid haematin method (Sahli/Hellige) 17 (in-
accurate).
TABLE 3.2
HAEMOGLOBIN VALUES BELOW WHICH ANAEMIA

CAN BE CONSIDERED TO EXIST, AND ASSOCIATED
HAEMATOLOGICAL VALUES Z8~G
Age group Haemoglobin Haematocrit Me He""

(g /100 ml) or PCV C%)".
Children 6 months
to 6 years 11 33 34
Children 12 36 34
Adult males 13 39 34
Adult females 12 36 34
Adult females, pregnant 11 33 34
• At sea level
*. PCV = Packed cell volume
.... MCHC = Mean corpuscular haemoglobin concentration
Anaemias are quite widespread in the Region. Clinically they

affect particularly pregnant women and young children, especial-
ly in the second year of life. Multiple factors are usually involved.
Iron deficiency is very common in both these two principle
vulnerable groups, and folate deficiency is probably quite com-
monly present at the same time in pregnant women. A systematic
study of this problem is now under way in several countries of
the Region.
The main types of nutritional anaemia are:
(a) hypochromic microcytic - usually due to iron deficiency
(b) megaloblastic - usually due to deficiency of folate and/
or cyanocobalamin (vitamin B12).
Iron is abundant in some animal foods (especially red meat,
and particularly liver; also snails) and in green leafy vegetables,
and moderate amounts are present in most staples and other
vegetables and fruits. 66 Its absorption is however very variable,
being impeded for instance by the presence of pbytates* (found in
.Phoephorou eompoundi ..hleb form In.,table .. ttl with fron and eaielum. See NlchoUa.
:lln.Wr " J.lIlff. (lWl. 156 pp. 81-88)
cereals) and possibly aided by ascorbic acid, sulphur-containing

amino acids, and various other factors. In general, only about
5-10% of dietary iron is absorbed, but this fraction is usually in-
creased in iron-deficiency states, and on the other hand may be
decreased in tropical diets. Also iron losses from the skin are
probably excessive in the tropics,t and from the intestines during
diarrhoea. 2a2f
Iron deficiency arises partly because of dietary inadequacy, but
usually there is also exCessive blood loss, e.g. from acute malaria,
menorrhagia, puerperal haemorrhage, peptic ulcer, haemorrhoids,
malignancy, etc. Careful search must be made for these. Iron defi-
ciency anaemia is also liable to occur during the second year of
life, and at 6 months in children born prematurely, because of
their low hepatic iron stores at birth. Protein deficiency, chronic
malaria and hookworm may be partial causes of anaemia'!' 241 but
usually other factors are also responsible.
In megaloblastic anaemias, red blood cell formation in the
bone marrow is defective, due to lack of vitamin B12 or folate.
Vitamin B12 is mainly present in lU}imal foods, especially liver.
Folates are present particularly in green leafy vegetables. Me-
galoblastic anaemias are most commonly seen during pregnancy,
but sometimes also in other groups such as children with protein-
calorie deficiency. There is some evidence that this is largely due
to folate deficiency, although this can easily be masked by con-
current iron deficiency.
There are also many other causes of anaemia, such as protein
deficiency,248 riboflavin deficiency,71 vitamin E deficiency,139 and
also various abnormal haemogiobins, various toxic chemicals (in-
cluding antibiotics).
The causes of anaemias are usually multiple, and their diag-
nosis is difficult. Since any iron deficiency tends to mask mega-
loblastic changes, the latter may become evident only when treat-
ment with iron is under way. The response to eral iron therapy
in any form is slow, but intramuscular or intravenous injections
are not usually necessary. Ferrous sulphate is usually adequate
(200 mg thrice daily). For children, a solution of iron and
ammonium citrate may be given, or colloidal iron.
Folic acid therapy is with oral tablets, usually 5 mg thrice daily,
but very much smaller doses are also probably adequate. Vita-
min B12 is usually given by injection. The response to all these
forms of therapy should be carefully followed.
Anaemia results in cardiac stress, increased body metabolism
and probably other ill effects, including poor resistance to in-
fection.
The WHO policy on administration of iron during pregnancy
and lactation is as follows:
(a) In areas where there is reasonable evidence of high
prevalence of anaemias in women of child-bearinlJ age and where
ctetailed characterization of the anaemia is not practical, the
routine use of iron preparations during pregnancy is advisable.
(b) In areas where there is not a high prevalence of anaemias
in women of child-bearing age and/or where full haematologic
characterization of the anaemia is feasible, the routine use of
supplementary iron should not be encouraged and the therapeutic
administration of iron should be reserved for those women iden-
tified as likely to benefit from the therapy.
It may be noted that the recommended consumption of animal
foods and of green leafy vegetables should cover the basic dietary
components for proper haemoglobin formation, but there may be
factors present which impede their proper utilization, such as
concurrent infection, parasitosis, etc. Folate is easily destroyed
by heat; leafy vegetables should therefore be cooked for the
minimum time.
Iron deficiency can also be minimized by fortification of suit-
able foods, e.g. in the Philippines, enriched rice provides an
additional 12 mg of iron daily.
6. ENDEMIC GOITRE228a
Goitre is an enlargement of the thyroid gland, graded as

follows:
Grade 0 - No visible swelling due to thyroid gland. even
on swallowing with extended neck. Isthmus
impalpable; or palpated only as a thin ribbon of
tissue or inferred because tracheal rings cannot
be clearly felt over the isthmus.
Grade P - No visible neck swelling due to thyroid gland
even on swallowing with extended neck The
isthmus can be clearly felt as a structure
thicker at its centre than at its top or bottom
borders. It can often be rolled up and down
over the palpating finger.
Grade 1 - No visible thyroid swelling with neck in the
neutral position. A visible thyroid swelling is
seen on extending the neck and swallowing. The
swelling is confirmed to be thyroid by palpation.
Grade 2 A - Small visible swelling with neck in the neutral
position, not as big as the subject's little finger
(distal phalanx. broadest part). The swelling is
confirmed to be thyroid by palpation. and may
be in any part of the gland.
Grade 2 B - Visible swelling with neck in neutral position.
and its transverse diameter estimated to be
between that of the little finger and the thumb
(distal phalanx).
Grade 2 C - Moderate visible swelling whose transverse
diameter is as big or bigger than that of the
subject's thumb (distal phalanx).
Grade 3 - Gross visible swelliQg of neck as large or larger
(on either side) in a~ea than the subject's clen-
ched fist placed in the midline with knuckles
facing the observer. but not necessarily as
thick as the fist.
Grade 4 - The grossest category of thyroid enlargement.
the thyroid is broader than the neck. If the
observer stands behind the snbject. six feet
away. the thyroid is simultaneously visible on
both sides of the neck.
(See Plate 13, p. 63)

Thyroids are also classified as nodular (N) when there is

a single nodule, and multinodular (NN) when there are multiple
nodules by palpation.
On the proforma. categories can be tabulated as follows:
, I I , :
o : P : 1 : 2A N NN: 2B N NN : 2C N NN ~ 3 N NN : 4 N NN
: " . : ; : :
(N is to be encircled when one nodule is felt; NN is encircled

if two or more nodules are felt.)
The condition is said to be endemic and of public health

importance when Grade I goitres exceed about 10%. However,
people in some communities do not necessarily consider even iargtl
goitres as undesirable. Very largtl goitres can only be removed
by surgtlry.
Goitres occur mainly among school-agtl children (with little

difference between sexes until the agtl of adolescence) and among
women during the reproductive years, especially during pregnancy.
There may be an association with deaf-mutism, cretinism,
myxoedema, thyrotoxicosis, thyroid cancer, neuromuscular inco-
ordination, dwarfism and other abnormalities. Elimination of
endemic goitre is considered desirable therefore.
. Not every individual in a goitrous area develops goitre; cer-

tain families appear particularly prone, and may have an inheri-
ted need for more iodine than others.
Endemic goitre is usually most prevalent in mountainous areas

where the soil and water, and consequently the locally available
foods, are low in iodine. Iodine intakes come more from the foods
than from the water. Occasionally the excessive consumption of
certain foods, especially in the cabbage (Brassica) family, may
cause goitre, because they contain goitrogenic factors. Labora-
tory tests can give presumptive evidence whether iodine deficiency
is responsible or not. The final test is by treatment with iodine
or iodate, but this may be effective even when goitrogtlns are
partly responsible.
The foods richest in iodine are seaweeds, but some sea-fish

and shell-fish are quite good sources. However, 100-200 g of sea-
fish may be required to supply the daily requirement of approxi-
mately 100 mcg of iodine.
The use of iodized salt (which is usually fortified with potas-
sium iodate, in concentrations of 1 part in 10 000 to 1 part in
100000) has been successful in many countries including China
(Taiwan),11 in reducing the prevalence of goitre.
Salt iodization is a relatively inexpensive procedure, costing
only about 0.2 US cent per person per year in Taiwan, where
UNICEF helped to establish salt iodation plants which now supply
the whole country with iodated salt. at
However, this method o.f goitre control is fraught with diffi-
culties in areas where little salt is consumed or where salt manu-
facture or importation are not directly under government control.
Goitre is endemic in many mountainous parts of New Guinea,
where salt distribution is impractical. A pilot campaign based
on the injection of iodized oil, which is apparently effective for
five years, is under way.Z6. 28
7. DENTAL DISEASES
Dental caries, or decay, is a condition in which there is pro-
gressive destruction of the enamel and dentine. This is especial-
ly common in the depths of the fissures in the biting surfaces of
the molar teeth.
Lactic acid and other acids are formed in the mouth by the
action of saliva and bacteria on carbohydrates in ingested food.
This acid can dissolve the enamel. After being chewed, foods of
a tenacious nature, especially toff~ or baked foods made from
refined flour, remain lodged in the crevices of the molar teeth.
The prolonged release of lactic acid promotes rapid decay.
Fluoride deficiency during foetal life and early childhood
apparently weakens the general structure of the teeth and their
resistance to the above process. A fluoride level of one part per
million' (p.p.m.) in drinking water is usually consider.ed desirable
during the mother's pregnancy and in childhood. Fluoride levels
THE PRINCIPAL NU'fRITIONAL DISORDERS IN THE REGION 85
below 0.5 p.p.m. are usually associated with much higher preva-
lence of dental caries. Certain foods such as sea-fish, coconut
and taro are relatively rich in fluoride. Abandonment of this
sort of traditional diet in French Polynesia, together with in-
creased consumption of refined carbohydrates, in areas where the
fluoride level in water is low, has been shown to be associated with
a spectacular rise in the prevalence of dental caries. Data
illustrating the rising prevalence of dental caries in American
Samoa are shown in Table 3.3, as well as the higher prevalence
with increasing urbanization.
TABLE 33
Changes in prevalence of dental decay in areas

of American Samoa*
Vear Age Group Percentage with

Location
decayed teeth
1934 5 - 74 22
Urban
1954 3 - 21 73
Moderately 1934 5 -19 9
isolated 1954 3 - 21 60
1934 5-19 3
Remote
1954 3 - 21 42
1934 5 -19 4
Isolated
1954 3 - 21 22
Pacific
'From, Cadell, PS. (1960) Dental health in South PaCific Territolies, South
Commission Tach. Paper No. 131, Noumea.
In French Polynesia and elsewhere, enamel hypoplasia also

occurs and mas hA du" +" il ..fective maternal nutrition.
Fluoridation v: ware} .,Uk'.. • • "'ossibly of salt, provide one
possible mode of preventing the rising .. lence of dental caries

in many parts of the Resrion.
Besides dental caries, periodontal diseases (gingivitis,

pyorrhea, etc.) are very prevalent and responsible for a good
deal of oral disease (Plate lOB). This is mainly due to poor oral
hygiene and should be largely controll~ble by proper toothbrush-
ing. Toothbrushing could also help 'to control dental caries.
However, it must be done within a very few minutes of taking
any meal or snacks. It is desirable to avoid snacks of refined
carbohydrates and sweetened foods, soft drinks, etc., especially if
immediate toothbrushing cannot be carried out. Local materials
such as palm fronds, coconut husk fibres, etc., can also be effectively
used. Rinsing the mouth vigorously with a weak salt solution
is the best simple substitute for toothbrushing.
Excess lluorine in the diet causes lluorosis, with characteristic
changes in the skeleton and teeth. Diffuse white patches, some-
times with pitting and brown discolouration, are seen commonly
in the incisor teeth (Plate 9C & D).
8. NUTRITION, INFECflON AND MORTAUTY2I2v·2d

Infectious diseases nearly always worsen any malnutrition
present, and conversely malnutrition usually weakens resistance
to various infections, which are more serious in a malnourished
host than in a well-nourished one. These effects are therefore
synergistic. This results in a strikingly higher mortality rate
among children aged less than five years in the developing coun-
tries, than in affluent countries. 'Mortality rates among toddlers
aged one to four years, and particularly the one-year-olds (12-23
months), are believed to rellect more specifically the nutritional
situation in a community. us The age-specific mortality rates are
accepted as indices of nutritional status. Difficulties which arise
in practice are (a) incomplete registration of deaths, (b) lack
of population data for children below five years, year by year.
Annex V gives methods for using toddler mortality rates as indi-
cators of nutritional status.
Qualitatively, it is recognized that malnutrition predisposes
to or aggravates a variety of infections such as tuberculosis. Re-
latively mild infections such as influenza and measles carry a
relatively high mortality in developing countries, compared with
affluent countries, where the mortality rate from measles is usually
only 0.1 to 0.5 per 100000 popUlation.
Diarrhoeal disease is common in developing countries, especially
among children aged six months to two years, when it is known

as weanling diarrhoeas4 because the poor diets at this age are
believed to play an important role. The usual pathogenic bacte-
ria, protozoa or viruses can be found only in the minority. Usually
there are repeated attacks, with dehydration and augmented
loss of electrolytes and nutrients. The relapses are difficult to
treat and often lead to severe malnutrition or death. Well-
controlled feeding trials among pre-schoolchildren have shown
that proper supplementary feeding can reduce morbidity and
mortality from weanling diarrhoea. Health education is also
important, to promote better feeding, food preparation and
hygiene in the homes.
On the other hand, infections can precipitate malnutrition.
Any infection causes increased metabolism, loss of protein,
vitamin A and other nutrients from the body. Protein-calorie
and vitamin A deficiencies, for instance, often become manifest
after measles, diarrhoea or respiratory tract infection. 'Food in-
take is also liable to be restricted voluntarily or by parents.
Nursing mothers should continue to empty the breasts even if
the infant's appetite declines, so as to prevent breast engorgement
which may permanently reduce milk secretion. In diarrhoea,
there is a regrettable tendency to introduce starvation regimes
or bland fluid diets containing no protein. Milk should be included
in the diet, even though stools may become more bulky, because
70-90% of it is nevertheless absorbed; breastfed infants should
not be weaned on account of diarrhoea. A regime of manage-
ment is given on p: 65.
Intestinal parasites probably impair appetite. Roundwormand
hookworm probably impair proteins;. 211 and energy metabolism
and growth.252 Roundworm may affect vitamin A status. Hook-
worm probably contributes to iron deficiency anaemia but only
when there is heavy infection. Go. 89. 91 Other chronic infections
especially amoebiasis and renal disease can cause non-specific
anaemias.
Malaria. Some important interactions of malaria and nutrition
are:
(a) Hepatic fibrosis. Combined malnutrition and endemic
malaria seem to be responsible for fibrosis of the liver in West
Africa. 220
(b) Anaemia. There is evidence that in areas where malaria

is endemic, haemoglobin levels tend to be lowered, and that pro-
laxis can cause return towards normal. 48
(c) Growth. Although one would expect that chronic mala-
ria would impair growth rates, because of its general metabolic
effects, and although growth retardation is almost universal in
malaria-endemic areas, there is no clearcut evidence specifically
incriminating malaria for this.128 Furthermore, a successful
anti-malaria campaign did not bring about an improved growth
pattern. 4 &
(d) Birth weights of infants with malarial parasites in their
placentae are lower than those without parasites in their placen-
tae. Malarial prophylaxis to mothers in holoendemic areas
causes an increase in the birth weight of their infants, compared
with mothers not given prophylaxis. 148
These comments only touch the surface of the subject. There
are many other aspects to this fascinating problem. There is no
evidence that better nutrition gives protection against malaria,
but it seems likely that it would minimize mortality and long-
term morbidity such as hepatic cirrhosis. Conversely, malaria
prevention will obviously improve the nutritional state, at least
with respect to anaemia. It seems that to eliminate growth
retardation and other ill effects in children, one needs both to
control malaria and to improve their diets. 241
Various infections (especially gastro-intestinal and respiratory

diseases and malaria) are very prevalent in the Region. Un-
doubtedly, these impair the nutritional state and contribute to
some extent to growth retardation and frank malnutrition. On
the other hand, poor nutrition undoubtedly contributes to the
relatively high mortality from the illnesses prevalent in develop-
ing countries (Annex V).
9. OBESITY AND OVERWEIGHT

Persons are said to be overweight when they are 10% or
more above an accepted standard. Persons are said to be obese
..when they have an excessive accumulation of body fat. There
are no accepted standards for obesity, but 'normal' skinfold
measurements are quoted by Jelliffe lO3c • There are however
no accepted norms covering the whole Region.
Obesity occurs mainly in more affluent countries but is also

seen in upper and middle income groups in urban areas in develop-
ing countries, and in some South Pacific islands. It is commonest
among women beyond the child-bearing age but occurs also earlier
in life, and among men, and in schoolchildren in affluent countries.
The hazards of obesity include increased incidence of diabetes
mellitus, arterial hypertension, atheroma and arteriosclerosis,
arteriosclerotic heart disease and cerebro-vascular disease and
chronic bronchitis. For these reasons it is usually recommended
to try to keep body weight not more than 20 % above a local
standard. At the same time it must be realized that there are
many causes of obesity (including endocrine disorders) and that
psychological factors playa major role. The physician or psycho-
logist should endeavour to assess these. To attempt to reduce body
weight by simple (or complex) dietary regimes may be successful
(or unsuccessful!) in the short term, but one has to consider
the psychological impact of upsetting the equilibrium. A patient
who lives a longer but frustrated life will hardly thank his phy-
sician for that!
For those who wish to keep a check on tendencies to gain
weight, the dietary· principles are simple. Foods rich in energy
must be avoided or taken in very limited quantity. Foods which
are rich in fat supply the most energy, but diets low in fat and in
protein are relatively unappetizing to those already accustomed to
foods rich in fat and protein. Restrictions on such foods are there-
fore not advised, except in proportion with the total diet. Carbo-
hydrates however can usually be considerably restricted by limit-
ing the amount of staple food to small servings and eliminating or
restricting all sweetened foods and snacks. On the other hand,
vegetables which are bulky, and low in energy value, can be taken
freely and will give satiety and variety. Some suggestions for a
weight-reducing diet are given opposite.
Taking a severely restricted diet will reduce body weight more
quickly but this is seldom necessary. Reduction by 0.5-1 kg per
week should be sufficient.
There is evidence that some of the hazards of obesity are part-
ly related to serum triglyceride and cholesterol levels. These tend
to be elevated on diets rich in fat and in saturated fats, res')Pctive-
ly Animal fats and coconut oil are saturated fats. Ot!:~r vege·
table oils are mostly relatively rich in polyunsaturated fats. These
tend to lower serum cholesterol levels. From the standpoint of

minimizing risks of arterial disease, restriction of animal fats and
coconut oil is advised and may be compensated if necessary by an
equivalent increase in polyunsaturated vegetable oils such as maize,
soya, peanut, sunflower, sesame or other cooking oils.
Physical exercise is known to play an equal part with diet in
the control of body weight, and also significantly reduces the risks
of arterial diseases. Many other factors also influence the inci-
dence of hypertension and arterial disease, including psychological
factors and smoking. Therefore the dietary regime should be
viewed within the context of the whole life pattern and should
not be manipulated in abstraction.
REDUCING OR LOW - CA LORIE DIET
A. FOODS ALLOWED IN MINIMAL AMOUNTS ONLY

1. Sugar in any form: table sugar, honey, syrup, glucose, jam, sweets,
lollies, chocolate, jelly crystals, sweet biscuits, cakes, puddings,
sweetened drinks, cordials, soft drinks, fruit canned in syrup, uncooked
dried fruits.
2. Starchy foodB:biscuits, cakes, puddings, pastry, crumpets, scones, gravy
or thickened sauce, cocoa, malted milk, bournvita, ovaltine, milo, custard
powder. Noodles, macaroni, spaghetti.
3. Fat.: Foods fried or baked in fat or oil. Fatty ham, sausages. Oil
or mayonnaise. Bacon. Cream, ice-cream, butter, peanut-butter.
Dripping lard, pastry, nuts, margarine.
4. Alcoholw drinks.
B. FOODS ALLOWED IN MODERATE AMOUNTS

1. Rice: One moderate plateful dally, for those used to rice as staple.
2. Bread: White or brown, not buttered. Maximum 1 slice daily. For
variety, 2 plain biscuits or 3 vitaweat biscuits may be substituted for
1 slice bread.
3. Sweet potato or other tuber staples: One moderate serving daily, for
those used to these as staple.
4. Potato: One small serving. Boiled or cooked in jacket. No chips
or fried potatoes.
6. Vegetables: All vegetables, moderate servings (not fried).
6. Fruit: 2 pieces, fresh or stewed without sugar.
7. M;[k: Fresh, evaporated or powd"ered (not sweetened). As a plain
drink or in tea or coffee.
8. Meats: Lean meat or fish or poultry. Discard any fat. Have it
grilled, steamed or simmered. Not fried, not cooked with flour or
breadcrumbs.
9. Egg.: Poached, scrambled, omelette, boiled. Not fried.
10. Cheese: Any variety, small portion.
11. Condiments: Salt in moderation.
C. FOODS ALLOWED FREELY

1. Salad vegetables and green vegetables: liberal servings.
2. Saccharin may be used instead of sugar.
3. Tea, coffee, beef tea, water, soda water, meat extract, fish sauce, pepper,
mustard, vinegar, herbs, curry, spiceS, lemon juice, gelatine.
CHAPTER IV
NUTRITION OF VULNERABLE GROUPS
I. INFANTS AND TODDLERS
1.1 Nutritional status at birth 42a.198,210b
At birth, the baby's nutritional state is greatly influenced by

the mother's diet during pregnancy. The average birth weight
among babies born in low-income households is distinctly below that
of babies from high-income households. The fat and protein sto-
iage in the foetus is less. Vitamin A and iron storage in the foetal
liver, and calcium deposition in the skeleton, are also less when the
mother's diet is poor. While it is true that the mother's needs are
sacrificed to those of the foetus, this is only partially true; the foe-
tus also suffers from poor nutrition. It has been well said, there-
fore, that the infant is already nine months old at birth arid his nut-
ritional career is already partially pre-determined. It has been
shown elsewhere that poor maternal diets increase the incidence of
developmental abnormalities in the foetus, abortion and stillbirth.
Experimentally in animals, deficiencies at certain times can cause
specific foetal lesions; the lesion depends on the time, not on the
deficiency. Because of this, the value of a 'proper diet from the
commencement of pregnancy should be stressed - not merely
during the last trimester when the main deposits in the foetus take
place.
Factot;s which lead to delivery before 38 weeks of pregnancy.
even if not to actual prematurity. result in the birth of babies whose
nutritional development is immature - in particular, the liver,
whose stores of vitamin A and iron will be low: For the same rea-
son, prothrombin formation may also be inadequate in immature
babies, and therefore it is advisable to adminis,ter vitamin K intra-
ml,lscularly to the mother (5 mg) during labour and to the infant
(1 mg) immediately after birth.
92
NUTRITION OF VULNERABLE GROUPS 98
Various infections (particularly malaria, also viruses and bac-

teria) and other conditions (e.g. pre-eclampsia, diabetes, hyperten-
sion, nephritis, multiple pregnancy) can lead to birth of immature
babies. The proper prevention or treatment of these conditions and
proper diet for the mothers will give the newborn infant a much
better start in life DUtriti~. In fact, this is probably the main
result to be aimed at and achieved by nutrition education during
pregnancy. However, the mother will also benefit, in that the dep-
letion of maternal ti88ues in the interest of the foetus will be mi-
nimized.
Differentiation between low birth weight due to prematurity,
and due to malnutrition during foetal life, may be important. ,The
premature infant can develop rapidly and catchup with the nonnal
infant. In the tropics, birth-weights between 2.0 and 2.5 kg seem
to be less hazardous than in temperate areas. If the infant can
suck, his prospects are good; but otherwise, very poor. For the
care of premature infants, standard texts should be consulted.
There is, on the other hand, evidence that the malnourished foetus
may, after birth, be left with some permanent defects including
impairment of mental development.
1.2 Normal and retarded development

Normally the tropical infant seems to thrive on breastmilk for
the first six months of life. Often there is little or no weight loss
after birth. For several months, his neuromuscular and behavioural
development is at least equal to that of infants in affluent coun-
tries. His condition often contrasts strongly with that of an older
sibling of toddler age. .
Beyond six months, breastmilk production usually declines and
is anyway no longer sufficient for the child's growing needs of
both calories and protein. Growth retardation usually becomes ap-
parent first in terms of l$lower weight gains, then slower height
gains, compared with well-nourished children.
Typical curves of mild a,nd severe growth retardation are shown
in Figure 4.1. Figure 4.2 shows how growth retardation some-
times proceeds to marasmus and kwashiorkor. Some data from
various countries in the Region are summarized in Figure 4.3 and
Table 4.1, showing slower weight gains in some developing coun-
tries. This general situation has been described by many authors.
Scrutiny of the weight curves shows, in fact, that retardation is
FIGUREU
MILD AND SEVERE GROWTH RETARDATION
/>JJSTRAUAN />JJSTRAlIAN
CHIMBU
KUNDlAWA
.."'-~~........., ....-""KUNDIAWA
CHIMBU
T
2 • a
AGE CMONlHS)
Chimbu is a District in the New Guinea Highlands; rural children - poorly

nourished
Kundiawa is the capital township of this District; these children were not 80
poorly nourished.
FIGURE 4.2
15 TYPICAL GROWTH CURVES (BODY WEIGHT) IN WELL-NOURISHED
AND POORLY NOURISHED CHILDREN
15
14
13
12
'"
'"<
'"c "
.
a
.
....
•
...
'"c
....
""
'"
If 15 21 • 21 30 11 1&
AGE IN MONTHS
FIGURE 4.8
A.veroge Weights of Young Children in the Westerrt Pacific
13
(I) Atllt,.I ••
11
Republic of Kor.o
Chino (hiwen)
11
Cambodia (Phnom Penhi

Malays (Singapore)
10 Viet Nam (Saigon)
.. New Guin." (Chimbu)

Philippin., I Boyomban131
<>
'"
NOTE: Dota forc"mbodia endChin.jTaiwan) for.g8~ 15. IBand21

months ar. not ."(lwn and th. 12 and 2'" monHu ('<;lures ar.
merely connected by straight lines.
i ,
i 12 15 18 21 1\
AG ON' " S
often already apparent, though of small degree, by four months

of age or even earlier (see Fig. 4.1). Tberefore, the assumption
that breastmilk alone is adequate up to six months should not be
accepted without question. Furthermore, when growth retardation
does become apparent, the diet must have been ~nadequate for some
weeks or months beforehand. In the same way, frank malnutrition
in the second year of life is usually the result of poor feeding in
the second balf of infancy. .
It is probable that caloric insufficiency is largely responsible
for this retardation, since the estimated calorie intakes of infants
from 6 to 12 months are very low in many countries, and these
data are confirmed by qualitative information from many other
countries.
Methods of following development of bodyweight and height
in children are discussed on pp. 140 and 272. A quick guide to
progress measurements for use in health centres for instance, is
given on p. 99.
TABLE U
MEAN WEIGHTS (lqr) OF YOUNG CHn.DREN IN THE

WESTERN PACIFIC
POPULATION AGE IN MONTHS WEIGHT IN KG

1 3 6 9 12 15 18 21 24
1. AustralIa .. ....... ...... 4.02 5.58 7.54 9.0. 10.28 11.22 11.94 12.48 12.87
2. CombodIa (PII.... ·P...., '" .. 4.76 6.45 8.07 8.68 • .32 - - - 10.43
3. ehh. (Tllwan) 116 ......... 4.10 5.70 7.00 7.90 8.50 - - - 11.10
4. Japan 141 ..... .......... 3.10 5.45 6.85 7.65 8.3/1 - - - -
5. Korell 117 ...... . . . .. ..
. - 5.70 6.95 7.60 8.45 9.00 9.65 - 11.40
6. Mala, 151Il0l.....) .... ..... - 5.34 6.58 7.48 8.OS 8.64 • .32 9.80 IG.32
7. New Gol_ (Clolmbu)" ..... 4.OS 5.29 6.63 7.42 7.82 8.39 8.26 9.09 '.40
8. PIollippl ... (~" .. - 5.55 6.4' 7.45 7.75 8.17 8.89 '.23 -
9. VleUam (Salp) 2U ....... 3.73 5.44 6.98 7.99 8.26 8.94 9.24 9.75 10.25
Besides the weight and height, skinfold thickness of indigenous

children in the tropics also is apparently less after infancy, but
relatively few data are available.k. .... II?
The chronological development of the primary dentition may
be affected in markedly malnourished children and especially in
rickets, but otherwise does not seem to be affected in the general
population despite rather poor dietaries. A normal pattern of erup-

tion of primary dentition is shown in Table 4.2.
Thepattem of development of bones ill affected by nutritional,
factors including the supply of protein, calcium, vitamins A and D,
and other nutrients. 50, 75h. 88, 165
TABLE 41
AVERAGE ERUPTION TIME OF DECIDUOUS TEETH-
TOOTH LOWER JAW UPPER JAW
Central Incisor" 6 .......11s 7·1/2 monills
Laterll incisor" 7 months 9montlls
Cuspid 16 months 18 montlls
First mollr- 12 months 14 months

Second molar- 20 months 24 OIontlls
•• Incisors: rante .±. 2 months

_ Molars: range ~ 4 months
• From: Massier. and Schour. Atlas of the IIIOIIlh and adjacent
parts in health and dl-.se. American dental Association,
Chicago. 1954
One should avoid discouraging over-anxious parents, but other-

wise it is justifiable to use these findings as a stimulus, to motivate
parents to provide the best feeding they Cl'-n manage for their chil-
dren. This may in fact be the strongest point of appeal in nutrition
educational activities. At the level of national economic planning,
these findings also warrant an emphasis on better nutrition as an
essential prerequisite for full manpower development.
The average normal timetable of motor, behavioural, and men-
tal development is shown in Table 4.3. At l1irth and in the first
weeks of life, the tropical infant is usually equal to or in advance
of infants in developed countries. Later a degree of retardation
of mental development commonly becomes apparent in poorly-
nourished children. 'T. as Nevertheless the role of strictly nutri-
tional and of other socio-economic factors in this association is not
definite. There is a correlation between nutrition and .mental de-
velopment, but although the evidence is strongly suggestive, it is
not finally proven that malnutrition is the specific cause of the
general impairment of mental development seen in many such
studies. The evidence suggests that when malnutrition occurs
during the preschool or school years, the effects are largely rever-
TABLE 4.8
NORMAL MOTOR, BEHAVIOURAL .AND MENTAL DEVELOPMENT
1 month some rtIIrd for surroundings; can raise had.

2 months smiles.
3 moltths turns head In direction of sounds.
4 months grasps objects with both hands.
5 monttn rolls ClWfr.
6months transfers object. from hand to hand.
7· 9 months sits up without assistance.
8 montllS crawls,
9 montbs gnlSps objects with thumb and fWefinttr.
10 months stands, holding OR to support.
11 • 15 months wa-Iks With support.
12 months stands Without supPOrt;. speaks single words.
12 • 15 months walks aiD",; crawls upstairs.
15 • 18 months throws a ball.
18 • 24 months runs, climbs, jumps, points to parts of his bocIJ. can use two combined wonb.
2 • 2112 )tItS toilet tralnod. '
2112·3\'1011 speaks f~irly well; points out mouth, nose and eyes, rfPllillts two numbers; lives corrttt
answers to: \'Whats JOur 11l1nt?"
4 roan tan say wMtMr boy or girl; names IImlltll objtcts: knl~ top, anlmlli. Statts which ot
two objects Is heavier. States whld'! of two parallel lines Is longer.
5 roan Copies square s"pe with pencil; dlSCrlbes purpo. rtf familiar object.s; repealS short sefttenCts.
6 roan COunts COins; telts Ume of di)" mornl"" ewenl",; carries out Un. limple tasks; open and
""" ...... 1l1li brl", • _ .
sible by nutritional rehabilitation. But it seems likely that severe

nutritional impairment in infancy, especially below six months, is
likely to have permanent effects.
Some apparent departures from the normal patterns of growth
and developmental milestones are to be expected in any child. How-
ever, a consistent lag in several or all respects calls for paediatric
assessment. It may be due to simple genetic factors, to nutritional
dwarfism, or to many causes of failure to thrivellZ other than
malnutrition. These are summarised in standard paediatric texts
and other articles. 15. 66. at. 180
1.3 8ft_feeding
Except in urban areas, nearly all infants are wholly or almost
wholly breastfed. Commonly, lactation is maintained for about 18-
24 months. However, in urban areas, with growing sophistication
and the bad examples of affiuent mothers, and the need or tendency
, of mothers to seek employment, fewer and fewer mothers are
breastfeeding, even among the low-income groups. For example,
in Singapore, between 1951 and 1961 the percentages of mothers
who brea!J1;fed their babies for even 8 months declined from 48 %
to 8% among upper and middle-income .groups, and from 71 % to
42% among lower income groups. a,s. 246 Even in the South Pacific
very few urban mothers breastfeed their babies for long nowadays.
Some of the advantages of breastfeeding are:
(a) Ready availability and no trouble to prepare;
(b) Adequacy for most of the nutritional requirements up to
six months;
(c) Economic - low cost;
(d) Partial immunity provided by breastmilk globulins to
diarrhoeal and other diseases;
(e) Minimizing gastro-intestinal infections;
(f) Fostering the mother-child relationship.
The technique of breastfeeding rarely needs to be taught in
rural areas, but among sophisticated communities some instructions
may be needed. There is an international league· which pro-
duces a variety of literature1l6 on these matters for educated
mothers. The lIaby should be put to the breast within twelve hours
of delivery, to initiate the suckling process and stimulate the milk
flow, even though the quantity of colostrum is small at this stage.
Normally, the young infant does not need any other fluids; sugar
water or artificial feeding should never be given at this stage.
The full milk supply normally takes at least three days, and often
a week or more, to develop. No one should be in a hurry therefore
to turn to artificial milk. However, it may occasionally be ne-
cessary to give some boiled water in addition to the breastmilk in
the first few days to prevent dehydration in very hot weather.
In some communities the infant is not fed on the colostrum.
This is a rich source of many nutrients and protective antibodies.
Its value should be emphasized, partly for its own sake, and partly
to establish early a pattern of sucking which will prevent engorge-
ment of the breasts and consequent temporary or permanent im-
pairment of lactation. These and other practical guidelines on
breastfeeding are vividly discussed by Jelliffe. 1G8 Unsophisticated
mothers often need no instructions at all at this stage. Health
workers should understand that, to prevent engorgement of the
-La ~he League Internatlona1e
95U MinneapoU. Avenue
Fl'a.nklfn Park. ntinola fOUl
U. S.A.
breasts, it is important to empty the breasts completely and re-

gularly. The baby must suck at least one breast until it is empty.
If some fullness still remains in the other, it should be carefully
emptied manually by the mother or nurse. The baby starts with
alternate breasts at alternate feeds. If engorgement occurs, it is
liable to impair permanently the milk supply, and there is danger
of infection and breast abscess.
To prevent infection, care of the nipples is important. They
should be kept dry and clean, and a daily bath and clean clothes
are essential. Sore nipples should be gently massaged with lano-
line, and if very painful, suckling should be stopped on the affected
side and the milk expressed regularly until the sore is healed. Bet-
ter still, if a nipple shield is available, this can be worn to protect
the fissure, allowing suckling to continue.
The frequency of feeding can vary and need not follow an exact
time schedule. Normally, young infants demand suckling about
every 3-4 hours. More frequent suckling is likely to exhaust the
mother. Feeding may be required twice overnight at first, total-
ling about 8 feeds daily, but should be reduced to six when possible.
A baby normally needs about 5-6 feeds daily at two months, and
3-5 feeds at six months.
Underfeeding is the principal hazard to watch for. A typical
pattern is that after prolonged suckling, the baby falls asleep ex-
hausted, and wakes up crying with hunger after an hour or so, and
when the breast does not satisfy him, he screams and struggles.·
Constipation is frequent, or there may be frequent small dark green
stools (so-called "hunger stool"). None of these is specific for
underfeeding however; green stools may be quite normal. The
principal sign is failure to gain weight adequately. The baby
should double his birthweight by 5-6 months and treble it by 12
months. Average figures are:
-.verage monthly Av~rage Wtighl (kg)
A9' weight gain Actual Desirable
1·3 months 700 9 monthly 4-5 4-5

4·6 manths bOO 9 monthly 5-6 6-7
7·9 months 400 IJ monthl y 6-7 8-9
10 • 12 monlhs 300 9 monthly 7-8 9-10
·Screaming immediately after breaatfeeding may indicate overteedina. Screaming about ".
hours after the evening teed is characteristie of '·collc. U IJQppoaedly due to excessive fermen-
tation of Iactoae tn breaetled babies. Thi. condition disappears after a few weeks.
However, some quite normal babies grow much faster or slower

than this. A contented baby is unlikely to be underfed, and a dis-
contented baby is more likely to be underfed than overfed.
BretUltmilk BUpplll is helped if the mother can let the child suck
frequently, and can herself have plenty of fluids and adequate rest
every day, including as restful a night's sleep as possible.
Complementary feeding is necessary only if the breastmilk sup-
ply is inadequate in the first three months despite the above mea-
sures. After breastfeeding, additional milk, prepared as indicated
in the next section, is giVeD using (preferably) a cup and spoon.
Usually, this complement is most needed after the evening feed.
For countries in the Region where protein-rich foods are scarce
and expensive relative to the people's purchasing power, it is re-
commended that breastfeeding be maintained for at least 12
months, and beyond that as long as there is a reasonable supply of
breastmilk. This is however subject to the conditions that ade-
quate supplementary feeding must be begun by 6 months, and that
the mother's health needs to be safeguarded by a diet which is
adequate in calories and all nutrients (see section 8).
1.4 Artificial feeding

This is adopted only when breastfeeding is unsuccessful Ar-
tificial feeding is difficult for the mother, costly for the father, and
dangerous for the baby because of faulty dilution or hygiene. Even
inadequate breastfeeding is- preferable to bottle feeding.
In a good general hospital in this Region a few years ago, it
was found that some sixteen babies had to be taken off the breast
for a variety of reasons during hospitalization of the mother. It
was found, on follow-up the next year, that fourteen of these
babies had died of diarrhoea. A bottle may be a death-sentence
for a baby.
For artificial feeding, fresh milk may be used if available. but
should be boiled. For infants below 3 months, it may be diluted
with 1 part of water to 2 parts of milk. provided that 2 large
tablespoons of sugar are added per pint (4 tablespoons per litre).
But it should not be diluted 1 :1, and no dilution is really necessary
or desirable in most cases. Milk powder is made up with 5 large
tablespoons per half liter of boiled water. The milk powder is
placed on the surface of the cooled water and whisked vigorously
with a beater or fork (previously boiled) until fully dissolved.

The quantity required is approximately 150 cc per kg of body
weight ·(2i fluid ounces per lb) per day, divided among several
feeds.
If bottles are used, the holes in the teat should be burned with
a red-hot needle and should be large enough to allow the milk to
flow out drop by drop. Powdered milk should be strained after
making it up; the strainer should be boiled beforehand. The baby
should be able to take the whole feed in about 10 minutes. Im-
mediately after the feed, the bottle should be emptied and cleaned
and the teat cleaned before the milk dries in them; afterwards they
are boiled. Milk left over from the feed should not be offered to
the baby again; bacteria will breed in it in the meantime. Boiled
water may be kept ready in a thermos flask, but not milk. The
baby should be held comfortably while, feeding' and afterwards held
upright for a short time in case he has "wind".
The practice of feeding a baby from a bottle propped up on a
pillow carries a very high mortality, through inhalation of milk.
A teat which is worn out or has unduly large holes introduces the
same risk.
With unsophisticated mothers, a moderately underfed baby will
have a better chance of survival than a bottle-fed one. Comple-
mentary feeding by cup and spoon, rather than by bottle, is prefer-
able where necessary. Evaporated milk (diluted with an equal
amount of boiled water) can replace fresh milk. Sweetened con-
densed milk should be avoided. With all forms of milk other than
breastmilk, vitamin C is needed, and can usually be supplied from
fruit juices or scraped fruit.
The principal dangers in all artificial feeding are poor hygiene
and over-dilution.
1.5 Supplementary feeding of infants
1.5.1 Timetable
Sometimes supplementary feeding is begun early - even as
early as the first day of life - with soft-cooked rice, tubers or
bananas. This practice is not recommended, because of the risks
of inhalation and infection. The mother's milk is normally suf-
ficient for at least the first 3 months.
Usually, however, supplementary feeding is too little, too late,

and too low in protein and vitamin A. Common practices are to
wait until the baby's first teeth (the lower incisors) erupt, about
7-8 months of age, or until his first birthday, or even until lactation
is terminated at 18-24 months. The child may be considered unable
to eat, chew or digest solid food before then. These are fallacies.
The gums are quite firm enough to allow mastication of soft foods,
even at 4 months. The practice of premasticating various foods
was quite widespread forPlerly in many countries of the Region.
This has the advantage of softening the food, and it is not harmful
bacteriologically, since the infant is anyway constantly exposed to
all the mother's bacteria from the first days of life. However, this
practice seems to be disappearing spontaneously.
Supplementary feeding should normally begin at three or four
months ot age. This is partly because breastmilk is liable to become
inadequate for all the infant's needs between three and six months
of age, and partly to accustom him to a good variety of soft and
semi-solid, easily digestible foods with different tastes, textures
and nutritive values by six months. Some malnutrition is always
bound to arise if supplementary feeding is delayed beyond this age,
and the longer it is delayed, the more difficult it is to introduce new
foods. This also applies if only a starchy staple is given. As early
as possible a small but balanced meal should be given, once daily at
first, after breast feeding, and uS\lally protein-rich food and yellow
or green leafy vegetable. Reasonably early, adequate and balanced
supplementary feeding is probably the most important single direct
measure throughout the Region to improve nutrition. Establish-
ment of an adequate and balanced diet by six months should mini-
mise malnutrition in the second half of infancy and also among tod-
dlers.
Special care of utensils and thorough washing of hands before
handling food and feeding the baby is necessary. Proper storage
and handling of foods not cooked immediately before eating, such .
as powdered milk, ground peanuts, etc., is essential. Hints on how
to introduce new foods are given overleaf.
Giving the staple food alone is not enough. Suitable foods and
times at which to begin them are summarized in the following tables
and pages.
SCHEDULE OF SUPPLEMENTARY FEEDING FOR INFANTS C2 to 6 month~ IN ADDITION T() BREASTMILK
ENERGY FO()DS REGULATING FO()GS BODY·BUILDING F()OGS (ALTERNATIVESI'

AGE Ric! & other Fruits Veoetables Egg fish Dried beans or drled·bean Peanuts Sol'bton.
to begin feeding ureals flour
Vegetabl • . .tor
in which .reen/
yellow Yf9flables
2 months Rlc~ water were cooked
C60 days -rl I t~sp. + Cl tb.p. +1
3 months Thin rlu grUfI
or porridge
scraped yellow
III.... zc::
2·4 tbsp. 'h·2 tbsp.
-~
4 months Thicker porridge scraped banana, Yellow . _ po- boil~ bollrd 112·1 tbsp. (dry amU
3·6 Ibsp. talo or pumptln .gg 'h Cal boIlrd till soft lhon
or """"yo
manggo, C_sIII boll~ 14. 111 Ibsp added 10 boiled rice or
2·4 tbsp. mashed a vegetable; mashed & o
strained, strained; or (bl made Into z
'h·1 tbsp. flour and cooked wltll rice
flour. (Reclpo lib f;l
5 ",o"ths Sam. lime Samo - 2·3 tbsp. limo 11m. 1·2 Ibsp. Bakrd '" flooly poundrd 0' <
4·8 tbsp. 4-6 Ibsp. Add bollrd,
mashed, strained
'h 'h·1
tbsp.
(dry amount)
same
ground, fed with mashed
banana (Recipe 12) c::
t"'
INfy greens 1·2 Ibsp. of ,,,jpo Z
(l tbsp.1
6 months Thicker jlOlTldge
6·9 Ibsp.
same, mashed
or thinly
sliced,
..me
4 tbop. ...
I whole sam.
1 Ibsp.
2 tbsp.
(dry amount)
sam.
same
2 tbop .
ot retip'
Boiled & ground; Fed wlln
rice or vegetable
(Recipe: 6)1t I-Z tbsp. E
6·B Ibsp.
-- -- ~
a Body-building foods are IIOt all expected to be ginn in OM day. For Children over 3 months, Ollt body-building food may
be 9iVM alone, alternating with the others.
b These and other recipes are liven in- Annex VIJ.A
SCHEDULE or SUPPLEMENTARY FEEDING FOR INFANTS (7·12 MONTHSI IN ADDITION TO BREASTMILK
~
;;J
AGE BODY·BUILDING FOODS
lO begin fHjin9 ENERGY F()ODS REGULATING FDODS
EOg, fi5ft, poultry, meat, mung-bean flour or mashed boiled dried beans
7·9 thick rice gruel or Pumpkin (sqUish), yellow sweet potato, 4 tbsp. All SOy and ponut recipes, 1-2 tbsp. (raw IngrtdlenU) ~
months porridge Leafy gretns, boiled and mashed, l/a·l 'tbsp.
vellow fruits, 8 tbsp.
Same; ma~hed, only if necessary for acceptance
I
10·12 Family rice Yellow fruits and vegetables, saft'll! amounts
months Leaf), greens! bOiled, mashtd onl)' If nassal')' for i
acceptance; ·2 tbSII. I
0,...
12 nlonths F u I I f ami I y mea I
....
o
Q1
- - - - -
FIGURE •.•
SIMPLE EQUIPMENT FOR GRINDING CEREALS AND LEGUMES
"
COMMERCIAL CORN GRINDER
STONE GRINDER
MORTAR and PESTLE

INTRODUONG TIlE BABY TO SUPPLEMENTARY FOODS
Usually the mothers !mow very well how to introduce new foods, which
present no problem if they are properly ae1eeted and properly prepared.
Health workers should not over-emphalize such problema. But occasionally
the following information may be useful.
1. How to illt1'odue. A _ food

a. Give half a teaspoonful of the prepared new food on the first occasion.
b. Give the new food before breast or bottle feeding.
Co The second trial of the new food should be given a day or 80 later,
and the quantity increased to one teaspoonful.
d. The amount and the variety of new foods should be increaaeq slowly,
until the child shows he likes the uew foods and has become accustomed
to their flavour and consistenC)'.
e. New foods should be introduced one at a time, waiting several days
before another is added.
f. Once the child has acquired a taste for a new food, it should be given
fairly frequently 80 that the liking for the food ia not lost.
fl. What tM motA.,. x.eda to b. AWAr. of 1IIAn mtrodueiftg BUfl1.I'--tG",

foods
a. The baby may spit out the new food during his ftrat experience with
it; new foods will be different in both taste and feel.
b. Some babies are alow to accept new innovations; some have a general
dislike of even minor variations from the regular routine of feeding.
c. When additional new foods are introduced, the baby may refuse the
new food; or may not take the full amount offered.
d. Forcing a baby to eat may cause him to reject the food altogether,
or not take the full amount.
e. As supplementary foods increase in variety, the child will take more
interest in hiB food and also in his surroundings and his attendants.
This interest is to be encourapd by:
i. letting him see the new food;
ii. allowing him to bandle the feeding bowl to see what it is like and
how it feels;
iii. giviD&' him a spoon and encouragiD&' him to feed himself by the
eighth or ninth month;
iv. Not 'CIi8CQuragiD&' hili early messy efforts, reeognising that this
helps the baby to be able to manap his feeding BOGner by him-

self;
v. realizing that sometimes a child will refuse food because he wants
to take it himaelf and not to be fed - the solution may be for
the mother and the chUd both to have SpooDS and to spoon up
the food alternately;
vi. permitting the baby to try to pick up some food and carry it to his
mouth, when more solid foods are being introdueed.
£. It is important to watch for changes in the baby's stool. If the stools
are loose and bowel movements are more frequent, she may reduce the
feeding of the last newly introduced food. If these symptoms continue
or are getting worse, or if skin eruptions occur, she should seek medical
advice.
g. Food hygiene;
i. Always give cooked foods, or fruits freshly peeled, e.g. banana.
ii. Feed freshly cooked foods.
iii. Protect the foods from flies.
iv. Left-over foods should not be given to babies.
v. Cleanliness of hands and utensils;
(a) Wash hands with soap before preparing foods and feeding.
(Baby's hands too.)
(b) Utensils should be separated from pneral use.
(c) Keep utensils in a clean plaee.
(d) Chopping board, pan, dishes and other equipment should be
washed immediately after being used.
(e) Boil utensils for at least three minutes after each use and
keep them dry and covered.
There are many bacteria present on the mother's hands and breasts but
most of these are a normal and well tolerated part of the baby's environment
from the first day of life onwards. The danger lies more in pathogenic bac-
teria from extraneous sources such as markets, or foods contaminated by
flies.
3. Food selection
a. Use green leafy vegetables which are freshly produced (in season),
if possible.
b. Select fresh eggs, fish and meat.
c. If no animal food is available use dried beans instead, or in greater
quantity.
d. Use yellow fruits when available.
A balanced meal contains each of these categories, besides the staple food.
Two months
Liquids may be introduced, using cup and spoon:
(a) rice water; or preferably -
(b) vegetable-water, in which green leafy or yellow vegetables
have been cooked. This will contain some protein and other
'Vitamins and minerals besides the carotene (which gives it
the yellow colour).
Formerly, the juice of citrus fruits was advocated. Often this
is accepted only if it is sweetened or diluted. This is safe only if
boiled sugar-water is used for dilution, and sterilized containers are
used. Under these circumstances and where citrus fruits and
sugar are readily available and cheap, this practice is sound. But
otherwise, it is troublesome and dangerous. .
Three months
(a) Scraped banana with yellow core. Remove the fibrous
strands on the outer surface of the banana and scrape it with the
back of a teaspoon run lengthwise along the banana. If some
fibres are accidentally included, strain.
(b) The dominant staple is usually the first or second food
given, but sometimes rice may be preferred over maize or tuber
staples; sago, starchy flours (e.g., cornflour, arrowroot, etc.) are
sometimes preferred, but are much poorer. Thin gruel or porridge
is made by boiling rice with an'excess of water until it is mushy.
This should be strained, i.e., passed through a fine-meshed sieve
made of wire or cloth. Alternatively, freshly pounded or ground
rice flour can be boiled to make a thin porridge, which does not
need to be strained. This is started once daily, usually before the
evening feed.
Four months
Scraped papaya or manggo (carefully avoiding fibres) as well
as banana.
Porridge can be thicker and need not be strained. Twice daily.
Boiled, mashed and strained yellow sweet potato or pumpkin
(squash).
Dried beans, boiled till soft, mashed, strained, added to rice por-
ridge or strained vegetables.
Fishflour and/or dried bean flour with rice flour, made as por-
ridge.
Soft-boiled egg (one quarter) or broiled fish (tender).
The early introduction of beans, fish, and egg are the second
most practical and dire.ct way to improve nutrition in the Region.
Five months
Porridge - thicker and more; 2-3 times daily.
Ground peanut with mashed banana (see p. 318).
(This may be introduced earlier, at 8-4 months, but should be
diluted with a little water or milk for easy acceptance.)
N.B. Use only fresh mature .peanuts free of moulds.
Add boiled, mashed, strained leafy greens to porridge. Other
vegetables, beans, fish preparation, egg and fruits as above; in-
creased quantities.
Six months
Thick porridge.
Fruits - mashed or thinly sliced.
Whole egg.
Add soybeans - boiled, ground, mashed, mixed with rice or
vegetables.
. Other vegetables, beans, and fish pteparations as above; twice
daily.
Seven to nine months
Thick porridge or softly cooked rice.
Soft vegetables need not be mashed; soft leafy greens, mashed
but need not be strained.
Boiled beans, mashed but need not be strained.
Fruits as above. May start soft meats (especially liver).
Ten to twelve months
May share family rice, vegetables including leafy greens and
dried bean preparations. By twelve months, should be able to take
all of the family foods. Remember the youngest member needs
the largest share of protein-rich foods.
In general, one supplementary feed will be adequate from 8-
4 months, two from 5-6 months, and thereafter three or four
small meals daily will probably be acceptable. The baby is ready
for weaning when he can take adequate amounts of the full range
of family foods, but prolonged breast-feeding beyond 12 months
wiII supply invaluable extra nutrients at low cost.
1.5.2 Animal protcjn foods

Formerly, it was thought that milk, meat and eggs were essen-
tial for a balanced diet. Since these foods are seldom available
and are too costly for most of the needy infants in the Region, it
is fortunate that there are adequate alternatives. When available,
their use is recommended as follows:
(a) Meat. Use red soft meat from only recently and hygien-
ically slaughtered healthy animals. The liver (especially chicken),
if immediately cooked and given to infants, is strongly recommend-
ed because it is such a rich source of many nutrients. Canned meat
is usually safer than fresh meat, more digestible, and just as nutri-
tious.
(b) Milk may be given as a supplementary food. If fresh, it
should be boiled unless properly pasteurized. If powdered, it is
usually best given with solid foods, i.e., sprinkled on and mixed in
smoothly with mashed banana, or rice porridge. Condensed milk
cannot be safely stored for more than 24 hours after the can is
opened, and evaporated milk for only a few hours.
Powdered milks are preferable and cheapest, but if liquid tin-
ned milk is strongly preferred, it should always be evaporated milk,
and never condensed milk.
(c) Fish.u. 160. 179. 209 Fish is the most readily available and
cheap form of animal protein in many parts of the Region,especially
isolated areas and small islands where milk and legumes are
often scarce. Small soft fish eaten whole such as anchovies (Phil-
ippines - dilis; Malaysia - ikan bilis) are extremely rich in pro-
tein and calcium. Standard recipes can hardly be put forward but
the following general principles apply:
(i) Large fish. Perhaps the simplest method, already used
in some places, is for the mother to take a portion of any fish being
cooked for the family and peel off some of the fleshy part, and feed
it directly to the baby with her fingers (clean), alone or preferably
together with any other food the baby will take, e.g., rice (por-
ridge, or ordinary cooked rice). For infants aged 4-6 months, the
fish should be mashed with a fork or between the fingers; for older
infants this should be unnecessary. Fresh fish which has been
cooked soon after killing and cleaning, and not contaminated by
flies, is best. However properly dried or smoked fish which has
not been allowed to rot nor exposed to flies, can be cooked until
soft and handled in the same way, and likewise shellfish. Tinned
(canned) fish is very suitable and it has the advantage of being

safer hygienically. Sometimes it is cheaper. per gram of protein,
than fresh fish. It should not be kept for any length of time after
opening the tin.
(ii) Small dried fish and small dried shrimps, if hygienic- .
ally prepared and stored, can be boiled and then mashed (and siev-
ed for 4-6 months infants), then mixed with any porridge, soup
or other food being prepared. Fermented fish pastes such as ba-
goong (Philippines), blachan (Malaysia) can also be recommended
for infants if properly cooked, mashed and sieved; bacteriological
tests have shown them to be relatively safe. They are so salty
that only small quantities can be used, but even so, these are use-
ful adjuncts to improve the appetite and the protein quality as well
as supplying additional minerals and vitamins.
(iii) Fish flour. This can be made from large dried fish
as follows: remove the skin and head, and shred the flesh from
the bones. Toast very lightly in a pan, then pound to a fine
flour, removing any bones missed. Repeat the toasting and pound-
ing if necessary, but toasting impairs the protein quality. Store
in an air-tight container.
Small dried fish and shrimps are usually cheaper and more
nutritious. They can be handled in the same way - without
removing bones, etc., if they are small and soft enough. Instead
of pounding, a grinder such as that used for legumes (see p. 106)
can be used, especially for demonstration purposes and for com-
munity feeding.
(iv) Recipes. In general, small dried or fermented fish or
shrimps prepared as in (ii) or flour prepared as in (iii) can be
used instead of milk powder in the recipes (Annex VilA), for peo-
ple to whom the taste of fish is acceptable - which means in prac-
tically all countries in this Region. Even a small quantity of fish
preparation will substantiaIly improve the protein value of a vege-
table mixture such as the dried bean/rice porridge. This is of
particular importance for non-breastfed infants.
The preparations of mashed fish are suitable beyond 6
months; if also sieved, or if fish flour is used, they are suitable
from 4 months of age.
1.5.3 Vegetable protein*
Research has shown that balanced mixtures of vegetable pro-
*For simple recipes, aft Annex VUA.
tein are just as good as animal protein. Furthermore, when diets

are su1Jlcent in calories but marginal in protein, even second-elass
proteins are apparently utilized more efficiently in the poorly-
nourished than in the well-nourished individual.
The vegetable foods rich in protein are chiefly the pulses or
dried grain legumes such as mung beans or green gram, soybeans
and peanuts. All these need special preparation for infants. The
main methods for dried beans are:
(a) prolonged boiling, and mashing for infants below about ten
months (and sieving for infants below six months) ; or
(b) grinding or pounding the dried beans to a flour, then ma-
king porridge together with rice flour, etc.
For peanuts, gentle roasting is necessary and then grinding or
pounding to make a paste or butter, to be mixed with banana, sweet
potato, etc~b Only mature well-dried peanuts free of mould should
be used. Commercial peanut butter contains other oils not well to-
lerated by infants. Thorough grinding is the secret. A perfectly
fine smooth paste or butter must be obtained in the case of pea-
nuts, or flour in the case of dried beans. Otherwise there may be
loose bowel motions. If this occurs, check the fineness of the
grinding, and if necessary reduce the quantity given for the time
being.
Coconut milk can also be used for infants in small amount, but
the age at which this can be.begun and the amounts tolerated are
not known, nor with which foods it is best to combine the coco-
nut milk. Research is needed on this question. Coconut milk is
made by grating the mature coconut meat, putting it in a sieve,
pouring water on it and squeezing. Thick coconut milk contains
about 2.5% protein. It should only be used fresh, and preferably
mixed with other foods such as mashed banana or rice porridge,
rice/bean porridge, etc.
1.5.4 Leafy greelUl and yellow vegetables/fruit
The classical idea was that fruits are the symbols of "good nut-
rition". While they are usually good sources of vitamin C, they are
often poor in other nutrients; however, papaya, manggo, canta-
loupe (Cucumis mew), persimmon (DWSpyTOS kaki) and tiesa (Lu-
cuma nervosa) supply carotene also. Most fruits contain useful
amounts of iron.
Food composition tables show that dark green leafy vegetables
are extraordinarily rich in many nutrients. Many of them are

quite useful as sources of protein. (about 5%) but more specific-
ally they are rich in carotene, iron, sometimes calcium, thiamine,
riboflavin, and ascorbic acid.
Yellow vegetables such as pumpkin, yellow sweet potato and
carrot are easily .prepared for infants. Yellow sweet potato is
usually the cheapest. .The carrot is by ·far the richest in carotene.
They may be mashed with a fork. These and leafy greens are also
easily ground and sieved using light-weight hand-grinders readily
available commercially. Sieving is advised for infants below 6
months. Again, some discolouration of the stools may occur, but
is not harmful; the mothers should be forewarned and reassured.
1.6 Special problem8
Difficulties in breastfeeding may be encountered for a variety
of reasons.
Twins are prone to malnutrition because their birthweight is
usually low and the mother's milk seldom sufficient for both.
Complementary feeding is usually necessary from the beginning,
and/or early supplementary feeding. Extra iron is also needed.
Premature infants have low birth weight (below 2 kg). Breast-
feeding should be frequent. Those who cannot suck are usually
under 1.5 kg and have a bad prognosis. Feeding is with express-
ed breastmilk using a teaspoon or pipette if the child can swallow;
if not, gavage feeding is necessary. All premature infants are
prone to rickets, anaemia and infections. They should be given
supplements of iron and vitamins.
A problem sometimes encountered in remote areas is the young
infant whose mother has died or has no milk supply. Sometimes
another nursing mother or even a grandmother can help. If not,
artificial milk should be given. If'this is not available, the foods
which will be of most value are--
(a) rice/dried bean porridge incorporating some fish;
(b) peanut/banana mash;
(c) coconut cream or milk,in limited amounts, with the above;
(d) soya milk or soya prepared as on p. 314,
It has been proved by practical experience that it is possible to
feed a baby from birth to six months entirely on coconut products. 21
1.7 Toddlers
The foundation of good n ..trition for the toddler must be laid
with an adequate and balanced diet in the second half of infancy.

The calorie requirements are more easily met than the protein re-
quirements in this age group. Annex II shows that the average
daily requirements (safe practical allowances) for an average child
of 1-3 years, taken as weighing 13.5 kg, are:
Calories = 1300
Protein (reference) 14.3 g
N Dp Cal % = 7.0*
A 12-month child weighing 10 kg and who is still taking 400
ml breastmilk daily will be able to meet his caloric requirements
(approximately 1000 Cals) with reasonable amounts of the com-
mon staples as shown below, but the N Dp Cal % will be inade-
quate:
Approx. amount required N Dp Cal %
Wheat 200 g 6.6
Rice or maize 200 g 6.0
Sweet potato 600 g 4.1
Cassava flour 200 g 3.0
This shows up the vulnerable position of infants weaned on to
tuber-staple diets, and the same goes for plantains. However, all
these staples obviously .need some supplementation with protein-
rich foods to raise the N Dp Cal % to 7.0, and much more if the
child is already weaned.
A guide to the composition of diets adequate in protein for
ON Dp Cal % meaft~ ··."et "letary protein calorie2! per cent", This is • eort of protein-caloriE
score. The basic idea i,l not diffieult. A person', diet and each meal should contain not merely 8
certain amount of pl'Qtein and number of calories. but a certain minimum pereentaae of total
calories should come from protein. The percentage of total ealoriea derived from protein
i.ll therefore given in the food composition tables, Table A.t.4. Annex I ("'" eala from protein").
However. the percentage of calories fimn protein or protein-calorie ratio in a food or
meal gives only a fint approximation to the protein value of a food or dieL Allowance
should be made for suboptimal quality and utilization of different proteins. Only breaatmUk
and egg have ideal quality (100%). In breastmilk. 8~ of the calorie. come from protein,
and tbil' i. of Ideal type. therefore N Dp Cal % ia the aame 811 the protein ealories %, I.e.
8.0%. Incidentally, th .. level is also therefore the required protein-calorie ratio (technically
called N Dp Cal ") for an Infant. For olckor children the reQuired protein-ealorie ratio or
percentage is leas. declining to 5% in adult. (Me p. 229).
For other proteins. thll! protein score or net protein utilization factor lift usually between
about 40 and 90%. The percentage of calorie. derived from protein in the food or meal must
be multiplied by this further percentage factor to wet- its tid protein-calorie ratio. i.e••
N Dp Cal '%. For example. in rice. 6.7,(% of the calories come from protein; the protein scorE
is 76%; therefore the net protein-ealorie !'Rtio Is 6.74.x 76% .:= 5.1% (approx.). Actually a
chart should be used to calculate N Dp Cal ?it from the protein score and protein-ealorie ratio
as shown in Figure A.Z.l (Annex II). or elsr a special standard vallle of NPU (NPU It)
Ihould be :used: this value is not available tor JnOfI't toods yet..
Tbe non-speeialillt need only understand that the net prote-in-ca&ol'ie ratio. or aetuany
N DJ) Cal 1%. Ihould· be between 810 and 6'Y., tor an meals. depending on the age ot the
consumer. The table above. and the food conspu.,itloll tables (D. 21S). show how Inadequate
arc many of the ~mmon fooda and hence why the,. need. llUJ)piementation with foods havill8
.. higher protein-ealorie ratio.
For the specialist In nutrition. Annex II t.rlel to aplain in more detaU bow the calcula-
tions are made and applied.
the toddler no longer receiving human milk is shown in Table 4.4.

Children 1-2 years old need about 5 small meals daily; aged 2-3,
4 meals; after 3 years, 3 meals. But for purposes of calculation, a
child can be considered to need about three main meals daily of
about 300-400 Calories each. With each meal therefore, the sup-
plementation needed for the principal staples is given (approxi-
mately) in the following table:
TABLE 4.4
AMOUNTS OF FOODSTUFFS REQUIRED FOR A BALANCED DIET
A. Food mixtures each supplying 360 Calories

and a protein value of NDpCal .8 per cent
Sweet Cassava
Wheat Rice Maize potato Taro flour
Egg Egg
Fish Fish
Chicken Chicken
W. M. P. W.M.P.
S. M. P. S. M. P.
Soybean Soybean
Wheat Rice Maize Sweet Taro Cassava
potato flour
S60 Calories is an appropriate amount for one meal for a child in its second
year. In addition to the main components of the diet, small quantities of
vegetables and fruits should also be given.
Notes: 1. All figures in the top left comer of each square indieate the
amount of staple food (in grama)
2. All figures in the bottom right hand ("Orner of each square indi-
cate minimum amount of protein food necessary (in grama)
3. All weights are in grama of edible portions
4. Fish = fresh sea fillet •
6. W.M.P. = whole milk powder (grama x 8 =mls. liquid eow'8 milk)
6. S.M.P. = Dimmed milk powder
7. In practice all weights should be eonverted to quantitative •
measure in local cups, tins, spoons, ..te.
8. If fresh cassava is used the quantities given for flour should be
trebled
•
9. Other dried beans would be required in about double the quantity
specified for soybean, because of inferior quality.
B. Protein supplements needed per meal of different staple foods
(in terms of household measures)
Sweet
Ri~e Maize Potato Taro
with with with with
One ~ egg i egg I egg i egg
I mbf ~ mb!" 1 mb! 1 mbf
of fish fish fish fish
1 mbf 1 mb! U mbf 1 mbf
these chicken chicken chicken chicken
2 mbf 1!. mb! H mbf g mb!
items soybeans soybeans soybeans soybeans
1 mbf = 1 matchboxful = 30 g fresh fish or chieken or 15 g drIed soybeans
The toddler's position in the family is most vulnerable be-

cause--
(a) If there is also an infant, the latter is likely to receive more
of the mother's attention.
(b) If there are protein-rich foods, he is liable to receive a
small share, in proportion to his small size, on the false supposition
that his requirements are correspondingly small.
(c) He is likely to be left to pick for himself from a common
dish or dishes, and he may be slow or may not select the more pro-
tective foods! The older child may be more aware of hunger, and
that food will satisfy him; the young toddler may not realize he
needs food, or may be unable to get it.
(d) The breastmilk supply may be suddenly withdrawn from
him for social reasons or because the mother becomes pregnant
again. Loss of the breastmilk drastically lowers the N Dp Cal %,
especially on tuber-based diets, and is the reason why kwashiorkor
usually arises after cessation of breastfeeding. For this reason, the
weaning process should be gradual, and breastfeeding should be ter-
minated only after adequate introduction of supplementary foods.
(e) Employment of the mother, either in urban communities, or
for agricultural work, during which the toddlers a.re commonly left
in the care of the grandmother or elder siblings who can seldom
cater to their needs adequately.
Besides the protein-rich foods, the green leafy vegetables are
particularly likely to be neglected in the diet of the toddler. This
is a major factor predisposing to vitamin A and iron deficiencies
which are relatively. prevalent among toddlers, especially in the
second year of life. These circumstances apply even in sophisti-
cated families, and sometimes more so. The child often rejects
these vegetables. The root of this trouble lies usually in the

mother's failure to introduce them early enough. The emphasis
returns therefore to proper supplementary feeding in infancy,
pregnancy and lactation - her ideas about a proper diet for ber-
self and the family 88 a whole.
2. SCHOOL AGE
2.1 Normal and retarded development
Schoolchildren are relatively accessible for examination and
many data on their growth are available. Sueh data are useful
indicators of community nutritional status.
During the early school years a steady rate of growth is nor-
mally maintained, but at about 10-12 years a pre-adolescent growth
spurt begins, usually with rapid increase in weight at first,
followed by rapid increase in height. The age at which this occurs
is affected by nutritional and possibly other factors.19Z
Two kinds of study of growth are possible:
(a) longitudinal, where a single group ("cohort") of subjects
is followed over a period of years, so that a complete record of each
child's development and a growth chart for each child is available;
(b) cross-sectional, in which averages of weight and height,
etc., are obtained for children of particular successive age groups.
These principal methods are applicable to children of all ages,
not merely school age. An introduction is given here in order to
discuss the seasonal influences and other fluctuations which affect
growth. These seasonal influences tend to be more obvious in
adults and schoolchildren, but may apply to infants and toddlers
also.
Longitudinal studies require painstaking effort over a period of
years but yield the most useful data. In cross-sectional stUdies,
the fact that growth spurts occur at different ages in different
subjects means that group averages show only a gradual accelera-
tion, which may conceal the dramatic growth developments which
take place in individuals just before and during adolescence; this
is discussed by Tanner. 19Z In the same way, retardation of growth
in infants and toddlers may be 'smoothed out' because it occurs at
a different age in different children. Nevertheless, cross-sectional
data in large numbers of children can often be more easily obtained
and are extremely useful.
Because of the marked differences at school age between boys

and girls, especially the earlier onset of the pre-adQlescent spurt in
girls (about 10 years) than boys (about 12 years), the data for
the two sexes should be analyzed separately.
A very convenient age-group to take for growth studies is chil-
dren of seven years, i.e. those entering Grade I. (Studies among
infants and toddlers are however equally or more important.)
If possible, not only should the weight and height status be
assessed at a given point in time, but the rates of growth should be
measured over an interval - preferably a 12-month interval. In
addition, 3-monthly measurements may be advisable, to assess
seasonal factors (discussed below). A simplified scheme is to
follow the 7-year-olds just entering school in this way, at 3-monthly
intervals for 12 months.
Besides weight and height, skinfold thickness is particularly
useful, being a direct indicator of caloric status. Weight and
height reflect mainly caloric status, while height may be influenced
more importantly by protein status. Further details are given
in Ch. V.
2.2 Food supply and shortages
A cross-sectional survey made in one particular year may not
necessarily reflect the prevailing general situation. Drought,
flood, or crop failures from other causes, or a wave of inflation and
unemployment, may hinder normal development. Annual checks
over several years are really needed therefore. Furthermore, the
condition at anyone time depends on the whole previous history
of each child. A previous episode of severe deprivation may leave
a permanent mark in the child's developmental histo.ry. Finally,
seasonal factors also influence growth. Three-monthly measure-
ments are required to assess seasonal influences.''' Sometimes
there is a period of relative food shortage ("hungry season")
before harvest-time, i.e., during the rainy season before the main
food crop has matured. This can cause an interval of stationary
weight or even weight loss, under conditions of relatively severe
shortage."oar Such severe shortages are not usual in this Region.
In this Region, nutritional inadequacy in the school age is pro-
bably mainly a matter of chronically insufficient calories, usually
because there is simply insufficient food in and for the household.
This is due to low agricultural production and/or low income,
tenancy problems, indebtedness, poverty, and other social, economic

and agricultural factors.
Dietary surveys commonly indicate surprisingly low intakes? 23
of the order of 1000 Calories in pre-school age children and 1500
Calories in school-age children. It is not surprising therefore that
weight and height are commonly retarded by about two years com-
pared with international standards.
A decreasing growth rate may be observed by careful longi-
tudinal studies in children during the school term. The conditions
under which the children live at these times, whether at home, with
relatives, or in the school itself, may not allow provision of ade-
quate or regular meals. Sometimes even the smallest children must
cook their own food. They may be too small to reach the heating
facilities provided, and are at a disadvantage in other ways as
well. But even in the most advanced communities. children living
in schools often lose weight progressively throughout the term. Of
course, this may be because they gained excessive weight during
the preceding holiday at home, through over-indulgence and dimi-
nished physical activity. Nevertheless, evidence of decreased
growth rate, or even loss of weight, especially affecting whole
groups, during school time, needs investigation of possible causes.
Children living at home whilst attending school may get insuf-
ficient food for several reasons. The child may have to walk
several kilometers between home and school; for this energy ex-
penditure his breakfast may be insufficient, especially when both
parents have to leave home early in the morning, which is often the
case in simple agricultural communities. A high proportion of
schoolchildren in the Region have no breakfast, at least in the
"hungry season". In some places the child may also arrive home
in the evening too late to participate in the family meal at that
time.
Children who walk to school in rural areas may have the oppor-
tunity of eating foods gathered on the way (growing wild).
Fruits, nuts, small fish and mollusC!! obtained in this way can be
important additions to the diet. Boys, more so than girls. usually
obtain these extra foods.
Because of these factors, some sort of school feeding is widely
recognized as necessary, and practised60a• 62f (gee p. 167).
On the other hand, there are some communities where nutri-
tional standards are known to have improved, resulting in steady
increases in the average weights and heights of children. The rate

of change is however slow, amounting sometimes to only 1-2 kg and
lesa than 5 cm over two or three decades. Since the changes to be
anticipated from nutritional improvement are slow to occur, they
require very accurate measurement, and careful assessment of
factors other than nutritional which may be responsible for the
changes.
2.3 Nutrition and associated conditions
The general effects of nutritional state on infections, and vice-
versa, are outlined elsewhere. There are however few data avail-
able on these associations in this Region. Anaemia is sometimes
severe among schoolchildren; besides poor diets, malaria, hook-
worm and other infections commonly play a part. Dental caries
and periodontal diseases are often highly prevalent. more so than
in the pre-school years, even to the exu,nt of interfering with pro-
per food intake. The common practice of taking snacks which are
sweet and sticky, or made of retined flour, promotes caries, espe-
cially in urban and semi-urban areas. Lack of toothbrushes or
the use of inadequate local substitutes is responsible for much
poor oral hygiene and periodontal disease.
Little is known of whether the state of nutrition affects intelli-
gence, but it seems obvious in the field that very poor nutrition
does impair concentration, learning ability and scholastic achieve-
ment. Even a simple mid-morning carbohydrate snack has been
found to improve concentration. Correlations between poor phy-
sical and mental development have lleen established in other partl!
of the world. 11. 18
3. VULNERABLE·ADULT GROUPS
3.1 Pregnant women
Maternal nutrition is discussed in detail elsewhere. 9 • 188 b. 80. 198.
2iOb. 282aComplex physiological adjustments occur, during both
pregnancy and lactation; in particular, there is apparently height-
ened absorption of energy, protein, iron, and possibly calcium and
other minerals and vitamins. The additional calories needed for
pregnancy are considerable, amounting to an additional 40,000
Calories during pregnancy or an increase of 20% daily during the
last trimester. This is approximately proportionate to the increase
in body weight. However, activities are usually curtailed in late
pregnancy. Dietary studies have shown that caloric intakes seldom
vary much from the customary level. There is no evidence that
this is harmful.
Th'3 usual weight increase in developing countries is much less
than in affluent societies78h being on average about 6 kg rather than
9-10 kg. Excessive weight gains predispose to toxaemia· of preg-
nancy (pre-eclampsia and eclampsia), and seems to be controllable
by limiting the calorie, salt and fluid intake. The weight should
be accurately measured each month during the first two trimesters,
then every two weeks, and finally, during the last month, weekly.
Gains of more than 2 kg in a month or 0.5 kg in a week call for
dietary restriction (calorie-wise), while maintaining a balanced
diet.
Other causes of oedema need to be considered in such circum-
stances, the commonest being nephritis. Beriberi needs consider-
ation, but it should be remembered that sensory and motor changes
in the lower limbs can be the result of pressure on the peripheral
nerves as they leave the pelvis, rather than beriberi. Anaemia may
be severe enough to lead to oedema. It is normal for the haemog-
lobin level to decline somewhat in the second half of pregnancy, but
haemoglobin levels below 10 g/100 ml (approximately 60,/0) may
be taken as definitely abnormal. Haemoglobin levels are commonly
taken by Tallquist method, which gives unreliable results, often
20'70 too low. Even the Sahli/Hellige method is unreliable in ~he
tropics because the comparator glass darkens slowly. If suffi-
cient iron tablets are available, routine supplementation is advised
during pregnancy in areas where anaemia is relatively prevalent.
Anaemia of the mother may also affect iron storage in the infant,
both before and after birth. Other diseases such as tuberculosis
may be exacerbated during pregnancy.
Well-nourished women store considerable amounts of nitrogen
during pregnancy, equivalent to about 3.5 kg of protein. of which
about one-third is estimated to be within the fop.tus and adnexae.
The remainder is stored in the liver, muscles and other maternal
tissues. Poorly nourished women undoubtedly store much less.
There is a tendency for oedema to appear unduly frequently in the
last trimester of pregnancy among women on very low protein
diets. Nevertheless it is remarkable how seldom protein deficiency
becomes manifest, probably because of heightened absorption of
protein, which has been clearly demonstrated in other animals. 9
It is not possible to define exactly the quantities of extra nut-
rients required. However, it is a safe rule to recommend doubling
.A condition which develops in the third trimester. ChflT:>.i'terized by oede-ma, relntive
hypertension and sometimes albuminuria. It should be rememhered that blood pr~"u~ is
commonly rather low in developing C()untrie5. and n pressure of 120 mm mercury By~tolic/80
mm diutoli~ may be abnormal.
the habitual intake of protein-rich foods (animals and portein) and
green leafy vegetables, say, an additional-
1 matchboxful (raw) of meat = 6 grams animal protein
or fish (30 g), or :
2 matchboxfuls (raw) dried 6 grams vegetable protein
legumes
! cup (raw) dark green 1200 mcg carotene (approx.)
leaf~ vegetable, or :
:\- cup (raw) yellow vegetable 600 mcg carotene (approx.)
(or yellow fruit)
These recommendations, together with the normal physiological
adjustments, should take care of the body's additional requirements.
An increase of 3000 mcg carotene daily from leafy vegetables dur-
ing the last month of pregnancy has been shown to cause a signifi-
cant increase in vitamin A levels in the cord blood. 78 • The additional
green leafy vegetables would also provide additional iron, folate
and vitamin K. The dried legumes such as green gram or soy-
beans would help to prevent protein, iron and calcium deficiency as
well as beriberi.
Very often, however, traditions and prejudices apply to mothers'
diets during pregnancy. A widespread belief is that a good intake
of animal foods will cause the baby to be too large and hence lead
to difficulties in delivery. The baby will not actually be notice-
ably larger, and the mother can be reassured that her better nut-
ritional state will help her to deliver the baby quicker (this has
been shown in the Philippines) and the baby will also be stronger.
Alternatively, or in addition, an augmented consumption of legumes
can be emphasized. Other widespread beliefs concern eggs - that
they may cause abortion, or cause the baby to be born a deaf-mute,
or with other abnormalities; that certain vegetables may cause
abortion or premature delivery, and so on. It is unlikely that the
mother will abandon a traditionally held belief. Health workers
should carefully classify all such beliefs as helpful, neutral or
harmful. Those which are helpful should be encouraged. Those
which are neutral should be left alone. Those which are harmful,
i.e.. prohibition of highly nutritious foods, should beeircumvented
by encouraging the use of alternative foods, or possibly by com-
bining them with other foods known to be acceptable.
3.2 Lactating women 210h.2S2••t
There is evidence of similar physiological adjustments and
heightened absorption of nutrients, as in pregnancy.8
Although thll official recommended additional allowance is 800

Calories daily62h, lactating women in the Region mostly take only a
little (about 10%) extra, or more commonly nothing at all beyond
their regular intake 163. If there were no adjustments, a steady
weight loss would be expected to occur throughQut lactation, and a
stepwise decline with increasing number of children. There is only
slight evidence of this sort, even in poorly nourished mothers 6c• 210B.
On the other. hand, there is sometimes evidence of protein
deficiency in the form of nutritional oedema among lactating
wo men 6a.d.". Although this is not widespread, it is an indication
that depletion of maternal tissues can become serious on very poor
diets, i.e., there are limits to the adjustments which can occur.
Calcium deficiency might be expected to be serious as a result
of calcium losses in milk. There is evidence that some calcium de-
pletion does occur, but there is no evidence that this is particularly
harmful, nor that the diet need be specifically increased in its pro-
portion of calcium. 91 . 210b. 2821
Milk production and composition are commonly believed to be
substantially independent of the mother's diet, except for the water-
soluble vitamins. The levels of vitamin B complex and C are read-
ily influenced by the maternal diet, and so also of calcium, appa-
rently. Vitamin A and carotene levels in milk, on the other hand,
do not respond so markedly to dietary increases. But there is evi-
dence of at least some response to increased carotene intakes: it has
been shown than an intake of about 3/4 cup of green leafy vege-
tables daily by the mother gives distinct improvement in the vita-
min A status of the child and helps prevent xerophthalmia. 7s•
Mothers should be willing to double their intakes of vegetables rich
in carotene if it is explained to them that this will help protect the
child's eyesight.
With regard to protein, tbe usual view is that breastmilk nitro-
gen is maintained at a constant level (about 1.2 g/100 ml) what-
ever the mother's diet. Normally, 20% of milk "protein" is non-
protein nitrogen. 32 However, there is evidence that the milk of
mothers from low socio-economic groups or on very low protein
diets does have less protein (about 0.8 g/100 m!) than normal. 6h.
47. 109 The protein component also varies in quality with the pro-
tein level of the mothers' diet. The protein portion consists of
curd and whey, and the curd/whey ratio shows a marked increase
in poorly nourished mothers.45 The physiological significance of
this is not known, however, and the amino acid composition remains
remarkably close to normal levels despite unbalanced diets.
The fat content and therefore calorie content of the milk are
apparently affected by the maternal diet. This has an important
bearing on the infant's nutrition, since the caloric content may
vary between 50 and 70 Calories per 100 g.
Usually the quantity of breastmilk is of even more significance
to the baby than the quality, since the baby's growth performance
correlates more with the quantity.6h The quantity is impaired in
conditions of extreme nutritional adversity, but on moderately poor
diets, there is no clear evidence of impairment. Indeed, New Guin-
ean mothers, whose diets are among the poorest in the world, are
apparently among the world's best lactaters, in terms of their ap-
parent ability to satisfy their babies fully at first and to continue
to suckle them for years. Conversely, sophisticated mothers on ex-
cellent diets often have very poor milk production, for mainly psy-
chological reasons.
The quantity of milk commonly increases fairly steadily during
the first months of lactation to reach a peak by about six months
(500-760 g) followed by a decline 178. 210.. But 400 g or more may
still be produced during the second, third and even fourth years of
lactation 6h. 161. 2l0a. There is little evidence of a decline in quality
during prolonged lactation, nor in successive lactations. The quan-
tity occasionally declines in mothers who have many children, but
this trend is not at all marked.
Many more studies are needed throughout the Region on the
quantity and composition of breastmilk.
The main aims in stressing a good diet for the mothers are
therefore -
(a) to prevent progressive depletion of her. tissues and ulti-
mately her strength;
(b) to achieve maximum fat and caloric value in the milk;
(c) to improve significantly the vitamin A/provitamin A levels
and protein levels in the milk, if they are deficient;
(d) to maintain the water-soluble vitamins at a high level in
the milk.
It is extremely important to ensure an adequate fluid intake,
which is necessary for optimum lactation.
ID most countries, there are certain foods (or herbs, or other
concoctions or dietary practices) which are believed to improve
.\,
lactation. Probably most of the so-called "galactagogues" have

no real beneficial action78a• But when taken because of the
mother's faith in their value, or in the herbalist who prescribes
them, they may indeed have beneficial effects. Furthermore, a
recent study in one country suggested that one kind of leaf (Loph-
etalum) did enhance lactation!2 Any such practices therefore de-
serve to be encouraged, provided these preparations contain no
toxic principles. Much research is needed on these poBBibilities.
Apart from this, there are, as in pregnancy, many traditions
and beliefs concerning maternal diets during lactation, and more
especially in the first week or month after delivery. A diet of rice
and salt only, as prescribed in some communities, is extremely pre-
judicial to the infant as well as the mother. In other places, chicken,
fish, and leafy greens are encouraged. Prohibitions against
the use of sour foods (usually rich in ascorbic acid, and some-
times in carotene) are common, and deprive the mother of vital
nutrients. Foods deemed to be "slippery" are sometimes avoided
because of fear of prolapse. Some foods may, of course, affect the
taste of milk, and care must be taken not to deter the infant
from taking the breastmilk* because of this. Legumes are also
quite commonly avoided during the early weeks or months. The
educational approach to be followed is similar to that described
for pregnancy.
Besides her diet, the mother's general health needs particular
care during lactation. Significant blood loss commonly occurs
at delivery in developing countries, and calls for continuation of
iron supplementation - routinely, if tablets are available. After
parturition mothers sometimes become very depressed and fati-
gued and need special support from the family, and from the health
worker. A good atmosphere in the hospital 'and home and free-
dom from worries is essential to enable the let-down reflex to dev-
elop; otherwise, despite the baby's suckling, the milk is retained
in the breasts which become engorged and painful. A small inject-
ion of oxytocin will help to promote the let-down reflex. If milk
production is excessive, small doses of oestrogen will control it and
so help to avoid blockage of the ducts. Proper care of the breasts
(including manual expression where necessary) and of the nipples
is vital. to"b. 116
Tuberculous subjects are apt to suffer an exacerbation at this
*Many drugs also are excreted in the milk. including for instance nicotine after smoking.
time and must receive continuous adequate medication and super-

vision throughout pregnancy and lactation. The baby is exposed
to some infection from the first days of life, and must be given
immediate BCG vaccination. Formerly, immediate weaning was
advised, but it has been found that bottle-feeding increases the
stress on the mother and does not avoid the hazards of infection.
Rather, a successful smooth lactation is all the more to be encou-
raged.
3.3 The elderly and destitute
Although protein-calorie malnutrition has been described main-
ly in infants and toddlers, it also occurs in adults.Ga. 82, 101e. 199
There is usually severe loss of weight and marked dependent
oedema, with low serum albumin levels, skin and hair changes,
apathy, diarrhoea and various other features. Sometimes this
syndrome occurs in .relatively young female adults, but usually in
the elderly. Commonly there is a life-long history of poor diet,
often culminating in an episode of severe deprivation of calories
and/or protein. The caloric deficiency is usually the basic and
immediate cause of the tissue depletion and oedema, but pro-
longed protein deficiency predisposes to it.
This syndrome usually occurs in communities as the end-result
of socio-economic and agricultural factors beyond the control of
health workers. It also occurs among destitute and problem fa-
milies who for one reason or another (social instability, unemploy-
ment, land tenure problem, etc.) have become derelicts in society,
usually unable to help themselves. Whole families may be in-
volved. Lesser degrees of social misfortune, such as the absence
of the father in a city, in search of work, or employed as a con-
tractual labourer on a distant plantation, are factors leading to
lesser manifestations of malnutrition, such as shown in Plate 1.
This picture depicts an undernourished and harrassed mother res-
ponsible for the farm as well as the children; one boy (the lar-
gest) with xerophthalmia and Bitot spot, another with dependent
oedema (kwashiorkor) and another with marasmus and primary
tuberculosis. While the immediate causes of malnutrition are spe-
cific n,utritional inadequacies, the root causes are socio-economic
ones. This is the basic reason why nutritional physiology, patho-
logy and clinical nutrition are only a backdrop in this manual.
The stage-play must be in food science and public health nutrition,
as described in the following chapters.
CHAPTER V
NUTRITION SURVEYS
1. ORIENTATION
Nutrition surveys are usually the starting point for practical
nutrition programmes.They should be part of an overall national
plan, but implementation has to come down to the local level.
Nutrition surveys are intended to define the nutritional problems
in an area and to set baselines against which the impact of nutrition
programmes can be measured, and so should be practical in ap-
proach. Nutrition surveys have already provided the impetus for
major nutrition extension programmes in the Philippines, Malay-
sia, Singapore, and many South Pacific islands.
Survey procedures are discussed in detail by JelJiffe lOlle, in-
cluding the advantages and disadvantages of longitudinal and
cross-sectional surveys and preliminary planning and field recon-
naissance needed. The actual surveys should cover ecological
factors affecting nutritional status besides the direct assessment
of nutritional status. Some sample survey forms are given in An-
nex III.
Preliminary viBits or pre-survey visits are essential for two
main purposes:
(a) To orient the surveyors, or at least the planners and team
leaders, on the local conditions and problems, and enable them to
become acquainted with local leaders;
(b) To enable the purpose of the intended surveys, and the
intended applications of the results, to be discus.sed with the local
people.
Ideally, a request for a survey should arise as the expression
of an already felt need on the part of local people - a need for
guidance in the clearer definition of their problem and how to solve
it. One of the difficulties in nutrition promotion in this Region is
the fact that often the local people are not aware of the existence
128
NUTRITION SURVEYS 129
of any nutritional problem and so do not have any felt needs on the
subject. To break this vicious circle of ignorance, unconcern and
inaction, any point of common concern on which the local people
feel the need of guidance or assistance can be a valid point of
entry. At all events, it is vital that, before surveys or any nutri-
tion programmes. are launched, efforts be made to discUSB with the
local people the nutrition problems and what can be done about
them, on the basis of whatever evidence is available, no matter how
fragmentary. Once a bridgehead and a dialogue are established,
they can be expanded gradually. These matters may be discuSBed in
depth with some local government personnel and. village headmen.
Sometimes however the latter may not have the confidence or abi-
lity to pass on the principal issues to the village people themselves,
and it may be vital for team leaders to participate in some sort of
village assembly in which procedures and goals are clarified, to
avoid misconceptions which frequently occur. Only on the basis
of satisfactory discUSBions of this sort should final decisions be
made as to the exact site of eventual surveys and nutrition prog-
rammes.
At about this stage, preliminary planning should be crystal-
lized in an action programme or plan of action, in which the plans
for surveys of ecological factors and for the direct asseBSment of
nutritional status are separately spelled out under more or lee the
following headings:
1. Introduction
2. Objectives
8. Methods including tentative timetable
4. Materials including vehicles
5. Personnel - responsibilities of each agency and person
6. Administration including finances
7. Recording and analysis
8. Evaluation
This may seem a tedious exercise but is really useful in stimula-
ting planning and in clarifying many details of final organization
which are otherwise liable to be overlooked. Such action prog-
rammes will have to be drafted by one individual after discUSBion
among the responsible parties, and finally reviewed and ratified by
the whole group, including representatives from the local level.
It is pertinent in planning the surveys indicated under both
180 THE HEALTH ASPECTS OP' FOOD AND NUTRITION
headings - ecological factors and direct assessment of nutritional

status - to consider the resources available for analyzing and
following up the data, as well as in collecting them. For the sake
of completeness, many items of interest, such as housing and edu.
cational levels, etc., may be included. but it may not be
feasible to process a large bulk of data. The subject-areas covered
should be selected with a view to concentrating on those of import-
ance from one or preferably both of the following standpoints:
(a) Defining the situation, the problem and the priorities more
accurately in order to make suitable recommendations for nutri·
tion education, etc.; e.g., is there a significant vitamin A problem,
or anaemia, beriberi or goitre?
(b) Establishing baselines against which to measure progress.
These must be selected in relation to the development activities
planned, e.g., housing standards are unlikely to change much but
food storage facilities might; food production in the homeyard
certainly should. Serum albumin levels might be expected to show
an increase in more vulnerable groups such as toddlers, but would
be less likely to do so in schoolchildren and unlikely to do so in
adults.
2. TRAIMNG
Once the location is established and the preliminary visits
made, as indicated above, the procedures for collecting as much as
possible of the ecological information 103e need to be worked out,
as well as for the nutrition surveys proper (see section 4 below).
The personnel who will be responsible need to be trained in detail
for the job. These should be the local workers as far as possible
_ principally government workers, but some voluntary assistants
can be extremely useful. Forms to be used for recording the data
should be worked out and pre-tested before being actually finalized
for the surveys. Working over these forms and procedures, and a
small trial survey, will be the main content of the training prog-
ramme. But within this context, the personnel must be provided
with sufficient background information to deepen their interest
in, and knowledge of, nutrition. Particular requirements for va-
rious fields of coverage are indicated in the following sections
and the personnel must each receive training appropriate to their
responsibilities in the team.
3. ECOLOGICAL FACTORS
The ecological factors affecting nutritional state include (see
JeIliffe 108c, p. 106, et seq.) :
(a) Food availability and production;
(b) Food patterns and consumption;
" (c) Environmental hygiene and conditioning infections;
(d) Socio-economic and cultural influences;
(e) Health and other services.
It is preferable therefore that surveys be planned within the
context of overall community development or community education
activities. Separate survey teams should be responsible for dif-
ferent parts of the total coverage. From the health standpoint, in-
direct assessment of nutritional status is made on the basis of health
statistics and hospital records, and a consideration of environ-
mental hygiene, conditioning infections, and health services, as
indicated above. In applied nutrition programmes (Ch. IX) the
other aspects should receive just as much attention as the health
aspects.
3.1 Food availability and production
Since this falls mainly in the province of agriculturists, it will
not be discussed here in detail. Sometimes statistics on food pro-
duction may be available for large or small districts, or even for
villages. Usually, however, such data are non-existent or unre-
liable. Nevertheless, they may give some indication of the im-
portance of (say) dried legumes of different sorts. A survey of
markets indicates the general range of foodstuffs available, and
their prices. One of the difficulties in gathering data on food pro-
duction is that often the vegetables which are of particular interest
from the nutritional standpoint may not be considered at all in rout-
ine agricultural statistics, surveys or extension work. Even so,
qualitative information should be gathered. Data on farming
practices should cover livestock production and home gardening
including the methods used, since these have an important bearing
on health, as well as field crops. Seasonal factors need special
attention.
3.2 Food patlerns and consumption
FAO has laid down comprehensive guidelines on household food
consumption surveys.58c.d 62cl Surveys of this type give average food
and nutrient consumption per caput for the family and for the com-
munity as a whole. Since relatively small numbers of households
can be covered, advice must be obtained from a statistician on the
sampling procedures. The size of the sampie depends on the va-
riability of the data to be collected. Since this is quite high for
dietary data, as many families as possible should be studied, and
for a minimum of three days and preferably five days. The limit-
ing factor for such surveys is usually the availability of person-
nel, time and funds. Local workers with only a general educational
background can, if necessary, be trained for collecting the data,
but the less background the surveyors have in nutrition, the more
inaccuracies will creep in. Therefore, a smaller survey by more
experienced workers (say, from a nutrition institute) is likely to
have more scientific value, although having less value from the
point of view of involvement of the local workers. The proper
assessment of incomplete data has to be considered; allowances for
refuse and left-over portions; use of appropriate conversion factors
from cooked weight to raw weight; the use of suitable food compo-
sition tables or other food analysis data; and the application of
suitable dietary allowance standards against which to measure the
results. The analysis of the data is usually much more time-con-
suming than the surveys themselves and requires great care and
patience, as well as moderate mathematical skills and, if possible,
an electric calculator. The procedures are discussed in more detail
by J elliffe1ose•
Despite all the problems, household consumption data do pro-
vide a valuable background against which to assess nutritional
state and on which to base general recommendations for nutrition
education, in conjunction with the other facets of the surveys, espe-
cially those of clinical nutritional status.
However, these surveys do not indicate in detail the dietary in-
take of the vulnerable groups especially infants and toddlers. Cer-
ta·in qualitative data can be collected, of great value in this res-
pect, using forms such as those shown in Annex III, and general im-
pressions can also be gained by watching for occasions when the
mother feeds the baby, either with breastmilk or with other foods.
Data can be collected about infants and toddlers by questioning
the mothers using the simplified rapid technique of Blankhart. 1s
The mother is first asked to say spontaneously what foods the child
is eating at the time, then how many times a day each food is being
eaten. The information obtained is recorded as given by thf!

mother, e.g., rice, twice a day, etc. When the mother has given her
spontaneous answers, questions are put systematically on the use
of other foods, and, in the event of an affirmative answer, on the
number of times daily. This questioning is done quickly, since too
much interrogation and cross-checking defeat their purpose and
leave both the mother and the interviewer confused. IS The infor-
mation may be entered on double foolscap lined sheets, on which co-
lumns are ruled for each of the local foods likely to be used for
young children. The frequency of use of different foods can be
calculated and expressed as the number of times they have been
eaten per week per child (Table 5.1). It may also be possible to
estimate the amounts used. in terms of local measures.
TABLE 1i.1
FEEDING OF YOUNG CHILDREN IN SIERRA LEONE VILLAGE
Averagr number of times different foods
takfll per week at follOWing ages
(and number of children studied)
Type of meal
7·12 months 13-18 mOllths 19-24 mo.ths
(12 children) (15 children) (11 <hlldr..)
Breast.milk 21 10 2
Rico 6 13 14
casad and foo-too pap •....... 6 3
Sweet pOtato 1/3 1/2
CIIstard or cornflour .... 4 2
Leo" _bios ............ . L1 12 10

B.!lnanas ............ , 2 11/,
OranglK ........ . 1 1'12
Tomatoes .•
MiI~ ..................... . 13 1'12 '/2
Ellt .•..................... 11:l8
Fresh fish .........•.........

Dried fisll .......••....••....
Oil ....................... . 5 5
18
• The Information for this table was obtained by l"~ rapid technique of Blankhart
& Ooe <lliid 0<11,.
Some particular points of importance are to find out whether
it is principally the mother or the father who determines the
amount and timing of commencement of infant foods, and whether
preference is given to males in child feeding.
If surveyors are available who already have experience in house-

hold consumption studies, it is feasible to undertake individual
intake studies by weighing the food eaten - either by each family
member or by one or two young children. The presence of an ob-
server and the weighing of the foods before consumption necess-
arily create a somewhat artificial situation. The foods consumed
in composite, non-homogeneous dishes are impossible to assess with
great accuracy, and the calculations are more complex. Never-
theless, such surveys have been carried out in several ,countries in
the Region and elsewhere. They indicate diets extremely low in
energy and most nutrients for older infants (6-12 months). The
most useful groups to study may be children under 2 years.
It may be feasible to include a small sub-sample of the house-
holds in a general survey, for individual·intake studies of this
sort. The most experienced field workers will be needed for this
job.
For breastfed children, an estimate of the intake of breastmilk
is most important, but also requires painstaking effort. Usually
public health nurses or midwives, who are used to handling
mothers, babies and weighing scales, are the best workers for these
studies.
Assessment of the quantity of breast-milk produced in 24-hours
can be attempted in either of two ways, both of which ideally should
be repeated on several occasions.
(a) First, 24-hour test-feeding may be carried out, in which
the child is weighed before and after each feed, usually in the
home and preferably under continuous surveillance. If frequent
suckling is permitted, amounts taken are too small to be accurately
tletectable. It is essential to use very accurate scales (sensitive
to 5 grams) and it is desirable to allow the feedings only once in
8 or 4 hours. Such studies may also be done in hospital, or it may
be possible to organize a whole group of mothers to stay at a village
centre for a whole 24 hours. In any case the artificial conditions
are liable to impair the milk flow. A modification of this proce-
dure rendering it much more practical is to carry out test-feeding
at 9 a.m., 12 noo'n and 3 p.m. and double the totals.213 The babies
need to be kept away from the breast from 6 a.m. to 9 a.m. Again,
a disturbance of the milk flow is likely.
(b) The second type of procedure, and the simplest in practice
although very artificial, is to keep the child from the breast for a
six-hour period and measure the amount expressible manually, and

multiply it by 4. 168
Because of the rapid evolution in the quantity of breastmilk and
supplementary foods, several children should be studied at monthly
or 3-monthly intervals covering the first two years of life if possi-
ble.
3.3 Environmental hygiene and conditioning infections
Among the data assembled should be any statistics available
from health services on the causes of death, especially for children
under five years. The use of toddler mortality data as indicators
of nutritional status is indicated in Annex V. The major causes of
death in this age group are usually gastro-intestinal diseases or
respiratory infections. Parasitic infections may be assessed in the
actual clinical survey. Ascariasis is usually the commonest,
especially where heavy clay soil and unhygienic disposal of excreta
prevail, but it is useful to assess the prevalence and the intensity
of infection (at least by si'mple criteria). Hookworm prevalence
is more variable, being higher in sandy soil. Again the intensity
of infection should be assessed, and the type of parasite (Necator
or Ancylostoma), and the correlation (if any) between haemoglo-
bin levels and hookworm infection.
Some information on the prevalence of malaria, tuberculosis,
measles, pertussis, bacillary dysentery, amoebiasis, and weanling
diarrhoea should be collected, even if it is only qualitative.
The prevalence of promiscuous defaecation; whether animal'
manure is carefully composted, or dispersed and neglected; the re-
lative intensity of flies; the extent of food contamination by flies;'
the sanitary condition of markets; food handling practices; all
these and other related factors have an influence on the prevalence
of infections (particularly of the gastro-intestinal tract) which
have a distinct influence on nutritional state.
3.4 Socio-economic and cultural influences

The most obvious of these are the p:.:evailing food habits, tra-
ditions, customs, and beliefs. It has been pointed out that tra-
ditional dietary restrictions apply most often to precisely the nut-
ritionally vulnerable groups: infants, toddlers and pregnant and
lactating women. Some highly nutritious foods are among those
which are restricted - certain animal foods, legumes, and leafy
greens and fruits. These restrictions vary greatly from place to

place, even within a country. Religious restrictions, such as on
pork for Moslems, are mostly not of major significance in this
Region. Pork, for instance, can easily be replaced with other kinds
of meat. The limiting factor is usually the price, when it comes
to any kind of meat. Buddhists traditionally eat no animals
slaughtered with loss of blood, but nowadays such restrictions are
less strictly observed in practice.
The information of most practical importance which ought to
be collected, concerning the restrictions or other food practices in
pregnancy, lactation, and among infants and toddlers, will mostly
be unearthed in the course of completing the questionnaires in An-
nex III. These data are difficult to analyze systematically but an
attempt should be made to draw out their practical significance.
The classification into useful, neutral and harmful practices is
most valuable.
Besides these traditions, economic factors play a most signifi-
cant role. It is unlikely that accurate estimates can be made of
average household income, but some estimates may already be avail-
able from other local surveys, or could be made during household
surveys. The results should be compared with any available
national-average figures.
The prices of the principal foods in local markets should also be
ascertaitled, and the amount of calories, protein, vitamin A and per-
haps other nutrients obtainable from the commonly available foods
per unit cost should be calculated.
3.S Health and other serviees

The information to be sought from health services is indicated
above. The number of personnel available to serve a given popula-
tion should be ascertained; their mobility - frequency and range
of village visits; availability of medication; etc. The scope of
existing activities related to nutrition directly (e.g. mothers'
classes) or indirectly (e.g. immunization) should be reviewed.
Similar enquiries should be initiated - through the proper
channels - in relation to educational, agricultural and community
development services. All this information will influence decisions
as to the proper channels for any follow-up action needbd in nutri-
tion promotion.
It is preferable therefore that surveys be planned within the

context of overall community development or community education
activities. Separate survey teams should be responsible for differ-
ent parts of the total coverage. ' From the health standpoint, indi-
rect assessment of nutritional status is made on the basis of health
statistics and hospital records and a consideration of environmental
hygiene, conditioning infections, and health services, as indicated
above. In applied nutrition programmes (see p. 200), the
other aspects should receive just as much attention as the health
aspects.
4. SURVEYS OF NUTRITIONAL STATUS

The ecological factors have been considered above first, because
health workers otherwise may look on the surveys of nutritional
status as the all-important part of the procedures. In balanced
programmes, especially of the applied nutrition type, food product-
ion, supplementary feeding, and nutrition education and training
have equal importance. Health personnel should see their par-
ticular field in due relation to the whole programme.
4.1 General organization

The need for an action programme, properly prepared in
advance, is emphasized.
The whole procedure including mustering the population
requires the co-operation of the local people; and every effort must
be made to suit their convenience. For instance, the time of day,
the location, and the day for examination must be selected with
care. If it happens to be raining, another visit may have to the
made. Someone may also have to go from house to house to remind
the householders to attend.
At the site of examination, a "line of flow" must be established,
beginning at a registration desk, proceeding to weight and height
measurement, then clinical examination, and finally laboratory spe-
cimen collection. Sometimes dietary interviews may be inserted
(for a sub-sample) somewhere along the line, but this and the re-
cording of the numbers of living and dead children (see Annex V)
may be better done when visiting individual households.
The efficient registering of subjects calls for a local person or
another worker familiar with the vernacular and preferably with
most of the local people. He should be thoroughly briefed on the

items to be completed by him on registering. A form such as that
shown in Annex IILF is reasonably adequate. Birth certificates
should be produced if they exist. It not, a calendar of local events
should be constructed so that age can be determined to the nearest
completed month if possible for children, and to the nearest com-
pleted year for adults. Other approaches are discussed by Jelliffe
(page 58) .10Se An approximation to age is given for children
between 7 and 30 months, by counting the number of teeth
erupted, and adding six, to obtain the age in months. 6f
For the numbering of subjects, a convenient system is to enroll
the subjects of households which are numbered ir. sequence (I, 2,
- , - , - ) and the family members are designated A (head of
household), B (his wife), C (oldest dependent), D (next oldest
dependent), and so on. The subject is given his form and passes
to the next examination table, and so on. Sufficient assistants
must be available to ensure that. there are no bottlenecks interrupt-
ing the flow. At the conclusion the completed forms should be col-
lected' by a responsible member of the team and checked for com-
pleteness before the subject leaves. '
4.2 Clinical examination

Usually a team of tW6 to four doctors will conduct this part of
the examination. However, for training purposes, a larger num-
ber of physicians associated with the project may be involved.
This may necessitate separate examination cubicles for males
and females. Usually a brief clinical examination such as shown
in Annex IILC will do. More elaborate forms are given by Jel-
litre. lOSe It is customary to make the clinical examination more or
less in sequence from head to foot, in the order shown in the form.
An entry + or - should be made beside each item. Grading by
multiple signs (+ +) is considered not worthwhile. A + entry
should only be made when the sign is positive without any doubt.
In the previous training, standardization of criteria for report-
ing clinical signs as positive is essential. First, a good sei of
pictures of clinical signs should be reviewed, or transparencies such
as those of the Institute of Nutrition for Central America and Pa-
nama, or the Nutrition Program, National Centre for Chronic Di-
sease Control, United States Public Health Service. Then a group
of 100 or more subjects should be examined by the personnel who
Will undertake the clinical examinations in the field. Any signs

considered "positive should be viewed and discussed by all the ex-
aminers until definite agreement is reached on all the signs. This
procedure should be repeated occasionally during examinations in
the field. Each examiner should initial the forms of the subjects
he has examined. At the end of each day's examination, the po-
sitive signs should be reviewed by the team leader and any appa-
rent discrepancies followed up.
In practice the clinical examinations may be useful mainly in
showing up any important prevalence of eye signs (vitamin A
deficiency), angular lesions (riboflavin deficiency), goitre, oedema,
rickets and anaemia. The grading of subjects into well-nourished,
mild malnutrition and gross malnutrition may be done. However,
the classification in the first two categories is very subjective, and
liable to vary between examiners, and for the same examiner bet-
ween different days or places. Probably very few or no children
Will be encountered in the last category anyway, in a small com-
munity survey.
In analyzing the results, computers may be used for large sur-
veys, but for smaller surveys the tabulation and analysis can be
done by hand, aided by an electric or hand calculator. The results
from each individual form are entered on a master sheet, some-
thing like that·in Table 5.2. The clinical signs are numbered from
1 to 23 and a separate column is made for each number. For mul-
tiple items in one category (p. 270) the appropriate letter is
entered in Table 5.2, e.g. for eye signs, the entry number 5 may
be a, b, c, d, e, and/or f. In this master sheet only the positive cli-
nical signs are entered as a + (or letter a, b, c, etc.)· under the
appropriate number. The incidence of these signs should be
tabulated in the following age groups:
0 - 11 months
1 - 3 years
4 - 6 years
7 - 12 years
13 - 19 years
20 - 39 years - (a) pregnant
(b) lactating
(c) NPNL*
over 40 years
TABLE 5.2
COMPILATION OF CLINICAL SURVEY DATA
2"
card
No.
Dale of
exami-
NAME
3 .~ g- .'j"o" i~ ll'
BIRTH DATE AGE WEIGHT HEIGHT SKIN FOLD
nation 0
~ ~~ a~ ...e '"= Kg em Mm Log 1 2 3 4
.
TABLE 6.2
(continued)
, HAEMO· SERUM URINE FAECES

CLINICAL SIGNS AND REMARKS
GLOBIN
~
VII.
5 b 7 B9Wll12U~~U"~"Wn~~~ 'Y. Gin Alb. Glob.
A
As<. Hk. Others
-
I
4.3 Anthropometry
Instructions for actually measuring weight and height are given
opposite.
The scales used should be reasonably new, robust, lever-type.
For adults, they should read to the nearest 0.1 kg (or 4 oz). For
infants, scales capable of weighing up to 15 kg, to the nearest 10
g (or 1/2 oz). are preferred. But often the child of 1 to 2 years
is very difficult to weigh. He may need to be held by his mother
while she stands on the scales. Deduction of the mother's weight
increases the possible inaccuracies considerably; this is not so im-
portant in cross-sectional surveys, but more so in longitudinal stud-
ies. The actual weight of the child should be calculated at once
by subtraction, but this should be checked later because many
slips occur when it is done in the field. Adults and children should
be weighed in minimal light clothing, and the average weight of
such clothing obtained by weighing 10 sets for each different age-
group and sex.
The care of scales is important. Someone in the team should
be thoroughly familiar with the mechanics of the machine - the
proper placirig of the knife edges and the necessary guards. An
unstable platform indicates some internal misplacement, if the
scales are properly placed on "level ground". The scales should
be checked and adjusted against standard weights before and after
each survey; a correction factor may need to be applied. Pro-
bably the commonest error is in failure to have the balance arm
correctly centred at zero when not loaded. If its initial reading
is not zero, all weight records will be in error.
The height may be read from a lever attached to the scales, or
against a vertical rod attached to a platform, or by fixing a steel
measure against a wall. Cloth tape measures should not be used
because of their stretchability. If the wall is used, a triangular or
L-shaped device with a vertical and a horizontal edge is run down
the wall to meet the crown of the head. Care must be taken that
the subject stands on completely flat ground, and that the vertical
measure reads exactly zero at that level. It is essential that the
horizontal arm piece be truly horizontal. Also, the subject must
be standing stretched upright with eyes looking horizontally
straight ahead. These are the two commonest pitfalls in taking
height.
For children under three years, Le., 0-2 years inclusive, the
Standard Procedure for Weight and Height

The subject should be weighed and measured between eight and eleven
a.m., should have recently emptied the bladder, and should have minimal
clothing (light shorts for boys, light dress for girls) with no shoes or socks.
A. Weight (in kilograms)

1. The scales should rest firmly on a horizontal base. Before each period
of examination the balance arm should be checked with no load on
the scale to verify that the arm is exactly horizontal when the scale
reading .is zero. If it is not zero, adjust the screw-head at the left
hand side 80 that the arm is horizontal with zero load.
2. Once every three (3) months the scale should be checked with standard
weights of 20 kg and 40 kg, and shown to have no error (i.e. less than
0.1 kg).
3. When reading the scale, care should be taken that the movable weight
resting in the slots at 20 kg, etc., is put accurately in the slot.
4. The subject stands steadily in the centre of the platform while being
weighed.
B. Height (in centimetres)

1. The subject stands barefoot on the centre of the platform fully erect
with heels together, legs, back and neck straight, and eyes horizontal.
2. The horizontal iever is lowered 80 as to rest firmly on the crown of
the head.
'3. (a) For heights abo". 180 em:
The reading is measured to the last completed ~ cm reading showing
above the break in the scale, neglecting fractions smaller than ~ em.
(b) For heights below 130 em:
The reading is measured to the last completed lcm reading showing
immediately behind the pivot-knob of the horizontal lever (not the
lower border of the horizontal level), neglecting fractions smaller
than i\ em.
4. If the reading is exactly half way between two marks, lift the lever
up and bring it down again to get another reading.
C. Birthdall
'the birthday of each subject should be taken from a birth registration
certificate. On a master-sheet the day of examination is recorded. The age
is calculated from the last birthday. If the actual birthday is not known,
the month and year of birth should be ascertained.
·Theee remarks apply when an extendable two-piee. vel'tieal measuring rod is used. 81.
with the Detecto ecalea supplied by UNICEF.
144 RECORD OF WEIGHT, HEIGHT, ARM CIRCUMFERENCE AND SKINFOLD
(FOr use in cammunily Or school suneysJ
Code No. Date
Name of village or school MuniciPAlity
Grade or Teacher or
househo!d head councilman
Instructions
(a) For schools: Teacher should fill m column }·4 before (ile examinalion.
(Use separate fOrm for boys and 9irli of each grade).
(b) FOr community: Use separate form fOr each household.
(c) Fill in columns 5, 7, 9 and 11 during eltc1min3tion; afterwards, fill in columns 0, 8, 10 and 12 and the
totals as indicated ,below. If measurements are in Ibs/OlS and inches, record these as measured, and afterwards
convert to Kg (see p ~3) and centimetres (p 294)
(ql (lO)
(ll) (l2)
(l) (2) (3) (4) (5) Ib) (7) (8)
HEIGHT ARM CIR· SKINFOLD
AGE WEIGHT CUMFERENCE
NAME SEX Birthday y&3.rs.montl\s
K, A or B em A or B Mm A or B Mm A or B
0-5 months b·ll months 1·3 years 4·6 years 7·9 years 10·12 years 13·15 years
Males "0. of A ,
No. of B
Total
Females No. of A
No. of B
Total
Both Sexes No. of A

I I I I I I II
No. of B
Total
horizontal length should be measured instead of height. The ap-

paratus for measuring length should be set in a solid framework
like a table with a fixed vertical piece at one end, against which
the feet are placed, and the other end consists of another vertical
piece attached to a horizontal flat rod, with appropriate markings,
which slides along a groove in the 'table'. The ordinary type of
infantometer is too flimsy to give accurate results. The measures
used should be read to the last completed ~ cm (or t inch).
The arm circumference is another useful indicator (Jelliffe,lo3c
p. 76). It is affected by bone diameter, muscle thickness, and
skinfold thickness. A flexible steel tape is used, reading to 0.1 cm.
It is passed gently but firmly round the left upper arm, midway
between acromion and olecranon, with the arm hanging freely by
the side.
The skinfold thickness is measured over the triceps, at the same
level (Jelliffe,lo3c p. 74), and also sometimes in the subscapular re-
gion. A fold of skin and fat is lifted up with the fingers of the
left hand to a height of about one skinfold thickness and the jaws
of the caliper applied just beyond the tips of the examiner's fingers.
To get consistent and accurate results, a physician with experience
of the Harpenden skinfold caliper should be selected, and his read-
ings checked against those of another experienced examiner, on a
group of subjects. Since there can be a considerable variation bet-
ween examiners, it is desirable for one person to do these measure-
ments throughout, or for each examiner to initial the forms of
the subjects he has examined.
The arm circumference may be used as such, or the mid-arm-
muscle circumference calculated from it using the following for-
mula:
Mid-arm muscle circumference C2 = C, -7(' S where
C. = arm circumference (mm)
S = skinfold thickness (mm)
7(= 22/7
This is believed to indicate more closely the muscular development
and consequently the protein status.
The results of these various measurements can be presented in
various ways:
(1) Averages
The arithmetic mean for each measurement can be given.
The age groupings depend on the indicator in question. The
following age intervals are recommended in general.
1. 3. 6. 9. 12. 16. 18. 21 and 24 montba (central age within ± 1% montha,
e.g. 6 months includes infanta from
,% up to 7% months inclusive)
2'h. 3. 3%. '. 4I,!,. 6. 6%. 6 years (central age within ± 8 months. e.g. 3 yrs
includes from 2 years 10 months up to a years
2 montbe. inclusive)
6%.7%.8%.9%.10%.11%. 12%. 18%. 1'%. 16% yrs (central age within
± 6 months)
In the case of skinfold thickness. for calculation of means. the read-
ings should be transformed logarithmically64 using the conversioD
table shown on p. 296 because the direct readings are not normally
distributed.
For the mean figures obtained. standard deviation and standard
error of the mean should be calculated.
All these mean values should ideally be compared with data
from both international standards and local standards.
A careful search for suitable local standards should be made.
These ma:v exist only for weight; or only for selected population
groups. not necessarily representative of the whole country; and
possibly not covering all ages. Nevertheless it may still be useful
to make comparisons with any available growth data. It may even
be valuable to endeavour to get national standards established. on
the basis of available data or special surveys. However. it must
be recognized that in developing countries the populations from
which these standards are compiled usually include some or many
malnourished or undernourished persons. Therefore in the scoring
method outlined below. a lower malnutrition score is to be expected
when using the local standard for comparison.
(2) Malnutrition Grade-Score
A simple method is to compare each measurement directly
witt. a local standard and/or with an international standard for a
child of the same age. A malnutrition score may be established for
each indicator (weight. height. skinfold thickness and arm cir-
cumference) .
Score 0 = 90 - 100% of stahdard (international· or local)
1 = 80 - 90% (exclusive) of standard
2 =. 70 - 80% (exclusive) of standard
8 = 60 - 70% (exclusive) of standard
4 below 60% of standard
=;0
-Such lUI thoee given b, Jefliff~~

From this an average malnutrition score for a group or com-

munity can be calculated. It is recommended to use the following
age groupings:
0- 5 months infants
6-11 months infants
1- 3 years (inclusive) toddlers
4- 6 years (inclusive) pre-school-age children
7- 9 years (inclusive) school.age children
10.12 years (inclusive) school-age children
13-15 years (inclusive) school-age children
Malnutrition scores for weight, height and skinfold thickness
should be determined for each sex separately and for the two com-
bined. Skinfold thickness measurements need not be transformed
logarithmically for this purpose; direct comparison can be made
to Table A.4.3.
This approach is useful in the first place for cross-sectional
surveys, where the aim is to find out in what age group there ap-
pears to be more definite evidence of malnutrition. Relatively high
malnutrition grade scores for skinfold and weight measurements
would suggest calorie deficiency, while high malnutrition scores for
height and arm circumference also would suggest some protein de-
ficiency as well. Secondly, these scores can be useful in longitu-
dinal studies, or for progress evaluation if the same communities
or children are studied at subsequent yearly intervals.
(8) Adults
The same indicators should be studied in adults for each
decade of age, as diseuaaed on p. 273. In addition, the data for
women -should be analyzed according to whether lactating or not
(excluding pregnant women) and according to the number of chil-
dren born alive to those women. This should reveal any serious
deterioration due to successive pregnancy/lactation cycles. In both
adults and children, correlations between parasitic infections and
these scores should be sought.
Either the malnutrition score method or the actual recorded
measurements may be used for the comparisons just referred to.
For the interpretation of all the foregoing results, a statistician
should be consulted. Control groups are often needed if periodic
comparisons are to be made.
j
4.4 Laboratory
Only a sub-sample of the total population covered is usually
included in the biochemical examination - often every fifth or
tenth subject. Probably the subjects who should be of most concern
are those under five years. Infants (below 1 year) should be in-
cluded as well as toddlers. Pregnant women should also be included
if possible.
Table 5.3 summarizes the most useful biochemical tests. The
most significant laboratory tests for this Region would probably
include:
a. serum albumin, amino acid imbalance test, vitamin A,
carotene;
b. urinary urea, thiamine, riboflavin and hydroxyproline
(per gram of creatinine) and iodine;
c. haemoglobin, haematocrit, thin blood film;
d. parasitism (malaria, roundworm, hookworm).
It is very desirable that capillary blood samples should be used,
especially from children. This requires micromethods, which are
feasible 4s • 119 but in the case of vitamin A and carotene the only
accurate method is not yet widely known. s Capillary blood samples
are collected in lengths of sterilized glass tubing. After the blood
has clotted, the end is sealed with some kind of wax and the tubes
can be spun at 3000 revs per minute for 10 minutes in an ordinary
centrifuge. The tubing is cut after scraping with a triangular file,
to obtain only the serum portion, which must be discarded if there
is evidence of haemolysis. Throughout, the tubes are labelled with
adhesive plaster; a separate serial number for laboratory speci-
mens is allotted, and the corresponding general survey number for
each specimen is recorded on a laboratory master sheet. The
serum should be frozen as soon as possible and kept frozen until
tested.
NUTRITION StfRVEYS 149
TABLE &.3
BIOCBmllCAL TBSTS APPLICABLE TO NUTRITION SURVEYS·
(1) PIoteiD AmiDO acid Imbalance Serum protein fractions by

Wt electrophoreaia
B),droznIroline
acretfon teIIt (F)
Serum albUJDiD
UrilllUT urea (F) b
Urinary creatinine
per unit of time (T)
(I) Vitamin A Serum vitamin A
Serum carotene
(8) Vitamin D Serum alkaline phoa-
pha~ (in young
ehfldren) Serum inorglUlic phosphorus
(4) Aacorbic acid Serum ueorbic acid White blood cell ucorbic acid
UrillAl')' ucorbic acid .
Load teIIt
(I) Thiamine UrilllUT thiamine Load Wt
(F)b Blood pyruvate
Blood lactate
Red blood cell haemol),sate
tranaketolue
(I) Rihoftavin Urinary riboflavin Red blood cell riboflavin
(F)b Load teIIt
(7) Niacin Urinary N-methylni- Load teIIt
cotinamide (F)b UrilllUT p)'ridone (n-meth:vl-
2-p)'ridone-6 carbonamide)
(8) Iron Baemoclobin Serum iron
Haematoent Percentage saturation of
Thin blood film ~errin
(') Folic acid Haemoglobin Serum folate (L.cuei)

Vitamin B,. Thin blood film Serum B" (E. gracilis)
(10) IodiDe UrilllUT iodine (F)
Te.te for thyroid function
2I2n
'Adapted f ...... WHO
Nota: a. UI'lIlaI7 a.reatiaine ~ .. "re.ferenoe for espreuin. otMr ...."remen.bI' In flni
-.".
b. £S..,..... per ....... of creatinine.
(F) In • .111&'. v,rine.peeJaaen..
(T) In timed wine .peelmen..
,,",vabb futi...
.
In communities where the taking of blood samples is liable to

evoke reactions or protests, biochemical assessment may be limited
to urinary examination on a single sample (preferably taken while
the subject is fasting, which means a before-breakfast specimen).
This does allow some assessment of most of the nutritional de-
ficiencies, but not of vitamin A status and anaemia.
Urinary specimens are sometimes difficult to obtain, especially
from toddlers and infants. About 30 ml is usually needed. It may
be passed directly into a small but wide-necked bottle; for boys, a
test tube may be tied over the penis; or plastic-bag urine-collectors
can be used (but are rather expensive). Preservatives should be
added: thymol, toluene, glacial acetic or hydrochloric acids are the
ones conmmonly used 36• 98d. It is advisable to store the specimens
in a refrigerator until analyzed, but it is not necessary to freeze
them.
For faecal specimens, the people may be asked to bring a suit-
able small specimen (pea-sized) in a labelled matchbox or other
suitable container. However, it is often difficult to collect these,
especially from children below school age, even if the people have
been notified in advance. An alternative is to take a small speci-
men using a length of glass tubing (about 5 mm diameter)
which is inserted into the rectum of the child. lOS For preparation
of the microscopic slide, recommended techniques are given else-
where. 2ud
Haemoglobin should be done with one of the reliable methods
indicated on p. 78 if possible. Otherwise there is no alternative
except the acid haematin method with a Sahli tube, which must
be carefully standardized against a calibrated instrument before
and after the survey. .
The results of all laboratory tests when available should be
entered in the master sheets (p. 138) along with clinical and
anthropometric data. Correlations should be sought between any
biochemical deficiencies present and the relevant anthropometric,
clinical or parasitological data, and also with any dietary data
available for the same subjects or families.
The facilities of a base laboratory will be needed for the bio-
chemical tests. The logistics of collection of the samples and their
transportation to the base without delay require careful planning.
•
5. REPORTING
Consolidated reports should be compiled: one of a technical
nature on the assessment of nutritional status, and one covering
the whole range of ecological factors including dietary surveys.
The survey procedures should be reviewed as to their effectiveness
in attaining the stated objectives and as to the efficiency of the
materials and methods used.
The reporting back to the local people of the results of these
surveys, in non-technical language, is a most important means of
leading on to nutrition education programmes with maximum com-
munity participation and, beyond that, to action programmes in
nutrition, usually of the applied nutrition type, adequately oriented
to the local nutritional problems as defined by the surveys.
J
CHAPTER VI
NUTRITION EDUCATION AND

SUPPLEMENTARY FEEDING
1. ORIENTATION U.82b.62d
Nutrition education, relevant to the needs, reaching to the

homes and capable of being applied in family food patterns, is
the ultimate road to good nutrition. It is therefore a means
rather than an end. It should be practical and applied, adapted
to economic and agricultural possibilities and in harmony with
the socilH:ultural setting. Nutrition education should include
effective demonstration, and sometimes supplementary feeding of
vulnerable groups, and practice by the mothers in food prepara-
tion. It can be an invaluable part of community development,
both in urban and rural areas. The emphasis should be on build-
ing better health through better food habits (and better food
production) as well as on preventing malnutrition and diseases.
The general content and priorities for nutrition education are
indicated in Chapters II-V above. A charter on nutrition for
health centres, and some hints on food selection and preparation,
are shown overleaf. Channels, techniques and training are
discussed below.
2. HEALTH CHANNELS
The health centre is the first obvious place for nutrition educa-
tion. Nutrition education should take place through:
(a) individual consultations
(b) mothers' classes
(c) home visits
(d) village visits
(e) other group organizations
152
NUTRITION EDUCATION AND SUPPLEMENTARY FEEDING 153
CHARTER ON NUTRITION FOR HEALTH CENTRES
GtlMrt1.l ob;ecti"••
- to develop nutrition advisory services and nutrition education of the public;
- to participate in co-ordinated community nutrition programmes wjl,ll the

co-operation of other disciplines and agencies where fe:utlll'ft' and
ne~ssary;
- to help develop supplementary feeding programmes where necessary and

provide continuing consultant services to them;
- to improve nutritional levels in the community by these and any other

available means.
Specific means
- Health or nutrition surveys, for baseline and progress assessment of

nutritional status, with special reference to vulnerable groups (pregnant
and lactating women, infants, toddlers, and school-age children);
Study of food patterns, and the socio-economic factors, beliefs, customs

and traditions affecting diets in the area, and/or any data that may be
already available on these subjects;
- Nutrition advisory services for individuals, and nutrition education pro-

grammes for vulnerable groups, in mothers' classes, etc.;
Participation in the nutrition aspects of other community development,

adult education and school education programmes;
Development of nutrition education materials adapted to the local situa-

tion;
- Supplementary feeding programmes in MCH activities;
- Technical advice to school feeding programmes on health aspects;
- Environmental hygiene programmes insofar as they influence nutritional

status.
CONSERVING FOOD VALUES
Hi,.,. on Food Selection and Preparation

A. G81IM1ll
1. Use freshly-picked vegetables when poaaible. Avoid long storage (even
in refrigerator) and exposure to sunlight. Wrap if stored in refrige-
rator.
2. Wash vegetables just before cooking. Cook whole when possible.
Cutting and slicing should be minimal. Avoid soaking; cook imme-
diately.
3. Put vegetables in water whieb i. already boiling and salted.
4. Include some leafy greens in every mixed dish, but add them last,
6 minutes before the others are ready.
6. Cook for minimal time in a covered pot, until just soft-not until
everything is mushy and leaves are black!
6. For the infant under one, mash his vegetables; if under six months,
sieve through wire or cloth.
7. Use vegetable-water and riee-water from cooked riee as drink for baby,
or in preparing other dishes (soup, vegetables with meat or fish, stew,
sauce, gravy).
8. Serve soon after cooking. Avoid keeping and re-heating cooked foods
(it is unhygienic and nutrients are lost).
9. Use only fresh meats and fish. Fresh fish have red gills, clear moist
eyes, and the ftesh does not "pit" when pressed with the finger. Clean
whole fish or chicken before cutting in pieces. To clean, wiping is
better than washing; use a clean damp cloth.
10. All fish, meat, eggs and vegetables must be eaten cooked, not raw.
B. Rice
- Selection: use undermilled white rice or brown rice with few broken
grains.
- Cleaning: pick out extraneous matter by hand.
_. Washing: once or twice only, quickly, without rubbing.
- Cooking: place in just enough water, already boiling and salted, and
cover the pot.
- Serve without delay.
- Avoid keeping and re-heating; cook only enough for one meal.
- Use pre-mix or enriched riee when available.
2.1 During consultations for other illnesses, foods and nutrition

are sometimes given a mention, but seldom as much emphasis as
is warranted. Most infective illness, for instance, is the result of
a combination of predisposing factors, such as poor environmental
hygiene, psychological outlook and nutritional state besides the
immediately operative causal organism. Commonly 70-90% of
health centre consultations are children or mothers, and there is
scarcely an illness in which the nutritional factor has no impor-
tance. To instill into people's minds an awareness that food affects
health is a basic educational necessity, in which health personnel
have a primary responsibility through daily work.
2.2 Mothers' classes commonly deal with child care in general,
with special reference to both hygiene and nutrition. Often, how-
ever, there is a predominant stress on maternal diet during
pregnancy-which is important in itself-but insufficient detailed
guidance is given on how to feed the baby, including breastfeed-
ing and supplementary feeding. In fact it sometimes happens that
the major teaching on infant-feeding is on regimes of artificial
feeding. The time spent on this should be minimal-otherwise
the public will get the impression that the hea1th centre is pro-
moting these "modern practices" as the acme of child care.
Mothers' classes, including talks and cooking demonstrations
when mothers come for consultatioll, are an established part of
most maternal and child health (MCH) services. Improvement
of the curriculum on nutrition will probably bring better nutrition
to the mothers and infants reached, more quickly than any other
measure through health channels. Nurses and midwives should
be thoroughly oriented on the food and nutrition priorities, with
particular emphasis on the highly nutritious locally available foods,
and how to prepare them for babies.
Usually a series of subjects is covered in a series of 6 to 12
meetings (talk plus discussion, demonstration and practical activi-
ties). Nutrition should comprise at least one-half of these topics.
An outline of such a curriculum on infant feeding is given on
p. 172.
2.3 Home visits are likewise an established part of MCH work.
These are often carried out during parturition and the puerperium.
These visits provide an ideal setting for nutritional advice and
demonstration and practice, particularly in the preparation of in-
/'
I
fant foods. Converse]y, since mothers are always concerned in

food preparation, food and nutrition form a useful and convenient
common ground for casual conversation instead of coming directly
to the point if this is a specific illness or other problem.
2.4 Village 11irit3. While theoreticaUy the health worker visits
aU the homes in bis area, in fact this commonly includes anything
from one thousand to ten thousand homes, mostly in rural areas.
For various reasons including transportation problems, the health
centre usually serves mainly the people living in its immediate
neighbourhood in the town, plus a few more enlightened individ-
uals from remote areas who are health-minded enough to visit the
centre. To reach the remote areas, village visits are usually re-
quired, and even if these are conducted only once a year, they still
should be utilised for nutrition education. Since nutrition is con-
sidered to be at least one-half of MeR care, no village or home
visits should be made without eareful provision for teaching and
demonstrating something simple and practical on nutrition. It is
obviously preferable that these should form a connected series if
possible. Better still. they should be associated with supplementary
feeding of infmts and toddlers, organised on a community basis
(see p. 169) as is commonly undertaken in applied nutrition
programmes. The main topics (each of which is enough for two
sessions) to be covered from the health standpoint are:
food values and food functions;
nutritional disorders;
growth retardation;
nutrition of vulnerable groups, especially supplementary
feeding of infants;
food hygiene;
nutrition and infection, and weanling diarrhoea.
3. OTIIER CHANNELS
Many other agencies, both governmental and private, carry
out nutrition education - either in organized programmes, or
incidentally in the course of their other activities. Government
agencies include schools and other educational services (including
adult education) ; and community development, agriculture, social
welfare and public information agencies. Private agencies - re-
ligious. philanthropic or civic - cover similar fields of activity.
It is important for health· workers at all levels (national, inter-

mediate, and local) to establish rapport With these agencies.
One special problem is to avoid nutrition education along diver-
gent or even conflicting lines by different agencies. This will
automatically nullify nearly all the efforts and result in confusion
and cynicism in the public, especially villagers. For instance. the
farmer may be told by the agriculture worker that what he needs
first and last is more of his staple (whether rice, maize, sweet
potato, or something else); the education worker may say he
eats too much of this and should take a more varied diet; the
public information and social welfare Services may assert, for
reasons of national pride, that malnutrition is no problem; and
the community development agency may say it is all a matter of
economics. There is an element of truth in all these assertions,
but none of them does justice to the actual problems and how to
solve them. It is therefore vital that all community workers reach
agreement on nutritional problems and priorities, at all levels--
the village, the town, the province or region, and at the national
level.
Actual field programmes should be planned jointly with these
other agencies where possible. Ordinarily all these agencies tend
to work rather independently of one another. Applied nutrition
programmes are one way of drawing them into co-ordinated team-
work.
Nutrition education through schools is of particular impor-
tance, because of its profound influence on the concepts of the
coming generation on foods and nutrition. Sooner or later (usually
soon!) after completion of schooling, boys will mostly become
farmers - or low-income urban dwellers - and girls will become
mothers. Therefore, co-operation with schools and the education
department is essential at all levels.
Likewise in agriculture, the outlook of the rural worker will
profoundly influence the farmers. Whether he actually gives a
meaningful place to the development of home gardens and pro-
duction of protective foods or not, may well make all the difference
between community co-operation or disinterest in a food and nutri-
tion programme.
4. METHODS
4..1 Planning
Most health workers have insufficient background training and
specialized knowledge in educational techniques. There are health

education specialists in many government services. Their specific
function is to advise health personnel on how to make effective
health education including nutrition education. Health educators
are not expected to do the whole job of educating in health. This
is the responsibility of all members of the health centre team,
equally. Each has his own field of special opportunities and res-
ponsibility, but it is likely that the nurse and midwife will actually
be the chief promoters of nutrition, under the physician's guidance.
The guidance of health education specialists should be sought par-
ticularly on methods of planning, implementing anci evaluating,
and on how to secure a fuJI community participation and follow-
up action.
In fact, in a properly planned nutrition programme, nutrition
education should be the subject of a separate plan of work or
action programme, drawn up for the same reasons and along the
same lines as indicated for nutrition surveys. This is important,
to ensure that the nutrition education programme will benot mere-
ly a "flash-in-the-pan" but an on-going programme with proper
sequence and development, and periodic evaluation. 24
4.2 Community education and community development

To evolve an effective nutrition education programme, commu-
nity participation is imperative. Involving people in the commu-
nity in planning this programme is one way of enlisting their
active support on a project. Other advantages are:
(a) several heads involved in thinking are better than one;
(b) they are committed all the more for the suCcess of the
programme which has involved their ideas and decisions.
Village councils are the primary bodies to be involved at village
level. If they do not meet regularly, their activities should be
stimulated. For each sub-district within a village, an active
organization may be needed, with leaders specifically designated
in the fields of (a) food production and (b) child feeding. The
activities at this level, which may inclu4e about 20 families, should
be co-ordinated by the village ~ouncil as a whole.
Voluntary civic, religious, and other community service orga-
nizations, should also be involved. To get their support, care
should be taken that their participation will not unnecessarily
withdraw them from their regular programmes and work. Mu-

tual understanding of "omplementary programmes should be deve-
loped through frequent discussions and visits, to show mutual
appreciation of each other's accomplishments, problems and diffi-
culties. One should work through existing organizations as far
as possible, rather than establishing new ones.
The participation of lay-leaders, and civic-spirited individuals
and citizens, should likewise be enlisted. Representatives of the
press, the radio, and other mass media channels may be invited
to participate and to help disseminate useful information about
the nutrition programme.
One problem in organizing and maintaining a nutrition t>duca-
tion programme may be how to get the attendance of mothers,
fathers, or other adults in the class sessions, conferences, discus-
sions, seminars, and workshops that are organized for them. Nutri-
tion education leaders should not overlook the fact that attendance
of participants in these classes is voluntary; that these adults are
busy with their home duties and find little time to atten~ confe-
rences; that they are too tired to attend classes after a hard day's
work.
While these are real factors, it is equally true that these
parents desire improvement in their standard of living, in their
earning capacity, in their social and cultural life. But they may
not want to attend formal classes after quitting these for many
, years.
Does the programme cover the problems, needs and interests
of the individual families and groups? These must be adequately
identified first, and programmes must be adjusted to their needs.
In this process, it is a sound practice to involve the individuals
or parents concerned. They should participate in initial surveys,
interviews, observations and other data-gathering activities, and
also in the evaluation and interpretation of the data gathered.
This is in itself an education for the participants. Defining real
problems and working out their solutions is learning at its best.
In this way they can share fully in the policy-making and imple-
mentation.
4.3 Implementation
After the fact-finding stage, the data obtained should be
analyzed and interpreted and reported back to the people concerned.
This should result in the crystallization of problems and needs

which should be formulated into practical and attainable objectives.
These objectives should serve as a guide and motivating force
towards the achievement of programme goals. Well-defined
objectives not only prevent confusion in the preparation of pro-
gramme units, but also insure the selection of activities which are
acceptable to the participants and which offer immediate solutions
of their wants.
The programme of action should be formulated out of these
objectives. It may consist of a list of project activities designed
to accomplish these definitely stated objectives. Since it is likely
that there will be many activities to cope with, it is necessary and
easier to classify and arrange them into the order of their priority
of importance. Problems may be solved one or two at a time. To
attend to all the problems at once may result in solving none with
satisfaction, and hence frustration among the participants.
The programme of action should also embody specific ways,
means and resources to be used in carrying out the objectives, and
activities arranged in order of priorities. These activities should
be presented as an outgrowth of the objectives accepted by the
group or the community. Thus the nutrition educators become
advisers and catalysts to a locally-conceived and implemented pro-
ject, rather than executors of a centrally-planned project.
Since the nutrition education programme is a co-operative pro-
ject involving the active participation of different community ser-
vice agencies, care should be taken to avoid overlapping of activi-
ties, and neglect of other important areas. A sub-committee may
work out co-operatively with the people a schedule to be follower..
These activities should be adapted to the needs and capabilities
of the group members. In this connection, schools may extend
technical assistance, not only in the organization of mothers'
classes, but also in the use of techniques and instructional aids
mentioned below.
4.4 Techniques
There are several methods and techniques of nutrition educa-
tion. Each of these methods has its particular virtue and effective-
ness in accomplishing certain objectives. There is no magic me-
thod for all objectives. The most effective methods and techni-
ques of educating mothers on nutrition are the following:
1. Discussions in varied forma, such 88:

(a) lecture-discussion
(b) panel-discussion
(c) symposium
(d) film-diacu8Sion
2. Demonstrations and practice claaaea
3. Role-playing
A wide variety of educational materials can be used as ins-
tructional aids, but they need to be carefully selected, adapted and
relevant to local conditions. They should simplify the subject and
make it more concrete, rather than more complicated and abstract.
They need to be-
(a) adapted to the learning level, experience and needs of the
learner;
(b) suitable to convey the ideas to be imparted to him;
(c) able to help him solve his problems;
(d) aesthetic but easily handled, cheap, light, pre-tested and
preferably home-made.
MOllt people retain only about 10% of what they read; only
20% of what they hear; but 50% or more of what they see and
hear together, if integrated properly, and up to 90% if they parti-
cipate actively in practical work (see Fig. 6.1).
4.5 Some instructional aids

Handbooks and manuals - for use of the worker, not the public.
Pamphlets and lea1lets - for distribution. A sample leaftet
on infant feeding is shown on pp. 303-310.
Pictorial materials: photographs, with suitable caption (e.g.
Plate I, p. 43).
Chart materials: bar charts (e.g. pp. 24-26) and pictures for
display.
Display materials: food models, other models, dioramas,
exhibits.
Chalkboard and ftannelgraph (overleaf).
Films, filmstrips, slides, posters.
Tape-recordings, radio, TV.
FIGURE 6.1
FIGURE 6.2
The device shown below can be made from loeaUy available timber and other
materials, costing about $2.
Bar charts can be made from coloured Manila paper. With sandpaper
stuck on the back these large bars can be placed effectively on a ftannelgraph.
Picture cut-outs of the appropriate food can be placed below each bar, so
that the bar indicates the relative nutrient content of that food (for a spe-
cified nutrient). This can be more easily appreciated by illiterates (and
literates!) . Members of a class can be tested afterwards to see if they can
place. the appropriate picture under each bar.
_ _ HANDLE
~PLYWOOD
CHALKBOARD
.. (BLACKBOARD)
FIipeharts can be hung in the middle of this device.

Some comments on the various instructional aids mentioned are:

(1) The natural obiect is always much better than any picture
or model. Usually with a little effort a small plant or some seeds,
or at least some leaves, can be obtained. It is better still to have
some seeds or cuttings available to give to interested persons after-
wards.
However, food models may be made from clay, plasticine or
papier-mache. Usually they should be the same size and colour
as the natural object. They may be used to illustrate a lecture;
or in tests for mothers, or games for children.
(2) Pictures should be easy to distinguish even from a distance.
Captions should be in the vernacular. Letters should be 1/7 as
thick as they are high. The distance between lines must be at
least Ii times the size of the letter. Schematic diagrams are
useful to emphasize an essential point and. minimize the rest.
Graphs may be used to illustrate the growth of well-nourished and
poorly nourished children (e.g. Figure 4.1, adapted as a bar chart).
(3) Photographs. To persons unfamiliar with them they may
seem to belong to a world of fantasy, even though they are photo-
graphs of local subjects or persons. Horror pictures should be
minimized. But usually photos of local subjects are particularly
appealing and meaningful.
(4) Posters should be simple, clear and aesthetic in colour and
arrangement. There should be only one main message, which
must be grasped at first sight. They should stimulate interest and
action. The placement (and replacement!) of posters needs care
and evaluation.
(5) The jlannelgraph!chalkboard is simple and inexpensive -
no more than $2. A piece of llannel pinned on to heavy card-
board with thumbtacks will do. The llannel must be of a colour
that will make a good background:' usually black, white or grey;
others like pink! Pictures and bar charts need some coarse sand-
paper stuck on the back so they will adhere to the llannel. In the
c9mbination-piece shown, llip-charts can be hung in the middle.
between the llannel-board and chalkboard. These should be on
durable heavy paper or light cardboard (Manila paper). They are
displayed by opening out the boards at the hinges. The pictures
and words are lined up in sequence on successive charts for a
lecture-discussion.
(6) The cka,lkboard is a most versatile medium. It is worth-.

while taking the trouble to learn how to make clear lettering and
diagrams or even cartoons which can vividly demonstrate a point.
The portable chalkboard is useful for lecture-discussiol1s at all
levels, from national food policy to village mothers' classes. It
is more adaptable to different situations which may crop up, than
the "railroad" prepared fiipcharts and fiannelgraphs.
(7) Film, filmstrips and slides. These are extremely effective
educational media, but the principal difficulty is in getting mate-
rial truly adapted to local situations, which djffer everywhere to
some extent. From this standpoint, a set of coloured slides is the
most versatile. A standard series (and suitable variations) can
be assembled on individual subjects (e.g infant-feeding), and to.
portray nutrition programme activities as a human-interest
stimulus. These could be standardized as filmstrips. However,
filmstrips tend to become outdated, and also easily become scratched
through repeated use. Even filmstrips but more particularly films
are very expensive to produce and can therefore seldom be made
to suit purely local requirements.
Practical difficulties with these media include:
(a) How to show them in villages without electricity supply.
Projectors which can be operated from batteries, or vehi-
cles with suitable generators, are obtainable but expensive.
(b) Language. Captions and soundtracks may be in the na-
tional language, whereas in many remote areas a dialect
is spoken.
On the whole, these media are suitable for medium-level govern-
ment personnel (e.g. paramedical personnel, teachers) but not for
village-level work.
(8) Exhibits and exhibitions. These should be simple and
attractive in colour and design. They shouid not be raised too
high above the fioor, so that they can be easily seen. Captions
should be clear and concise, but the emphasis should be on the
object rather than on printed information, e.g., a model village
nutrition station, together with vegetable garden, safe water supply
and sanitary latrine. The best staff available should be assigned
to the booth, to answer questions put by the public.
4.6 How to make a food demonstration

(a) Personal qualities: Pleasing personality, vivacity, poise
and a good sense of humour; adaptable and flexible in case of
interruptions or emergencies; open-mindedness and willingness to
listen to ideas that differ from her own; clear enunciation; a natu-
ral pleasing voice, well-modulated and easily heard by everyone.
(b) Thorough preparation: The demonstrator should know
points to stress, principles underlying the demonstrations, and
plan carefully each step necessary to put across the main point.
Time-consuming tasks should be done in advance, e.g. chopping or
cutting of ingredients, prolonged boiling, etc. Tools or utensils
should be in good working order. Equipment similar to that
used in the homes of that community should be used, to make the
transfer of learning easy.
(c) Presentation: The purpose of the demonstration is ex-
plained and the sequence outlined. A demonstrator should move
quickly and with ease of manipulation, but should not rush through
it. Wastefulness in time, motion and use of supplies should be
avoided. Explanation and action should be co-ordinated and sim-
ple, ending with a summary.
(d) Work area: An orderly attractive setting, e.g. maybe
with a colourful plant placed near the demonstration area. The
minimum number of dishes should be used, and afterwards
stacked; waste products should be discarded. Each process be-
ing demonstrated should be visible to the audience and not obscured
by equipment or demonstrator. A large mirror placed (slanting)
above the table may be helpful to let the viewers obtain a bird's
eye view of something that would otherwise be concealed.
(e) Feeding. Enough should be prepared to enable mothers
and children to taste, including infants if an infant food prepara-
tion is being demonstrated. It is simplest to ask mothers to bring
their own cup and spoon for this purpose. If the preparation is
still hot, mothers should be forewarned to let it cool first.
(f) Evaluation as to effectiveness of demonstration: Interest
of the audience, and challenge to their thinking, should be assessed.
Were they on time? Were the products prepared of adequate
standard; well displayed, well received? Did they really like it?
Could the audience do it at home? Eventually, the mothers should

be followed up in their homes to see if they used the recipe at
home subsequently, and if not, why not? Are they too expensive,
too complicated, too unfamiliar, too tedious to prepare? Are they
still considered unsuitable for infants or are the mothers simply
not convinced that the infants need anything beyond breastmilk
until they are twelve months old? Has any mother noted diarr-
hoea or allergies, etc., attributed to the food? Which recipes are
the most readily adopted at first? Perhaps some others prove
more acceptable later on, but not at first? Some preliminary
evaluation along these lines in a community under close study
might be a wise step before going further afield in nutrition edu-
cation programmes along these lines.
(g) Practice. If facilities exist (and they should be sought
and provided), mothers should have the opportunity to make the
same preparation under supervision, on the same day or another
day. The mothers may be requested to provide the ingredients
themselves for this.
5. SUPPLEMENTARY FEEDING
5.1 Orientation
Health workers generally are not directly responsible for feed-

ing programmes other than hospital and dietetic services. How-
ever, school health services are often directly or indirectly involved
in school feeding programmes, and school feeding is one way of
correcting and preventing nutritional deficiencies. MCH pro-
grammes and health centres often have available considerable
quantities of milk or other valuable supplementary foods, besides
vitamin and mineral supplements. Health workers are primarily
concerned with the prevention of malnutrition, which occurs most
often among toddlers. Programmes of supplementary feeding for
infants and toddlers are therefore a priority for health personnel.
For hospital diets, the usual limiting factor is finance. For
malnourished children, high-calorie, high-protein diets are needed.
Low-cost recipes will be needed, such as indicated in this manual.
Suggestions for reduction of obesity are given on p. 89. Special
diets are needed for diabetes mellitus (carbohydrates fixed at low
level), nephritis (high or low protein), peptic ulcer and various
other gastro-intestinal disease. Special texts should be consulted
on these. It is often possible in some hospital precincts to grow

some of the highly nutritious vegetables mentioned in this manual,
for demonstration purposes as well as for supplying the hospital
kitchen.
Supplementary feeding programmes serve two main purposes:
(a) directly to improve nutritional status and prevent mal-
nuuition;
(b) as a means of nutrition education.
Of these, the latter is probably the more important. 'Supple-
mentary feeding programmes which consist in the distribution of
foods such as milk, wheat or maize products, can on a temporary
basis favourably affect individual and community nutritional
status. Particularly after natural disasters, they can avert star-
vation pending the re-establishment of normal food production and
supply lines. But food donations of this sort are usually essential-
ly stop-gap operations, often short-lived and of limited scope.
Applied nutrition programmes sprang out of efforts to develop
local food production to meet the nutritional needs, rather than
depending on unreliable external supplies. -
Nevertheless, such external supplies can be a stimulus to better
patterns of feeding for young children and for schoolchildren, if
other local foods can be provided for consumption together with
those supplied from outside.
5.2 School feeding

School feeding programmes of some sort are operated in prac-
tically every country in this Region, because-
(a) many children have had inadequate breakfast;
(b) some have too far to return home for lunch;
(c) a snack is physiologically needed by mid-morning anyway.
Feeding often takes the form of a mid-morning snack, because
the resources for a full meal are usually inadequate, but sometimes
a lunch or breakfast is provided, based on foods provided by gov-
ernments, or external agencies, or by the local communities them-
selves. Probably even more often, pupils buy a small snack from
a school canteen or private vendor.
If properly run, school feeding programmes can serve several

useful purposes:
(a) directly to improve the child's nutritional state during this
phase of rapid development;
(b) to stimulate local community interest in nutrition in
general;
(c) as a practical demonstration on food and nutrition - the
proper selection, storage/preservation, and preparation of
highly nutritious foods;
(d) to provide opportunities and illustrative material for
nutrition education, health education and agricultural edu-
cation during class work in various subjects - not only
directly related subjects e.g. health, home economics,
science, biology, agriCUlture, sociology, etc., but also in
arithmetic and other basic subjects;
(e) as training for parents who may be involved (in rdtation)
in the preparation of school meals or snacks, and in food
production programmes to support them.
School feeding should be linked with agricultural education and
school gardening programmes as well as with nutrition and health
education, so that all these are intertwined and integrated.
It can be a useful medium for spreading health education and
improving health habits generally, e.g. by encouraging washing
of hands before meals, brushing teeth after meals and snacks.
Another indirect advantage is to improve existing school snacks
which are commonly sugary or refined wheat products, i.e. chiefly
carbohydrates without sufficient protective foods to balance them,
and very inj urious to the teeth.
The responsibility of the health workers is mainly related to:
(a) the general health and educational principles and techni-
ques to be applied in such programmes;
(b) assessing nutritional priorities for different age groups
and their nutritional needs and requirements;
(c) assessing the effects on nutritional status;
(d) ensuring adequate food hygiene at all stages of prepara-

tion handling and consumption, and related aspects of
environmental hygiene in the school.
For further information, F AO publications should be consulted,
since that organization is mainly responsible for school feed-
ing.6Oa, 62f
5.3 Nutrition centres for infants and toddlers

Some feeding programmes have been initiated for infants and
toddlers in both rural and urban areas. They serve ~
(a) improve directly the nutritional state;
(b) demonstrate the value of locally available foods and their
proper preparation, especially for infants;
(c) promote the acceptance of these foods for infants and tod-
dlers, through community feeding in a picnic atmosphere,
which introduces both the mothers and children happily to
the new preparations;
(d) encourage the production of such foods when there is land
available (even a little) in the fields or home-gardens.
Motivation is an important prerequisite for launching such a
programme. Orientation may be given through community edu-
cation or development programmes, farmers' and mothers' classes,
or applied nutrition programmes. Usually a series of community
educational meetings is needed to convey an appraisal of the nutri-
tional situation. A survey may have been done previously, or a
small survey may be proposed and undertaken at this stage. Most
often, general guidelines on nutritional priorities will already be
available or can be formulated on the basis of existing knowledge.
Food production activities can be initiated and as spon as some
local produce is available group supplementary feeding can begin.
A detailed plan of work or action programme should be drawn
up under the same headings as described for nutrition surveys.
A pattern for nutrition centres, capable of application in many
countries in the Region, is described below.
Activities should be developed among groups of no more than
20-30 families. With these numbers, enough food can usually be
prepared for the 20-40 toddlers present, using existing cooking
facilities and utensils. In rural areas and sometimes in urban
areas, two local leaders are usually necessary: one (an influential
farmer), to lead the food production activities; the other (an

influential mother) , to lead the child-feeding activities. Each
group of families should be under the close supervision of a govern-
ment or voluntary worker with adequate background in nutrition,
e.g. a nurse, teacher, community development or social worker,
who has been given specific training for this responsibility. Lay-
men in the community, including farmers, labourers, and youths,
can also give effective leadership and dem9nstrations in cooking,
gardening and farming.
Usually one nutrition centre will be needed for each 20-80
families. A local homestead may be used, but it is usually con-
venient to construct a simple shed out of local materials, avail-
able at little or no cost, more or less as shown at the end of this
chapter.
Community feeding for infants or toddlers may be carried out
two or three times weekly; sometimes more or less often, depend-
ing on the weather and season, and on local enthusiasm and ge0-
graphy. Parents may be asked to provide materials in kind, or
cash instead, to cover the ingredients needed. After courses of
instruction, the mothers or local voluntary workers can carry out
the food preparation in rotation. One recipe should be used for
infants and another for toddlers. The recipes may be based on
those shown in Annex VII A & B, locally modified with the guidance
of a nutritionist. The nutrition centre should have its own safe
water supply, e.g. pump- well, and sanitary latrine, and also a
small demonstration garden which should supply vegetables (espe-
cially leafy greens) for the feeding.
Such nutrition centres may become a regular feature of village
life or may only be needed temporarily, to familiarize mothers with
suitable recipes and feeding practices.
In urban areas it has proved feasible to conduct nutrition acti-
vities similar to the above, based on the health centre or the com-
munity school, where facilities can be obtained for mothers to
practise preparation of the recipes. For these circumstances a
course of six topics is suggested (overleaf) to cover some simple
infant-feeding recipes. A course of instruction may be prolonged
as long as 12 weeks but should not go beyond this; it may be re-
peated the following year covering a different syllabus or a dif-
ferent group of mothers.
Nutrition centres of the above type could be operated by health
personnel independently of other agencies, but it is desirable to co-

operate '. with other agencies where possible. . Health personnel
could usually cover only a small part of their territory intensively
in this way. This problem could be resolved by working inten-
sively in different villages each year, in rotation. Alternatively, if
the co-operation of school teachers, for instance, can be obtained,
they may be willing to maintain the routine supervision of the
nutrition centres, but with the technical advice of health workers
on matters of infant nutrition 'and general health.
Such activities should be evaluated as to their educational
impact in the way described on p. 166. If possible, their in-
fluence on nutritional status should be assessed at least by the
increments in body weight over suitable intervals of time (three-
monthly and annually). However, control groups are necessary
for evaluation along these lines, and the participation of these
mothers is likely to be irregular. Proper evaluation is therefore
difficult. If there is no immediate effect on body weight, this should
not give undue concern, provided the educational impact appears
adequate.
Other types of nutrition centre for infants and toddlers, ope-
rated successfully in some other regions, are termed "nutrition
rehabilitation centres". Severely or moderately malnourished
children are brought to these centres, instead of being hospitalised.
They may come for single meals or for full daily attendance (three
meals). During their attendance intensive nutrition education is
provided for the mothers, and practice in the preparation of suit-
able foods for the young child. These centres, although seeming-
ly costly to establish and operate, may in fact be economical, by
forestalling severe malnutrition and so minimizing the needs for
hospital beds. They are mainly of value in localities where there
is a substantial number of severely malnourished children. This
is the case in Saigon, where one such nutrition rehabilitation centre
is in operation, and serves also for training of health and social
workers in nutritional rehabilitation. Further details on the ope-
ration of nutrition rehabilitation centres are available. 2ssb ,
All these programmes may be transient as operated on a com-
munity basis, but should substantially affect family food consump-
tion patterns, and especially those of infants and toddlers. Pro-
gress surveys in pilot areas are really needed to assess this, cover-
ing both food consumption and nutrition status aspects.
OPERATION OF URBAN NUTRITION CENTRES

1. Co-ordination
Secure sponsorship and participation of the relevant Nutrition. Council
(city or municipality) . Enlist the local experts in nutrition, health and
education - especially nutritionist, physician, health educator, nurse, mid-
wife, teacher and home economics supervisor, and the mayor and village head.
2. Nutrition education on infant feeding
Organize classes for 20-30 mothers twice weekly - one talk and demons-
tration, one practice class each week.
Invite them to the school, where there are facilities for teaching and
practical work.
Suggest a series of 6 weeks covering the following main topics:
1st Week
Infant feeding - general review:
Better food for baby means better development of body and mind.
Use of cheap local foods, simple recipes, e.g. mung beans and small dried
fish for body-building, if no milk.
Baseline: Weigh the babies; complete the information sheets of each
child (parents, age, weight, height, etc.).
(Practice session later in the week - mothers make recipes them-
selves).
Ind Week
Green leafy vegetables: value of different kinds - nursing mothers should
eat plenty, to give more and better milk, protect baby's eyes.
Demonstration - mung bean/rice porridge with leaves (strained if
baby below 6 months)
Practice class - same (mothers to bring green leaves).
8rd Week
Yellow vegetables and fruit - protect eyes (yellow sweet potato, pumpkin,
carrot, mango, papaya)
Demonstration - yellow sweet potato and dried beans (boiled and mashed)
Practice class - same.
~th Week
Ground peanut - how to grind or pound. Emphasize no moulds.
Demonstration: Ground peanut/mashed banana (yellow core) for baby.
Practice class: same.
5th Week
Fish - how to feed to infants - fresh; fish dour, dried shrimps.
Demonstration - fish flour in mung bean/rice porridge.
6th Week
Care of the mother - diet during pregnancy
diet after delivery
diet during lactation
Demonstration - mother's choice (specify the week before)
Operation of urban centres (continued)
3. Evaluation
During the next 6 weeks, follow up each of these mothers in the home:
Are they using these recipes! If not, why not! Too expensive? Not con-
sidered necessary? Not considered suitable for baby? Not liked by baby?
Not liked by mother?
Progress surveys: reweigh the baby. Compare the increases with those
found in a group of other children (not included in the classes but same
age).
4. Expansion
Start with another group of mothers only if satisfied that the first group
is already following the recommendations in their homes, individually, or if
they are continuing group feeding in their own homes on rotating basis.
(Suggest a competition.)
MATERIALS AND EQUIPMENT FOR
VILLAGE NUTRITION STATION
A. Coutf'UCtWn Ma.terials
Approx. cost
Bamboo (or locally available timber) $ 8.00
Nipa thatch (alternatively: palm") 20.00
Nails 1.00
Rattan 1.00
$30.00
·Less expensive but less durable
B. Kitchen Equipment (Minimum)
Approximate
Cost per Number Total
unit Needed Cost
Stoves (clay) $0.25 2 $0.50
Sink (galvanized irotl) 1.60 1 1.60
Kettles (vats with lid)
(20-litre capacity) 2.50 2 5.00
Petroleum cans (20 litre capacity) 0.25 2 0.50
Wash-basins (plastic, 45 j:Dl wam.) 0.50 3 1.60
Water-reservoir with faucet 1.50 1 1.50
Colander 1.00 1 1.00
Wire or bamboo strainers 0.26 2 0.50
Com mill (grinder) 8.00 1 8.00
Chopping boards 0.25 2 0.50
Ladles (coconut-shell) 0.25 2 0.50
Kitchen knives 0.50 2 1.00
$22.00
Total cost for materials and equipment: approx. $50 - $60 (for 50 participants)
175
176
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1
CHAPTER VII
FOOD HYGIENE AND STANDARDS
1. FOOD HYGIENE201.232a. K .F.23,h.231b
1.1 Orientation
Food hygiene has been reviewed in several authoritative docu-
ments and in regional seminars held in Manila in 1962235b and
New Delhi in 1967237b. These documents emphasize the hazards
to health and the economic losses, which may sometimes be tre-
mendous, from poor food hygiene. It is stressed that while some
financial outlay is involved in food sanitation programmes, the
rewards for this outlay are proportionately greater in develop-
ing countries.
Food hygiene or sanitation covers all measures necessary to
ensure the safety, wholesomeness and soundness of food at all
stages from its growth, production or manufacture, until its final
consumption. This entails proper food handling. The aim is to
prevent food poisoning and other food-borne illnesses, which are
classified in Table 7.1. Table 7.2 indicates the causes of some of
these in more detail. More broadly, food hygiene includes also
measures to maintain proper food standards and the safety of
food additives, as discussed in section 3 below.
The foods most commonly responsible for food-borne diseases
are milk and milk products, meat, fish and shellfish, eggs, salads
and other vegetables eaten raw.
179
TABLE 7.1'
CLASSIFICATION OF FOOD·BORNE ILLNESSES
Group Examples of illness in each group
Bacterial infections Typhoid and paratyphoid fevers

Staphylococcal intoxication
Bacterial toxins Botulism

Salmonella food poisoning
Tuberculosis
Brucellosis
Bacillary dysentery
Streptococcal infectiona
Parasites Taeniasis
Hydatidosis
Trichinosis
Ascariasis
Amoebiasis
Chemicals Mineral poisoning (e.g. antimony, arsenic, copper.

lead, selenium, tin, zinc)
Lubrication oil poisoning
Natural poisons" Mushroom poisoning

Cassava poisoning (root or leaves)
Lima bean poisoning
Fish poisons
232ft
*Modified frorn WHO 156
Q
4- On thete .ubjects. see Nicholls el al.
TABLE 7.2
FOOD·BORNE DISEASES*
The list given below contains some diseases in the transmission of which food plays an essential role, such as in the caae
of certain parasites where a food animal is the host or intermediate host. It also contains other diseases ·whlch can be trans.
mitted by the contamination of food as well as in other ways.
DiselUl6
1. B acunal diseases Causative organism Vector or means 0/ .pread
Anthrax Bacillus anthracia Contaminated meat
Botulism Clostridium botulinum Anaerobic growth of spores in adequately
processed canned or bottled food
Cholera Vibrio cholerae Contaminated water or food; flies
Dysentery bacillary Various species of genus Shigella Contaminated water or food; ilies
Paratyphoid fever Salmonella spp Contaminated food, particularly with flies - milk,
milk products, shellfish, etc.
Salmonellosis Salmonella spp Contaminated food, particularly meat and meat
products, and milk products
Staphylococcal infections Staphylococcus spp Food contaminated from human sources
Streptococcal infections Streptococcus spp Food contaminated from human sources
Tuberculosis Mycobacterium tuberculosis Contaminated milk, milk products and meat
Typhoid fever Salmonella typhi Contaminated water and food, particularly milk,
milk products and shellfish
Z. Para8it~ dis "lUI'"
Amoebiasis Entamoeba histolytica Contaminated food, particularly vegetables eaten
raw; water
Ascariasis Ascaris lumbricoides Contaminated vegetables eaten raw
Clonorchiasis Clonorchis sinensis Raw or partially cooked infected fresh-water fish
Diphyllobothriasis Diphyllobothrium latum Raw or partially cooked infected fresh-water fish
Enterobiasis Enterobius vermicularis Contaminated food
Fasciolopsiasis Fasciolopsis buski Contaminated vegetables eaten raw
Hydatidosis Echinococcus granulosus Contaminated food and water
Taeniasis and cysticercosis Taenia saginata Infected beef
Taenia solium and its larval form Infected pork
Cysticercus cell ulosae
Trichinella spiralis Infected pork
Trichiura Contaminated food 181
•From 2Mb
Foods of animal origin are favourable bacterial cultural media.

If contaminated with pathogenic bacteria, they readily produce
and convey large doses of toxins (especially from Staphylococci
or Clostridium botulinum) or pathogenic bacteria (Salmonellae,
Enterococci, Clostridium welchii, Proteus, some Escherichia coli
atrains, etc.) which cause gastroenteritis and sometimes neurolo-
gical disorders. Staphylococcal t.oxins are probably the commonest
cause of food poisoning. Once food is contaminated, bacteria can
multiply with fantastic rapidity. If toxins are formed, these are
not eliminated by heating. When cooked foods are cooled to room
temperature, bacterial multiplication can proceed rapidly, even for
a time after placed in a refrigerator, because it is some time be-
fore the central portions of the food become too cold to prevent
bacterial multiplication.
The consumer should take particular care to purchase only
uncontaminated foods, remembering the hazards of contamination
by flies, and of purchasing meat or fish which are not fresh even
though they may look clean. This underlines the need for strong
programmes of health education to support food hygiene pro-
grammes.
Vegetables are liable to contamination during both production
and marketing, with faecal-borne bacteria and amoebae and other
parasites. This is particularly true where human night-soil is
used as a fertilizer in their production.
Multiplication of bacteria in foods is minimized by heating,
drying, salting, pickling (in vinegar), canning with sterilization,
cooling (to 10·C or lower), freezing, and irradiation with ionizing
radiations. Bacteriostatic or bactericidal chemicals are some-
times permitted on foods to meet special problems, but are only
allowed within strictly defined limits as specified in documents on
foods additives and antibiotics 2850•
1.2 Some hygiene hazards of certain foodstuffs

Fresh milk228b • 2820, b is always liable to contamination during
the milking process, and may transmit diseases present in the
animal concerned (such as tuberculosis, brucellosis). Herds should
be inspected by veterinary officers, and infected animals elimina-
ted. In most developing countries the consumption of raw milk
is not advisable, and it should be made safe by bringing it to the
FOOD HYGIENE AND STANDARDS 188
boil; commercial pasteurization is not dependable. Contamina-
tion of milk powder is discussed on p. 28.
M eat23'lm is probably responsible for more food poisoning than
any other food. In developing countries, the animals are often
infected with some illness when slaughtered and there are plenty
of flies and few refrigerators! Meat should always be cooked
(especially pork) - through to the central portions - before con-
sumption. Abattoirs should be maintained in a sanitary condi-
tion and food animals should be examined by a qualified person
before and after slaughter. Diseased animals should be con-
demned and only wholesome meat passed for sale for human con-
sumption. Meat for sale should be protected from contamination
and where possible kept cool at a temperature below lODC. Ven-
dors should be required to handle meat in a clean manner and
protect it from flies. These rules are always difficult to enforce
but especially so in developing countries!
Poultry and eggs. It is desirable to eviscerate poultry when
slaughtered. Eggs should be produced under clean conditions
and should not be washed, because this removes the protective
albuminous layer.
Fish and shellfish should be inspected, and rejected when neces-
sary. They should be protected from flies. Oysters and shrimps
are known to have been responsible for cholera transmission.
Fish and shellfish should not be consumed raw unless obtained
from known hygienic sources. The practice of salting fresh fish
when they begin to decompose is dangerous.
Vegetables are very liable to be contaminated with the ova of
parasites (particularly Ascaris), especially if human night-soil is
used in their cultivation.· Unfortunately, treating them with
vinegar, potassium permanganate, detergents, etc., does not eli-
minate the contaminants; these processes are almost entirely use-
less, and they give a false sense of security. The only effective
means of control really is by boiling or steaming for three minutes.
In general, salad vegetables are not safe to be eaten raw, unless
produced in one's own homeyard with no risks of contamination,
and then only after thorough washing with running water. Banana
flower is an exception.
Fruits which are peeled before consumption are safe. Fruits
*.see Paguia. A.D .• Cysts Ilnd ova of intestinal parasites found in vegetahles usually eaten
raw. WPR/Env. San. I Food S."ln.12. 10 Octobf'r J962. IRd. 23Sbl.
which are likely to be eaten unpeeled and which are sprayed with
poisonous insecticides may cause toxic effects in the consumer.
They should be thoroughly washed to remove spray residues.
Peanuts may be contaminated with afiatoxins. These are
produced by a mould (Aspergillus) which may affect peanuts when
they are harvested or stored under damp conditions. Studies on
afiatoxins are under way in several countries in the Region. Afla-
toxins are highly toxic or carcinogenic to some animals (e.g. rats
and ducks, but not mice or monkeys), and their possible effect on
humans is not known. Peanuts should be examined for signs
of mould and the sound nuts stored in dry conditions; those with
moulds should be rejected.
Other foods can be contaminated in many ways during pre-
cessing and can be hazardous, e.g. exposure of meat or fish to flies
during drying; barefoot trampling on shrimps to remove their
shells. Canned foods if not properly heat treated and hermetical-
ly sealed can contain highly dangerous gas-forming organisms and
toxins so evidenced by the "swells" or "blown" cans (expanded at
the ends because of internal pressure). Composite and cooked
foods such as pies, pastries, prepared meals, cooked hams which
are subjected to some manipulation and handling are often dan-
gerous through the build-up of organisms or toxins. Protection
and proper storage of such foods, either hot (above 60°C or 140°F)
or cold (below 10°C or 50°F) is especially important.
Ice cream, frozen novelties, and ice if produced under unhy-
gienic conditions or exposed to contamination during manufac-
ture, delivery or storage, can contain viable pathogens.
1.3 Some food handling hazards

Some illustrations would include:
(a) Storage: rodents, cockroaches and other pests may con-
taminate food with bacteria through their nibbling habits
and excreta.
(b) Wrapping: newspapers are not hygienic! Banana leaves
may become contaminated during their handling before
foods are wrapped in them, but otherwise are one of
nature's best provisions.
(c) Displaying: slicing fruits or other foods invites contami-
nation from road-dust "fall-out" and flies. However, these
foods are often not particularly good media for bacterial

culture, therefore the risks may be leas than they appear.
Dry or salted foods, and vegetable foods, are leas hazardous
than moist foods and animal foods, from this standpoint.
(d) Retailers and eCJting houBu: unwaBhed banda, unclean
containers and utensils. and lengthy exposure of foods to
local surroundings, including flies, are the common pit-
falls. These aspects tend to be the main worry of such
health personnel as sanitary inspectors in some areas.
(e) Community or institution feeding: One careless food
handler, or one human carrier of disease, who prepares
food at home, will jeopardize the health of only a small
number of persons, mainly members of the family. When
one 8ucbperson works in the kitchen of a restaurant, hos-
pital, factory, canteen, school, or other places where meals
are supplied to many people, the number of potential vic-
tims is correspondingly greater.
It should be remembered that apparently healthy persons may
be transmitters of such dangerous diseases as infectious hepatitis,
amoebiasis, bacillary dysentery and typhoid, besides diarrhoeal
disease and ascariasis.
Commercial and communal feeding present major food-hygiene
problems. Dangers arise mainly from the methods employed in
cooking and storing food. Food is often cooked long before it is
served, and kept warm for a number of hours. In certain ins-
tances it is transported long distances before serving. These
practices provide conditions suitable for the multiplication of any
pathogens which may have been present in the food when it was
introduced into the catering establishment, or may have gained
access to it subsequently.
In the home, the whole family is subject to a relatively stable
bacterial environment, and the children of a "carrier" mother are
likely to have an established immunity. But such a person may
easily convey sickness to large numbers of people if she serves
in a school-feeding programme, for instance. It is imperative
that all as,sistants be free from infectious disease or from any
condition causing a discharge of pus or serum from any part of
the head, neck, banda, or arms. It is important that they main-
tain a high level of personal hygiene and in particular wash handa
frequently and serupuloua)y especiaUy before commencing work in

food bandling or preparation and especially after visiting the
toilet. Ideally, all should have a faecal bacteriological ~t (for
non-lactose fermenting organisms). The same should apply to
kitchen staff and servers in public eating houses.
The principles of food hygiene in commercial and communal
feeding are the same as in any other type of food handling, but
they need to be applied with particular care because of the special
risks involved. Care is needed to ensure that food supplied to
the catering establishment is in a wholesome condition when
delivered. Within the catering establishment the food may become
contaminated by members of the staff carrying pathogenic or-
ganisms, and by insect and rodent peats. There is also the possi-
bility that bacteria may be conveyed by utensils. Bacteria may
survive on crockery, glassware, cutlery, containers, and other
utensils, and strict cleansing is, therefore, most important for
the destruction of harmful organisms from infected food, or from
the mouth or hands of infected persons. Most important of all,
food not intended for immediate consumption should be stored at
a temperature sufficiently low to prevent bacterial growth. On
no account should it be kept warm, or even cool, for long periods.
(f). Markets: Apart from eating-houses and community feed-
ing, the markets are the places par excellence where food
hygiene is maintained or spoiled. Standards vary tre-
mendously from air-conditioned, fly-proof, spotlessly clp,an
"supermarkets" - to shacks where stalls stand in the
mire, footpaths are open drains, refuse collects almost up
to the roof, tame rodents run around, flies have permanent
fiestas, and every kind of malpractice in food sanitation
is displayed!
Obviously much depends on civic conscience, the health-
consciousness of civic authorities and their ability to
enforce statutes and regulations, sometimes in the face of
public ignorance and apathy. The principal requirements
for hygiene in the markets are:
(1) Adequate space, and sectioning, ventilation and light-
ing;
(2) Floors preferably concreted, graded and drained;
(3) Adequate and safe supplies of water for drinking

and washing purposes, and adequate plumbing, drains,
surface drainage;
(4) Thorough cleansing of food stall counters and floors
at least daily;
(5) Garbage: Regular and adequate collection and storage
in covered bins, and removal at least daily;
(6) Sanitary latrines;
(7) Control measures for flies and rats;
(8) Prohibition on sleeping in market stalls.
1.4 Hygiene in the home*

Communicable disease reports indicate that home hygiene is
more often responsible for food-born infections than community
handling of food. For instance, the highly prevalent "weanling
diarrhoea" is seldom due to "eating out" but rather to food con-
tamination in the home. The factors to be considered in home
hygiene are:
(a) Potable water.Z19b Piped water is safest, but seldom
available in rural areas. Open wells are commonly contaminated
by surface-water run-off from homeyards (contaminated with
human or animal excreta), and also by dip-buckets which rest on
contaminated ground around the well when not in use. Even
water from hand-pumps is often contaminated because of seepage
externally down the pipe to the closed well from which the water
is drawn. (Nevertheless, pump-wells are naturally preferable.)
The surest simple method of sterilizing water for consumption
is by boiling, and this should be done whenever the water is of
doubtful quality. Chlorination and/or filtration are alternatives,
which may be practicable in some circumstances. Chlorination in
the usual dosages does not eliminate cysts and ova of parasites,
and filtration does not necessarily eliminate bacteria.
(b) Waste disposalZ 19a including garbage, animal and human
wastes. The simplest safe low-cost latrine is the water-sealed
pour-flush latrine, of which there are many designs219a. The main
problems usually are to convince the householder that he should
have one and use it, and also to have water on hand when and
-See BIaeeke. WPR/Env. San./Food SRn/3. October 1962 (Ret. Z35b).
where needed. Household waste water can be used for this pur-
pose, if water is really in short supply.
Animal wastes should be carefully collected in a distant corner
of the block and composted with alternating layers of manure/
soil/leaves and grass/ashes. This will generate heat and so elimi-
nate any pathogens present, provided it is regularly turned every
few daYS.S6
(c) Personal hygiene. Hand-washing must be taught as a
routine after toilet and before meals, and throughout the prepa-
ration of meals. Subject to this, the use of hands for eating, as
is traditional in many parts of the Region, is quite permissible.
(d) Food storage and preparation. The necessity for cook-
ing all animal foods and vegetables has been emphasized above;
also the hazards of letting it stand, especially if exposed to flies.
A fly-screen is a help and can be made of local materials. Keep-
ing foods from one meal to the next is to be discouraged.
(e) Insect and vermin control. Proper food storage and waste
disposal should largely solve this problem.
(f) Domestic livestock. These should be kept overnight in
stalls separate from the house if possible. Attention to manure
disposal is essential for health of the humans as well as the animals
concerned.
All these factors have to be considered within a socio-cultural
and physical environment which may necessitate acceptance of
intermediate goals which fall short of the ideal. Advocating too
high a standard alienates the people whom it is intended to help.
But on the other hand, accepting present practices because "they
were good enough for our forebears" will also bring the same high
morbidity and mortality in the next generation. Health educa-
tion is essential to promote family and individual health conscious-
ness. Efforts to improve environmental hygiene are complemen-
tary to those aiming at nutritional improvement Food hygiene
in the home is the common ground on which the two areas of
concern most clearly overlap.
2. ORGANIZATION AND LEGISLATION

Food hygiene programmes at present are oriented more to
urban than rural problems: food importation standards, food
processing and manufacturing, and inspection of food and food

premises including eating houses and markets. Work in rural
areas is difficult because of the distances, scattered populations,
lack of transportation and staff.
2.1 Personnel
The personnel responsible for supervision of the food premises
are usually health inspectors (variously designated) , who are
usually attached to health centres, and _they are responsible for
overall environmental hygiene programming. Food processing
and importation standards are mainly determined and supervised
by centralized food and drug administrations of the health depart-
ment, but may also be partly the responsibility of units of agricul-
tural departments (e.g. food laboratories). This falls mainly out-
side the scope of this manual, but the international supporting
framework is outlined in the next section.
To support proper investigations in matters of food sanitation
and processing, more adequately equipped bacteriological and che-
mical laboratories and trained personnel (both technical and
administrative) are needed.286b Laboratories are needed in the
periphery, as well as the strengthening of central laboratories.
2.2 Legislation
Ordinances and regulations covering these fields do exist in all
countries of the Region, but are seldom complete or consolidated.
The 1962 seminar in Manila recommended that governments should
(a) compile all basic legislation into a food sanitation act embracing
the whole subject, and (b) embody the more detailed and technical
legislation in regulations which could be changed easily to take
account of changing circumstances. 216b
2.3 Fieldwork
The principal problem in the field however is often how to
enforce existing legislation. The effectiveness of any food sanita-
tion programme is largely dependent on the nature and extent of
the work carried out in the field and the thoroughness with which
it is done. This work includes the inspection of food, both local-
ly produced and imported; the inspection of all premises in which
food is manufactured, processed, stored or sold; the inspection of
markets and stalls used for the sale of food and of vehicles used
for the transport or sale of food; the sampling of food to ascertain
its fitness for human consumption; and the education of all sections
of the community, including food handlers, the general public and
schoolchildren, in the principles of food sanitation. The effective-
ness of this inspection depends partly on whether inspectors have
authority to enforce compliance with the regulations, and partly
also on their determination to stick to the defined criteria.
(a) Inspection of imported food
In some countries there is a fairly close check on food imports,
particularly perishable goods such as meat, meat products and
dairy products, and certificates of fitness are required from the
countries of origin. In others, however, little or no public control
is exercised over imported food. The importance of the proper
inspection of imported foodstuffs is indicated by the fact that
during the year 1961, 6,060,000 tons of food were imported into
Japan of which approximately 1,700,000 tons were rejected or
had to undergo additional processing before being released for
human consumption.
The requirements and controls of importing countries should
cover the following points:
(1) safety and cleanliness;
(2) compositional standards;
(3) labelling;
(4) additives, including colourings, fiavourings, preservatives,
sweetness, and antibiotics.
It is unfortunate that there should be so much variation in
the degree of control over imported food.. All countries should
exercise adequate control and should take steps to standardize
their requirements. '
Exporting countries should assist by ensuring that fooda sent
abroad were produced and/or processed, packed and transported
under strict hygienic cOnditions; where necessary official certifi-
cates to this effect should accompany shipments.
(b) Inspection of locally produced food
Provisions are needed for:
(1) adequate inspection of all foods both fresh and cooked;

(2) seizure and disposal of unsound, unwholesome or
suspected food;
(3) securing adequate precautions against decomposition
and deterioration of perishable articles of food;
(4) prevention of contamination by physical, chemical or
biological agencies;
(5) safe and hygienic transportation of foods, e.g., fresh
milk, fish, meat, etc.;
(6) prevention of contamination of foods by dies, cock-
roaches, rodents and other pests;
(7) discouraging the use of unhygienic material for wrap-
ping foods.
Particular attention is needed to meat, fish and any locally-
produced milk.
Animals slaughtered for human consumption in urban areas
are usually slaughtered and inspected in abattoirs where inspection
is performed by veterinary officers or health inspectors. The meat
may have to be stamped to indicate that it has been passed. One
problem is the temptation to pass sub-standard animals, for some
consideration. In rural areas inspection and control are practically
impossible outside the towns.
(c) Food premises
Most countries have adequate legislation concerning the
hygiene of food premises, particularly shops, restaurants and
markets, but in some areas it is not properly implemented. This
is partly due to an overall shortage of public health inspectors
(who are responsible for the bulk of the work in promoting food
sanitation) in the Region, and partly to insufficient training to
cope with the enormity of work in connection with food sanita-
tion.
Where markets are owned by central or local government
authorities, these authorities should set an example to private
owners of food establishments by maintaining the best possible
standards.
3. FOOD STANDARDS
3.1 Expert committees
FAO/WHO have established expert committees on food hygiene
and the hygiene of specific foods (e.g. milk, meat). Also, an
FAO/WHO expert committee on food additives has held a series
of meetings since 1955 and has published several reports. 2S2b ,p
Several other special fields have been also covered, e.g., irradiation
of foods. Members of these various expert committees are
appointed by F AO and WHO, on the basis of their knowledge and
experience in the field under discussion; they act as independent
experts, and their recommendations are based on scientific consi-
derations alone.
Food additives are usually anti-microbials, antioxidants, emulsi-
fiers, stabilizers, flour-treatment agents, various acids and bases, or
food colours and flavours. These and various related topics (e.g. car-
cinogenic and other toxicological hazards) are reviewed in a series
of technical reports, which are the reports of committees of experts,
based on purely technical considerations. 2S2d.e,K,h,j,k,m,O,q.u. w •x ,z,c.D
A large number of additives is covered in the reports listed,
but some substances are not yet dealt with, and some are not fully
covered. These additives are mainly used in countries with ad-
vanced food technological development. In general, the Expert
Committee works only on data published in the literature. Two
zones of acceptability are established - "conditional" and "un_
conditional". Up to the lower limit (unconditional zone), the
amount of additive in the food is not considered dangerous, having
regard to the amount of food likely to be consumed and the age
groups of consumers, even if there is no expert advice or super-
viSion available in the country. The "conditional" zone is a higher
level of the food additive. It is applicable when the risks are
higher, e.g. when the level of consumption is higher (for instance,
in affluent countries) or when the consumers include vulnerable
groups such as infants; under these circumstances, the zone of
conditional acceptability still allows a margin of safety, but it is
considered that at this level some expert opinion and supervision
should be available in the country.
3.2 Codex Alimentarius Commission(CAC)6'
A Joint FAO/WHO Conference on Food Standards met in
Geneva in 1962. It emphasized the need to develop and codify
work on international food standards, both on a world-wide and
on a regional basis. Such work would be beneficial to develop-
ing as well as developed countries. The problems need to be
appraised from many points of view - health, scientific, techno-
logical, economic, administrative and legal
The Joint FAO/WHO CAC was established in 1963 as the
principal organ of the Joint 'FAO/WHO Programme on Food
Standards. The purpose of the Codex Alimentarius is to be a
collection of internationally-adopted food standards presented in
a unified form, aiming to protect the consumer's health and to
ensure fair practices in trade. Eventually, all principal foods,
whether processed, semi-processed or raw, for direct sale to the
consumer or for manufacturing purposes, should be included,
Food additives and food contaminants are of particular impor-
tance, affecting practically all processed and many raw foods.
The CAC's work depends upon draft standards prepared by
adhoc FAO/WHO expert groups, such as those referred to in
section 3.1, and outside bodies (e,~., international semi-govern-
mental organizations). The CAC itself consists of representatives
of all governments which have requested F AO or WHO to become
members. It has established Codex Alimentarius Committees on
General Principles, Food Additives, Methods of Analysis and
Sampling, Food Hygiene, and Pesticide Residues, and a number
of Commodity Committees (e.g., on Milk and Milk Products, Meat
and ~eat Products, Fish and Fishery Products, Fats and Oils,
Poultry Meat, Processed Fruits and Vegetables. Sugars, Quick
Frozen Foods).
The CAC's Committee on Food Additives is the responsibility
of the Netherlands Government. This Committee considers the
recommendations of the FAO/WHO Expert Committee on food
additives, in rel"tion to the practical problems of food and nutri-
tion and the implementation of those recommendations in the res-
pective member countries of the CAC.
On the basis of all the Codex Committee reports, the CAC final-
ly formulates its international published food standards (Codex
Alimentarius) which includes standard specifications for a wide
variety of processed foods. besides questions of additives. The
specifications include definition, composition, quality, designation,
labelling, sampling, analysis and hygiene.
Meetings of the CAC are held annually in Rome or Geneva.
Attendance of government representatives is the government's own

financial responsibility. Otherwise, the CAC is now financed
directly from FAD and WHO budgets. All the relevant literature
is distributed free to member governments. It is desirable there-
fore that all governments in the Region should become members
of the CAC in order to become familiar with the problems being
dealt with by the Food Standards programme. Some personnel
within the Food and Drug Unit of health departments should spe-
cialize on this field.
In the implementation of the recommendations of the CAC,
national legislation is required, and supervision of its implemen-
tation in industry by adequately qualified and trained personnel.
The various activities (of the CAC and expert committees)
described above, together comprise the Joint FAD/WHO Food
Standards Programme.
3.3 Food enrichment and food technology58a
Food enrichment or other developments in food technology and
food processing may be an important means of improving nutri-
tion, particularly for the urban population. Some examples are:
(a) Vitamin A fortification of condensed milk (Singapore);
(b) Rice enrichment with thiamine, iron, and niacin
(Philippines) ;
(c) Margarine enrichment with vitamin A (Papua/
New Guinea).
There are also possibilities for developing low-cost protein-
rich foods for human consumption such a.s coconut flour, fish flour,
egg, soy and peanut products, and eventually unconventional
sources such as yeast.
A regional plan for development of protein-rich foods as sup-
plementary foods for infants is under consideration by FAD,
WHO, and UNICEF, having due regard for the available raw
materials and industrial resources in the various countries. Such
developments are co-ordinated at the top level by the Protein
Advisory Group (PAG) of FAD/WHO/UNICEF, located in New
York. Requirements for the preliminary testing of these pro-
ducts are summarized in several P AG documents.
The P AG also distributes bulletins on recent developments in
this field. 176
CHAPTER VIII
ADMINISTRATION, CO-ORDINATION
AND TRAINING
1. ADMINISTRATION
Health departments are responsible for public health nutrition

activities along the lines indicated in -the preceding chapters.
It is desirable to have a nutrition unit within the department,
at a similar level (for instance) to the maternal and child health
(MCH) unit. Public health nutrition is in fact mainly concerned
with these vulnerable groups, and conversely nutrition should, it
is estimated, be at least 50% of all MCH work. The nutrition unit
should include at least one medical nutritionist (and preferably
a deputy); a public health nutritionist (non-medical) or nurse
specialized in nutrition; and if possible a biochemist and a tech-
nician, with laboratory facilities. This unit should be responsi-
ble for the health aspects of nutrition surveys and the nutrition
aspects of health surveys. If it is feasible to have specialists at
intermediate levels (regions, states, provinces, etc.), so mUl!h the
better. The nutrition unit will be responsible for the nutrition
education and related activities discussed in this manual, and
for the nutrition training of all health personnel, in collabora-
tion with the training division. and other units.
A chart indicating the functions of a nutrition unit is shown in
Table 8.1.
2. CO'()RDlNATlON
Within the department, co-ordination is needed between the

nutrition unit and various other units: principally MCH, environ-
mental health (especially in food hygiene), food and drug admi-
195
TABLE 8.1 .....
CO
0>
FUNCTIONS OF NUTRITION SERVICES IN PUBLIC HEALTH
EDUCATION, AGRICULTURE,
ECONOMIC PLANNING, INFORMATION I-i
& OTHER MINISTRIES OR DEPARTMENTS :x:
t1'J
:x:
t1'J
:0-
t"
I-i
COLLECTION OF INFORMATION AND INVESTIGATIONS :x:
:0-
m
"tI
t1'J
C'l
I-i
m
COORDINATlO:--j
o
"'l
1. Clinical nutritional 1. Nutritional 1. DittaI')" survey 1. Protein. calorie deficiency 1. Basic training of personnel: 1. Intradepartmental: "'l
1. Vital Statistics
IIld hospital records studies: -clinical biochemistry (1,)Individuals 2, Vitamin A deficiency doctors -MCH o
2. Socia-economic Indices -anthropometric 2. Haematology (b) families 3. Anaemias nurses -Environmental health o
3. Food 8I1.nce Sheets -laboratory 3. Parasitology (c) communities 4. Endem Ie gOitre sanitarians -Dental health t::I
4. Sampling, survey and 2. Nutrition in the 4. Nutritional 2. Supplementary S. Food·borne diseases teachers -Food and drug
5. EvaluatiOfl proeedum community: Ecological pilthology fftding trials 6. Others OIher. -Laboratory :0-
factors and sociological 5. Food anal_, Ia) hospital 2. Applied nutrition: -Nursing Z
assessment food standards subjects (a) orientation training -Health education t::I
3. Melf services: 6. Biological tests (b) communities B. PROTECTION OF Ib) In·servlce training -Training
dl$(lrden -food standards VULNERABLE -uniyerslty departments 2. Interliepartmental: Z
-vlul statistics -supplementary -heillth workers -Food & Nutrition Institute
growth data feeding
GROUPS
_ education workers -Education Department c:::
4. Dental health survey -agricultura1 workers -AIIIrlculture Department I-i
S. Food and drug: 1. Infants (6·12 mas) --community dew. workers -Social Welfare Department l!:I
....
2. Toddlers (1·3 yrs) 3. Nutr. educ. of the public: -Community Development .Dept,
toxicological events
3. Preschool.age children -health centres -Economic: Planning and ....o
I-i
4. School·age children -schools Development units
5.
6.
Pregnant and lactating women
Elderly and dertitute
-towns
-villages
3. Others
-universities, voluntary groups
z
-home visits international agencies.
-press, television, radio
C. HOSPITAL DIETETIC -publications
SERVICES
ADMINISTRATION, CO-ORDINATION AND TRAINING 197
nistration, health education, nursing and training. This intra-

departmental co-ordination can be promoted by the formation of
an intradepartmental committee which can usefully review nutri-
tion programmes being developed in the different units, monthly
or quarterly.
In some countries nutrition institutes (governmental or semi-
governmental) of some sort exist, outside the health departments,
and sometimes have shouldered the main nutrition research and
promotion programmes for some decades. Valuable laboratory
facilities may exist, and these facilities are essential to a strong
national programme, although much nutrition research and pro-
motion can be done without laboratories. Co-ordination between
these and nutrition units in university departments of medicine is
essential.
Nutrition is however not purely the concern of the health
authorities, as was observed in Chapter V and VI. Co-operation
with other departments is essential: to avoid working at cross-
purposes or in diverging directions, and to avoid wasteful overlap
or areas where no coverage is given by any agency. The principal
departments with much to contribute on nutrition are health, edu-
cation, agriculture, community development and public informa-
tion; and also nutrition institutes and some university depart-
ments. An interagency committee for planning food and nutri-
tion policy and programmes exists in some countries. It should
be a formally constituted body, preferably under the sponsorship
of the economic planning or development agency of the govern-
ment. This body should review monthly or quarterly the pro-
grammes within each department, in addition to intradepartmental
food and nutrition committees. The interagency committee should
also review national nutrition policies as a whole, with a view to
setting targets on food production, food importation requirements,
etc. Due weight will have to be given to production of both staple
foods and protective foods; and to various ways of promoting the
consumption of the necessary protective foods; to protection of
the public by proper food hygiene measures of food standards in
the broadest sense; and to the personnel and training required
in nutrition to achieve these ends.
Applied nutrition programmes presuppose or necessitate the
formation of stich an interagency food and nutrition committee.
A nutrition institute in a country may well serve as the secretariat

of such a committee.
3. TI(,\INING ON FOOD AND i\UTRlTION
This takes place in several different contexts.
3.1 Ba:-;ie trajnin~
The food and nutrition component of basic training for medi-

cal students, nurses and other health workers varies greatly in
adequacy in different countries and in different institutions within
a country.
The common weaknesses are:
(a) It tends to be bookish and oriented towards nutrition as
conceived in western-oriented texts, e.g. dealing with diets
for diseases or nutrition problems which are not the prin-
cipal ones in developing countries.
(b) Partly because of this, it tends to be too much devoted to
biochemistry and physiology.
(c) Local foods naturally tend to get insufficient consideration.
(d) There is commonly a time lag of ten or more years before
the incorporation of new concepts irito standard texts.
The modern concept of nutrition training and teaching is that
it should be problem-centred and practical. Nutrition problems
should be observed in the field (rural and urban areas) by surveys;
and in the h')spital (especially the paediatric wards) and health
centre. Then, the necessary background biochemistry. physiology
and pathology should be studied to enlighten the student on the
cause of these pl'oblems and to help him work out their solutions.
These solutions should be planned in their social context, and if
possible actually implemented under supervision. As indicated
in Chapter VI to learn by doing in this way will be vastly more
meaningful than to be instructed in the principles.
A much stronger community orientation is usually needed in
the training' 011 nutrition. The trainees should observe at first
hand the circumstances of life in the villages and slums. because
few of the trainees come from such backgrounds themselves. This
ADMINISTRATION, CO-ORr.INATI0N AND TRA!1\'!1\'G 199
may entail rather radical reorganization of basic training pro-

grammes, with earlier inclusion of ward work and field work.
After the study of the problems, their social and nutritional
background, and possible solutions, trainees need to be given train-
ing in the methods of nutrition education, and how to supervise
and train workers in the field who, under them, will actually be
responsible for food and nutrition activities. Nurses and doctors
are frequently given a training which concentrates on clinical
entities (sometimes the wrong ones!) and pays too little attention
to training these future health workers as teachers, trainers and
supervisors.
A good deal of this training must be done within training ins-
titutions purely for health workers. However, at least some part
- for instance, training in nutrition surveys (especially ecolo-
gical factors) and nutrition education - should be done in col-
laboration with other disciplines - particularly education, agri-
culture and community development - as in applied nutrition
work. Collaboration between university faculties or training ins-
titutes towards this goal should be obtainable if the effort is made.
Eventually, basic training curricula should be enriched with
the findings, emphases, and methods evolved during implementa-
tion of an applied nutrition programme in the country. This
should ensure relevance to local conditions and at the same time
is the logical fulfillment of an applied nutrition programme.
3.2 Training for applied nutrition programmes (ANP,,) 58e. 232y
This type of training is usually best conducted at least partly

on a multidisciplinary basis. This will broaden the outlook of
the health worker and foster subsequent co-operation between
agencies in the implementation of the applied nutrition programme.
Two main types of training for ANP are needed:
(a) Orientation
This entails a relatively brief familiarization with the plan-
ning, implementation and evaluation of applied nutrition pro-
grammes. It is required at all levels, and for representatives of
all participating agencies. Early orientation programmes in the
planning stage should include some policy planners at national
level. Later, a wide range of personnel involved at the local level

should be included.
(b) In-service training for implementation
This is a more detailed process, undertaken partly within the
respective disciplines and partly on an inter-<iisciplinary basis, to
equip the personnel for the job to be done within their own agen-
cies as ANP members. This training also is needed at successive
levels from national level down to village level. It is a supple-
ment to basic training.
For planning and implementation, some basic nutritional facts
have to be considered, while health workers need to go more deeply
into the health aspects. At this stage, training is primarily for
purposes of collecting and analyzing baseline data, including train-
ing for any baseline surveys required. For evaluation, the train-
ing is related to the various techniques of evaluation, and the
detailed consideration of evaluation criteria, use of evaluation
forms, etc.
3.3 Higher-level training

Post-graduate training in nutrition will also be needed for
senior personnel working in nutrition units in health departments,
or in nutrition institutes, university departments, etc. It may
often be taken overseas.
In order that such training should be as relevant and applicable
as possible to the home situation, it is usually desirable to take
this training in a nutrition institute in a developing country,
preferably where food patterns and sociocultural conditions some-
what resemble those of the trainee's home-eountry. Failing this,
a basic course can be taken in one country and fieldwork of a more
relevant kind can be undertaken in another country.
CHAPTER IX
APPLIED NUTRITION AND

INTERNATIONAL AGENCIES
1. APPLIED NUTRITION PROGRAMMES

Applied nutrition programmes have been defined as co-orliina.
ted educational activities among health, agricultural and educa-
tional authorities and other interested agencies, with the active
participation of the people to help themselves. The aim is to raise
the level of nutrition of local populations, particularly mothers
and children, through improved food production and consumption.
The principal methods of ANPs are:
(a) baseline and progress surveys, covering nutritional levels
in the community and all aspects of ANP activities as
indicated in (b), (c) and (d);
(b) food production and agricultural education to meet the
nutritional needs as defined in (a) ;
(c) supplementary feeding programmes for vulnerable groups
where necessary, based on locally produced foods;
(d) applied nutrition education for village people, and applied
nutrition training programmes for all government and
voluntary personnel involved.
Emphasis is placed on community action and the production
of low-cost protective foods, including animal foods, grain legumes,
green leafy vegetables, yellow vegetables and yellow fruit. Their
utilization for vulnerable groups in the family, especially infants
and toddlers, is emphasized, sometimes through community supple-
mentary feeding programmes, with or without externally-provided
foods.
These are long-term programmes requiring careful planning,
co-ordination of different agencies which are usually not accus-
tomed to working together, and evaluation against established
baselines. The implementation should be continuously adapted to
changing local conditions. The programme should be an integral
201
part of overall national development programmes as well as

national health plans. The fruits of ANP field experience should
be fed back into the basic training of workers in the respective
disciplines (see Ch. VIII).
2. INTERNATIONAL AGENCIES
International assistance to food and nutrition programmes is
given directly and indirectly by the following United Nations
agencies: FAO, ILO, UNESCO, UNICEF, World Food Program
and WHO. Bilateral governmental agencies also give substantial
assistance which may be along similar or different lines. Non-
governmental agencies, both international (e.g. Red Cross) and
national, also give considerable assistance.
International assistance usually takes the form of:
(a) services of advisers, consultants, experts;
(b) supplies and equipment;
(c) fellowships to assist in the training of national staff.
Usually these forms of assistance are provided within the
context of nutrition projects. These projects are planned jointly
with the government concerned, as a governmental project with
the assistance of one or more UN agencies. In general, it is
WHO's policy to help these projects develop with the technical
assistance of both F AO and WHO, and with the substantial sup-
port of UNICEF. Sometimes UNESCO participates. Current-
ly, WHO assistance is being given to nutrition projects in all
developing countries in the Region.
FAD assistance is both direct (to nutrition projects) and in-
direct. The latter includes various food production programmes,
e.g. fisheries, animal husbandry or soil fertility projects. Direct
assistance is usually supported by funds from the United Nations
Development Programme, either its Technical Assistance or its
Special Fund component. Special Fund assistance is usually on
a larger scale, with a substantial team of international advisers.
Examples are fishery development projects in the Philippines and
in the South Pacific, and food technology in Malaysia. Assistance
has been given to applied nutrition projects in the Philippines,
Korea and the South Pacific. Assistance is also extended to nutri-
tion work in each member country through the Regional Nutrition
APPLIED NUTRITION AND INTERNATIONAL AGENCIES 203
Officer, Home Economics Officer and Food Technologist, stationed

in the Regional Office for Asia and the Far East in Bangkok.
Region-wide planning of international assistance to food and nutri-
tion programmes is done jointly by the Regional Offices of F AO
and WHO. In addition, publications from FAO Headquarters
have been widely distributed in the Region. Many nutrition docu-
ments have been published at the same time in WHO's Technical
Report Series and FAO's Nutritional Studies Series or Nutrition
Meetings Series.
ILO has also given assistance to food technology development
in the Region, and UNESCO gives assistance to countries particu-
larly in the field of teacher-training, on nutrition (among other
subjects). UNESCO-assisted teacher-training centres have proved
suitable foci for applied nutrition programmes in Thailand and
the Philippines. The UNESCO Regional Training Centre in the
Philippines gives specific attention to applied nutrition. Confe-
rences have been held at the Regional level with FAQ and UNICEF
on matters concerning nutrition, and a joint consultant of FAO/
UNESCO/WHO/UNICEF on nutrition education was assigned to
visit several countries of this Region in 1968.
UNICEF has provided direct and indirect assistance to nutri-
tion in practically every developing country, as one of its primary
concerns. Initially this was mainly in the form of milk distribu-
tion programmes. Later, this effort was channelled more and
more into applied nutrition programmes and the development of
protein-rich foods. Assistance to ANPs is being given in Korea,
Cambodia, Philippines, Malaysia and the South Pacific. UNICEF
assistance is chiefly in the form of (a) supplies and equipment
for nutrition projects (including, in a few countries, supplies of
protein-rich foods), and also a variety of related health projects,
especially MCH work; (b) stipends and fellowships to assist in
the necessary training of personnel both within the country and
externally. Supplies and equipment for applied nutrition pro-
grammes covers such fields as survey equipment (including labo-
ratory equipment), equipment for food production and community
feeding programmes, literature and audiovisual aids for nutrition
education, and vehicles. These projects are subject to technical
approval by the appropriate United Nations agencies, usually FAO
and WHO in the field of nutrition.
The World Food Program was established in 1962 by the
"
United Nations and FAO, its headquarters being in Rome. Major

projects are in operation in Korea, China (Taiwan), and the
Philippines. It provides aid in the form of food, which serves as
part payment for workers in social and economic development
projects. Most of these projects are therefore labour-intensive
efforts in rural areas, such as drainage or irrigation, road and
bridge construction, reforestation, or sometimes as livestock feed
or to feed vulnerable groups of the population. A project of par-
ticular interest to WHO is one concerning environmental sanita-
tion improvement in China (Taiwan). WFP assistance is also
available in times of natural disasters. Several types of food
can be provided, covering usually one third or one half of a day's ~ I
requirements (for each member of the family, as well as the
worker). The foods can include some cereals (usually wheat or
maize) and protein-rich foods (e.g. meat, fish, milk, and beans)
but rice is not available. WHO provides advice on health aspects
of these projects, including any health hazards which might arise,
e.g. the possible spread of schistosomiasis or malaria. The pro-
ject is administered in the countries mentioned by WFP Project
Officers stationed in the UNDP representative's office. In other
countrien, the UNDP representative is responsible from the inter-
national side. The recipient government is required to provide
the cost of storage and transportation of the foods within the
country, and to supervise the developmental works undertaken
and the distribution of the food. Each project is covered by an
Agreement signed by the Government and WFP.
The principal WHO assistance in the field of nutrition in this
Region since the establishment of the Regional Office, has been
through the services of consultants and advisers. In the 1950's,
two WHO teams were assigned in Malaysia to study rural nutri-
tion problems (especially protein calorie deficiency) and related
socio-cultural factors in Malaysia. Since 1960, regional pro-
gramme-planning was strengthened by the appointment of a WHO
Regional Adviser on Nutrition. Besides some sixty field visits of
the successive nutrition advisers, short-term consultants have been
assigned on request to French Polynesia (nutrition and dental
health,1960, 1963 and 1968) ,Philippines (goitre, 1967 and 1970) and
Singapore (nutrition teaching in the University of Singapore, 1954,
1963 and 1966). In co-operation with FAO and UNICEF, assis-
tance was given to pilot applied nutrition programmes launched
APPLIED NUTRITION AND INTERNATIONAL AGENCIES 205
by the government of the Philippines in 1964 (now being ex-

panded to cover selected areas throughout the country), and the
governments of Cambodia, Malaysia and Korea in 1967. WHO
is providing medical nutritionists for Cambodia and Malaysia, and
later on will provide additional advisers. Sponsored jointly with
FAO, UNICEF and the South Pacific Commission, an applied
nutrition education and training project in the South Pacific began
in 1967, with short-term training programmes in New Caledonia
and Western Samoa. Courses are being planned in other territories
and a WHO nutrition team is based in the school of nutrition and
dietetics of the Fiji School of Medicine since 1968. Altogether
twenty nutrition fellowships have been awarded, and 3 seminars
on nutrition have been held, one in Baguio (1955)33 and two in
Manila (1962 and 1964).23••
The trend is in the direction of assisting governments in the
Region to develop practical programmes of the applied nutrition
type, in an attempt to meet the nutritional needs and problems
of the vulnerable groups in the community and family, through
improved local production and consumption of protective foods.
The principal agencies involved in the respective countries are
health, education, agriculture and community development. A
strong recent trend is in the provision of consultant services
to schools of medicine, public health and nursing (e.g. Korea.
Philippines) .
Other projects included the provision of nutrition advisory
services in French Polynesia, Laos and Singapore beginning in 1968..
Particular study of urban nutrition problems is being undertaken
in Singapore. Possibilities for establishing a Food and Nutrition
Development Institute in Kuala Lumpur/Singapore are being ex-
plored, to serve some of the major long-term needs for applied
nutrition research and training in the Region.
Besides assisting in the development of applied nutrition pro-
grammes, WHO will continue to assist in (a) the establishment
or strengthening of nutrition units in health departments;
(b) strengthening the nutrition component in the training of
health workers at all levels, especially by making it more relevant
and applied to local conditions; (c) the development of low-cost
protein-rich foods.
WHO aims to foster co-ordination among international, bila-
teral and national agencies, so that governments can, with any
international and bilateral assistance required, formulate and
develop sound national nutrition programmes along the lines
indicated above, both in their national health plans and in the
broader framework of national development.
ANNEX 1
FOOD COMPOSITION TABLES
1. INTRODUCTION
The food composition tables included in this Annex cover a
wide range of foodstuffs available in the Region. They aim to
be selective rather than comprehensive, including representative
foods of different types, those which are more widely available,
more commonly consumed, or of particular interest because .of high
nutritional value or for other special reasons.
Table A.lo9 gives a qualitative summary of the main nutrients
commonly found in the principal food categories.
Tables A.1.4-8 give the detailed composition of selected foods.
The principal sources from which these data were compiled is
shown at the right-hand side of the tables, the key being:
a-FAO Nutritional Studies NO.3 and No. 11 (C. Chat-
field) 62b. "
b - Peters (1958) 170b
c - Peters (1957) 170.
d - United States Department of Agriculture Handbook
No. 34 249
e - Platt (1962) 171
f - Nicholls, Sinclair & J elliffe (1961) 15.
g - Philippine Food Composition Tables, Food & Nutrition
Research Center (1964) 67.
h - Osmond, Wilson & Kirk (1961)166
i-Hipsley & Clements (1950)91
j - Department of Agriculture, Stock & Fisheries,
Port Moresby (Laboratory communication)
k - McCance & Widdowson (1960) 125
m- Nutrition Department, Fiji School of Medicine
(Food Composition Tables for use in the South Pacific)
Priority has been given to the sources in the order liRted.
The F AO food composition tables 62b •g are still authoritative
documents, and Chatfield mentioned 62h ( p . " that those figures,
206
FOOD· COMPOSITION TABLES 207
based usually on suitably weighted average figures from several
sources, give better approximations than local figures if these are
based on few samples.
The modes of expression and calculation adopted have been
those used in the FAD publication. This necessitated small
changes in figures derived from some of the other sources, as noted
below.
2. SPECIFIC NUTRIENTS AND RELATED ITEMS

2.1 Calories
The factors used for calculating calorie values are shown in
Table A,l.l. They were taken from Table 13 of Merrill & Watt143 ,
as for the FAD tables62b•
Platt's tables l7l (and some others) use the factors 4, 9 &
4 per gram of protein, fat and carbohydrate (excluding fibre)
respectively. This procedure has the advantage of simplicity and
the use of these figures is endorsed where no specific data are
available. The factors used in the FAD and United States
Department of Agriculture publications are retained here, how-
ever, because they are still the most widely accepted and
apparently their validity is not seriously questioned. There is
little difference ultimately between these two ways of calculation.
2.2 Protein
The usual procedure was to multiply the nitrogen content by
6.25, except for the foods indicated in Table A.l.2. These are
taken from Table 3 of Merrill & WaW~s. Again, protein values
from Platt's and some other tables had to be adjusted slightly.
In practice the differences are sometimes significant, e.g., in the
case of soybeans, peanuts, and other seeds.
The protein referred to is "crude protein", i.e., includes all
the nitrogenous portion. "True protein" may constitute as little
as 50% of the total (crude) protein.
Protein scores and NPU· data were taken from F ADo8f. As in
that publication, two figures are given calculated by the two me-
thods given by WHD232r and F AD62i respectively.
Based on the two protein scores, two values for N Dp Cal %
(see pp. 229 and 213) were calculated using the method of Miller &
*NPU = net protein utiliZation (see p. 229).
Payne 1• ., and their nomogram reproduced in Figure A.2.2. *

Actually, N Dp Cal % should refer to the total composition of a
meal, rather than a single foodstuff. However, a single foodstuff
often predominates in the diet. Presentation of values of N Dp
Cal % also indicates partially which foods could be expected to
improve the net protein quality and protein value of a diet. Ulti-
mately however, this depends on the balance of protein and calo-
ries and on the proportion of amino acids, so the caloric, protein
and amino acid content of typical meals must be analyzed for
proper appraisal of protein quality.
2.3 Carbohydrate
This was calculated by difference, subtracting the moisture,
protein, fat and ash from 100 g. The fibre is thus included in
the total carbohydrate portion, following the FAO procedure. In
Platt's tables l7l , on the other hand, "carbohydrate" excludes the
fibre, and where his data were used for incorporation in our
tables, his two figures (for "carbohydrate" and for "fibre") were
added to get total carbohydrate, and calories were re-calculated
by the F AO method.
2.4 Vitan:in A282A
The values are expressed as retinol (vitamin A alcohol) where:

0.3 mcg** retinol = 1 International Unit (as formerly in gen-
eral use) of vitamin A
0.6. mcg** ~-carotene = 1 International Unit (as formerly in
general use) of provitamin A
If other food composition tables are used showing vitamin A
and provitamirt A activity in terms of international units, the reti-
nol and ~-carotene content can be calculated from the above equi-
valents.
3. "EDIBLE PORTION" (E.P.) AND "AS PURCHASED" (A.P.)
The tables give the composition of the edible portion (E.P.) of
raw foods. The refuse, in preparing a foodstuff from its form
"as purchased" (A.P.), may be anything from zero to more than
50%.
*Tbe NPU data of F A058f do not correspond to NPU at 88 defined by Miller " Pll)'Ile:
therefore. these NPU figurea could not be used to calculate N Dp Cal ~ directly, See a1Bo p 112.
"me&, =- micrograms
FOOD COMPOSITION TABLES 209
In household consumption dietary surveys, data are sometimes

most conveniently gathered in the form of quantities "A.P.".
Ideally one should have these foods prepared and weigh the
cleaned portion, since practices vary considerably as to how much
is discarded. However, standard factors such as those shown in
the tables below may be used where no specific data are available
in the country.
A.P. values per unit weight are normally lower than the E.P.
values; or the same, if there is no refuse. For ease of calculation,
the tables show what percentage the E.P. is of A.P., rather than
the "refuse" (which is AP - EP). The A.P. value is obtained sim-
ply as follows:
% ofEPinAP
AP value = EP value x - - - - - -
100
e.g. a food of which 60% is EP and retinol content (EP) is 1000
mcg:
60
Retinol content = 1000 x 600 mcg retinol (AP)
(AP) 100
4. COOKING WSSES & CHANGES

The subject has been scientifically studied for a very limited
range of foods, but some countries in the Region have studied
changes in weight and nutrient content of selected foods during
cooking. The food composition tables refer to composition of the
raw food. 124•126
4.1 Weight gains and losses

Some dry foods gain weight during cooking, especially rice,
which approximately doubles its weight (depending on the manner
of cooking), and other cereals and dried beans.
Food cooked with excess fluid, in soups, etc., largely retain
their weight; and so may foods whiCh are steamed.
Otherwise, foods mostly lose weight during boiling in small
amounts of water, and particularly during baking, frying, grill-
ing, roasting, etc.
It is difficult to generalize usefully on this matter, but it is
of paramount importance in dietary surveys where cooked foods
are weighed. If the raw weight is not known, one can take an-
other weighed sample of the same food, cook it, find the conver-
sion factor and so calculate the raw weight of the cooked food as
weighed in the survey.
4.2 Fluid and nutrient losses

Fluids commonly exude from meats and vegetables during dry
cooking, and may then be lost (e.g. cooking in ashes) or retained
(e.g. in a pan, made into gravy or soup). Another way of losing
nutrients is by discarding the cooking water after boiling. The
losses of nutrients can easily amount to 50 '/t, as a result of these
processes. Hot stone ovens as used in the South Pacific tend on
the other hand to minimize these losses, but some losses of
nutrients in exuded fluids still occur.
4.3 Proteins
Protein losses in exuded fluids average 5-10'/t, for meat and
fish, and 10-40'/t, for some vegetables, including tubers, but 10Hse~
are minimized if the latter are not peeled.
4.4 Minerals
Losses occur in exuded fluids and in boiling water which is
discarded. Freely soluble minerals such as sodium and potassium
are lost relatively more than calcium and iron. Losses of the
more soluble elements may reach 20/0 from peeled tubers, and
6070 if vegetables are previously soaked or chopped. For boiled .
meat, losses may amount to 5070. Losses up to 10'70 may OCClll'
in exuded fluids in hot-stone ovens.
4.5 Vitamins
All vitamins can be lost in exuded fluids as described above.
In addition, some (particularly thiamine, folic acid and ascorbic
acid) are very heat-sensitive. An estimate of losses of these,
based on poor fragmentary evidence in the literature, is given in
Table A.l.3. Losses are greatly enhanced by:
(a) the presence of alkalis;
(b) allowing cooked foods to stand for a long time (hot or
warm);
(c) re-heating.
FOOD COMPOSITION TABLES 211
For rice, additional thiamine losses are incurred during wash-

ing; 2070 if quick, 8070 if drastic. Cooking removes about
30% of the remainder, so very little may remain.
For other vitamins, the same remarks apply in general, but
average losses are estimated at 5-107<) only, with conservative
methods, reaching 30-50% when the boiling water is discarded.
4.6 Practical purposes

For practical purposes, losses of most nutrients during cook·
ing may be kept within the 5-10% range except for thiamine and
ascorbic acid (average 2570), by careful conservative cooking
methods. With non-conservative methods including peeling, chop-
ping up, soaking, prolonged or severe heating, these losses may
easily be doubled or trebled.
Besides cooking losses, the following 10sseR are liable to occur:
(a) Carotene: is lost by exposure to air or sunlight, especially
after leaves are cut.
(b) riboflavin: destroyed by sunlight.
A set of recommendations covering all these points is given
on p. 153.
TABLE A.l.1
DATA USED FOR CALCULATING ENERGY VALUES OF

FOODS OR FOOD GROUPS
CALORIES PER GRAM OF

FOODSTUFF PROTEIN FAT CARBOHYDRATE
Tubers 2.74 8.37 4.03
Sago, Sugarcane 4.0 - 3.87
Rice (brown) 3.41 8.37 4.12
Rice (white) 3.82 8.37 4.16
Flour (wholemeal) 3.59 8.37 . 3.78
Flour (white) 4.05 8.37 4.12
Milk 4.27 8.79 3.87
Meat, fish 4.00 9.02 4.27
Egg 4.36 9.02 3.68
Beans, nuts, coconut 3.47 8.37 4.07
Fruits (including banana, 3.36 8.37 3.60
breadfruit, jackfruit,
tomato)
I Vegetables (all other) 2.44 8.37 3.57
.
TABLE A.l.2
FACTORS USED FOR CALCULATING THE PROTEIN CONTENT

FROM THE NITROGEN CONTENT OF FOODS
FOODSTUFF FACTOR
Rice 5.94
Flour (wholemeal) 6.83
Flour (white) 6.70
Peanut 5.46
Soya bean 5.71
Nuts, coconut 6.30
Sunflower, pumpkin and 5.30
melon seeds
Milk 6.34
All others 6.26
TABLE A.1.3
THIAMINE AND ASCORBIC ACID: SUGGESTED PERCENTAGE

LOSSES IN COOKING
I
FOODSTUFF HOT-STONE OVEN BOILED
Tubers (unpeeled) 20 (to 60*) 50 (to 80*)
Tuber (peeled) 40 (to 80*) 60 (to 90*)
Leafy vegetables 40 60 (to 90*)
Meat, fish 40 50
Rice - 30"
"'Prolonged standing near :fires or re.heated.

"Preliminary Quick washing removes about 20%: thorough wuhiq remove. up to 80"'_
Cooking nmovt!I about 11)%' of the remaInder, tn each caae.
TABLE A.U
SOURCES OF ENERGY
(Rich in carbohydrates or fats)
CompoUtion per 100g of raw foodataff. edible portion (E.P.)
_NY"'", ICALCI •• I."
.
E.P. MOIS
...,
PIIOTE.N FAT
...
,RO·
VITAMIN A
t-CARorEN THIAMINE l80fUVIN "IAClfIII A$CO«BIC
ACID
I
- ...
.".
TURE i1U Protein
••• NOp I, TotIl (JIll I",
...
1m"
...
I", 1m, I., REMARKS
~t~~ ~l~" l~ II
% cal!. I.U ..... I.., ...
"
.l.P.
I",
.00 " • 00 • fr ...... "'" ~I;. 'Y.
.~" 00 ,I
100 " 100 ,I 100 ,I 100 II '"
100 ,) 100 II
1.1 78.0 0.7 1.0 (0) (0) 0.16 0.04 2.5 (0)
• 7Q.74'1'o
_.......... (_,..,_ltd)...
1. RICE-''twowft'' (under..... llled 01' bOmt 100 13 159 7.1 6.7 76,57 70.2 5.0. '.0 l'
(o.,a IItIval ....... Ion
100 13 360 6.7 7.1 77.56 57.2 5.2.4.2 0.7 78.9 0.4 10 0.9 (0) (0) 0.08 0.03 1.6 (0)
• 70% IIIrIctlOft
lZa_lf_
-
62.7
2. IlAJZE (.......... _I) 100 12 J56 9.5 9.6 55.41 51.1
54.5
5.0.4.0 4J 72.9 2.1 7 2.3 450" 270 0.45 0.11 2.0 CO)
• '7-100'1'0
aIr.Iction
38 73.9 92 3.' 9.0 - 73.7
-
- 1.2 ZO.7 1.0 5 0.6 350" 210" 0.15 0.09 1.7 14 •
3. SORGIlUM 100 11 343 10,1 11.9 42.31 4.7,3.8 3.3 73.8 1.7 39 4.2 ZOO 1ZO 0.41 0.15 4.0 (0)
• 8(1.100'1'0
4. MILLET ...
~(Ratl , , _ 100 11 nz 65 7.9 59.45 - 5.0,.4.0 1.7 78.0 2.6 J50 4.0 (100) 60 0.35 O.OS 1.5 (0) •
extraction
80·100'1'0
eatrad.iIM
5. WHEAT (grain or whole mal)'
CTrH~ _lire) ,_au flour'
100
100
12
12
333
36S
105
8.6
1U
95
68.43
50.30
40.3
-
7.0.4.7
4.6.3Jl
1.9
1.1
73.9
77.9
2.1
0.2
36
16
4.0
1.0
(0)
(0)
(0)
(0)
0.41
0.13
(0.10)
0.04
(4.6)
1.1
(0)
(0) •• 94-100,..
ntraCtiOll
"'l
6. MEAD. 1001. _ _ ISOISOl 100. 37 Z45 72- 11.2
-- -
- --
- 1.8
::i
5U 0.4
---
ZO 1.7 0
0
0 0.19 O.OS 1.9 0 ••
80% ed.Iac:t1on
..If ...... IIoIf
g
---
5Z5 14 1.0 0 0.10 0.03 0.9 0 IIrown flour
-CooI._
-1'041 C.-n lII.n
100 37
100 24.6
254
325
6.7
10.1
10.7
12.6 - 37
59.8 24 3.0 - - 0.22 0,15 3.0 - • C'l
7...SCUITS (....t
- ...... mal) 15(/50) 100
100
2.7 420
6.2 452
73
4.8
6.6
43
-- -- -- 105
17.7
77.0
69.1 -- 45
45
2.7'
1.2
0
0
0
0
0.16
O.OS
0.12
0.02
1.5
0.5
0
0 •• halfbrown'.
")"1 IIoIf o
;;::
100 2.7 477 7.5 6-4 - - - 19.~ 69.0 36 2.8 - - 0.16 0.10 3.6 - •• ."
III. BARLEY (whole except "'1111 ;and posts)
(Hordeum .ulllre)
9. OATMEAL IroIltd 0IIsl
C- lit...)
100
100
87
12
10
70
. 332
38S
117
11.0
13.0
13
11.9
12.1
3.0
78.54 64.& 8.1.5.9
79.57
64.38
65.7
--
8.2.6.2
2.0,1.2
1.8
7.5
0.4
71.4
67.8
27.3
3.'
1.'
0.8
J)
56
~
3.&
3.8
1.0
(01
(0)
500"
(0)
CO)
300"
0.46
0.63
0.10
0.12
0.1'
O.OS
5.5
0.'
0.6
(0)
(0)
23
•
•b
60·70'1'0
extraction
.........
40-55'1'0 -
§l
.;
o
z
--
10. SWEET POTATO
--
UpGftIOII "utls) 68.0 lZO 0.8 1.8 0.1 29.1 0.6 0.6 60 36 0.07 0.0Se 0.24 65 .....
68.0 127 0.6 13 - 0.1 30.8 0.8 30 0.6 1670 1000 0.07 O.OSe 0.7 65 b Jlliow
~
- - -
11. TAllO Ie.
12.y,.. _ _ J
__
(Colocula I
",.)
as
82
70
72.5
S3.5
l19
104
165
2.8
1.9
1.4
6.4
5.0
2.3
69.53
- -
- 3.8.2.7
-
03
0.2
05
27
24.2
39.0
1.0
0.9
3.0
25
22
22
1.0
1.1
-
0-4000
J>
5
11-2400
JJ
3
0.1
0.15
0.27
0.04
0.03
0.04
0.7
0.'
0.20
30
5
5
•
•b
;
86 72.4 lOS 2.' U 75.50 -- 45.3.0 0.2 24.1 0.9 22 0.8 4 2.4 0.09 0.03 0.5 10 •b
-- --
(D••IIta, wilKe) 545 161 1.4 '-6 0.1 38.7 05 Z3c 05 0 0 0.14 - 0.19 o-e
as 73 106 2.0 5.2 - 0.2 245 0.5 10 1.2 20 12 0.1 0.03 0.4 10 •
/I
13. POTATO, Irish (Solanllln luMroun)
1....
as 78 82 2.0 6.7 53.34 59.6
--
4.8,2.3 0.1 18.9 0.4 B 0.7 JJ
• JJ
0.10 0.03 1.4 10 •
••
14. CASSAVA (... IItlllsslma) ,mit 75 625 146 1.2 22- 03 34.7 13 33 0.7 0.06 0.03 0.6 36
. .1 .... fI. . 100 14 DB 15 Z.8 84,41 2.2,13 0.6 815 - 12 1.0 IT B (0) (0) (I.O) 0
IS. STARCHES (_rdl, ........
arrowroot., sqo)
100 12 362 05 O.SS - - - 0, 86.9 0.2 0 0 0 0 0 0 0 0 •
l6. PUllTAlIIS 1_ ....dl..." 66 68.2 113 1.2 3.6 - - - 05 29.2 0.4 7 0.8 320" 190 0.06 0.04 0.6 1& •
17........ ' .._.,....., n 735 94 13 4.&
~ ZOO" 120 0.04 O.OS 0.7 l1 •
.. __
, Soe (III. 1'trHI"
206. 229 ~
.. ,........... ...,
_ _ ..........I~·; "" necessarll, "0"
......
CO
TABLE A.l.4 (continued) .."'"
N
~~-
PROTEIN FAT CARBOHYDRATE AlelUM IRON PRO· .CAROTEN THIAMINE Rl80FL.AVI NIACIN ASCOR81C
E.P. MOIS_
as ~.
"
A.P.
TURt:
~~U-
(",
100 e)
,
'"
".als
100 • fro prot.
P,OIPin
~.
NPU ND,
C.. .. (,
Ira',)
fOUlI
('.1/100 ,I Flbrr
(Incl. fibre ) (11/100,
(.,
l:r '" g)
(m,
00 ~)
VITAMIN
I.U. per
100 "
(~,
'"
100 !J}
(m,
'"
100 9)
(m,
'"
100 ,I
(., ACID
'"
100 I) ( .. '"
100 ,I
I'
jj REMARKS
18. SUGARCANE JUICE

(Saccharum rol!wslum)
100 BI 7l 0.3 1.7 - - - ~ IB
• 6 2.0 ~ ~ 0.02 0.1 0 0 •
19. SUGAR, mined 100 - 3B7 - - - - - - - - It 0 0 0 0 0 0 •
20. SUGAR, crude (from cane, palm, coconut)
21. MOLASSES
100
100
7
24
351
232
1.0
-
1.1
-
-
-
-
-
-
-
-
-
90
(60)
-
-
78
273
5.0
6.7 - II
0
II
0
II
0.06
)1
0.11
J1
2~B
0
0
•
• AP means In
22. COCONUT meal, fr!Sh, maturt
(Cocos nuciferaJ
46 4B 351
414
4.2
4.0
4.1 82,55 55.0 3.5,2.4 34.0
40.0
J 12.8
l"i.O
3.3 9
14
1.7
2.2
0 0 0.06
0.04
0.03
0.01
0.6
0.6
2
38 •I ......;
EP. means WI'
- meat, ftt'Sh, immature 34 70 lBO 4.0 7.7 - - - IS 10 3 8 1.3 10 b 0.05
004-.025
0.03
.02
0.7
.3· 5
4
5.3 •m ......'"
lOb (1,4) 9 6 (O.7e) b O~B
- milk (from mature nut> 100 5B~5 311 25 2~8 - - - 34 5 0 IS 1.0 0. 0. 0.029 0.01' 0.30 0 t
346 4.3 34~B 6 11 2.3 0.03 0.008 0.9 2.8 m
-- --
- Wiltet' (mature nutl 100 94.3 22 0.3 4.7 - - - 0.4 5.0. 0 20 0 - 0 0 0 t
- water (immature nut) 100 94.B 17
11
0.2
0.2
4.1 - - - 0.4 3.b
2.b
- 30 -
0.7
- 0
0.002 O.OB
- 10.1-0.2 1.4
I
m
~
23. BREADFRUIT (Artoc:arpus altilis) BO

77 70.B
lOb
102
0.9
1.7
2.B
5~b
-- -
-
-
-
1.5
0.3
2S~2
26.2
1.2
1.2
35
33
0~5
1.2
19
40
11
24
0.08
0.11
O.Ob
0.03
0.8
0.9
72
29 •
d
24. JAKFRUIT (Arlocatpus heterophyllui) 28 72.0 98 L3 4.5 - - - 0.3 25.4 1.0 22 - - 11
-
0.03 -- 0.4 'B
,
d
",d, 52 129 5.1 13.3 - - - 0.5 30 4.0 60 - - - - -
25. VEGETABLE OILS 100 0 884 0 - 100 0 ~ 0 0 0 0 0 0 0 0 •
2(). MARGARINE
27. BUTTER
100 15.5
100 15.5
720
7lb
O.b
0.6
-
-
-
-
-
-
-
-
81
81
0.4
0.4
-
-
(15)
15
~
~
.. 0
..
0 0
II
0
/I
0
)1
0
0
•
•a
28. PORK FAT
29. ALCOHOL & OTHER BEVEIWiES
100 0 81b 3 - - - - 89 0 0 0 0 0 0 0 0 0 0
a. Beer, brown ale, bottled

()Oo/. aleohoU
b. Palm wine (112-1 day ftnMnUltion)
100 97 35 0.3 - - - -
~ 3 0 8 0.1 0 0 Jl 0.05 1.0 0 •
10.5'"1. alcohol) 100 99.5 17 0.2 - - - - 0 3 - - 0.32 - - 0.02 0.01 0.38 145 •
,• - • •
c. Spirits, 70% proof (31.5% alcohol)
(mean of brand)'. 9in, rum, _isley) 100 685 222 Ii - - - - 9 I Jl II If I II /I
d. Coffee, extract" from 100 9
ground eolfte by bcllII~ 5 minules
c. Tea, erlracted from 100 9 lea,es
100 92 48 6.8 49.1 - - - 6 0 30 1.0 Ii /I f1 0.01 270 0 •
with hot wat~ (5·10 minutes) 100 90 24 10.0 100 - - - - - 0 30 ~ 0 0 0 0.9 b.O 0 •
- See pp. 2Ob, 229
'means ''trlc!''
- means "no dai.<l awialable," not necessarily' '0"
.. Total Vitamin A activity: (Satmmer) 4000 I.U. (1200 meg retlnoll per 100 g. This includes the pnwitamln A (~"caroteM) actiVity.
(Winter) 2400 I.U. (720 mcg retinol) per 100 9.
.- ...
RU''''OL ITHIAMIN ItlBOFUVI N~IACI" ASCORBIC
..
PROTEIN fAT WIOHYDIltATE: CAlCIUM IRON
[.,. l1li015 - CALD.
, T..., I",.
...
1m,
IIITAMIN ..
(mCi f",.
''''' I. .
ItID
RC .....ItIC$
..."
on '"I. TURe: RIES P,ot.,ft I,
.... uh. 'o, ~ .• (t/1OO II FIIIr. I.U. pr,
''''
100 ,I '"
100 • fr. pret
C.I~
l~iJ U""I. IjM 't/1OO, 1~" 00" 100 II
p"
100 ,I
...
100 tl '"
100 tl 100 • ''''''
100 ,I
3D. HUMAN IIILK Ubture, I.t'. aftft

30 dlrs of lactatiOfl)
68 1.2 B.O (l00l - 8.0 3.8 7.0 0 33 0.15
... ...
171 ~3 01-.02 .02-.04 0.17 4.3 .... 32,136
31. COWs MILK fmh, wIIol" 0.50/. fat) 100 87.3 65 3.5 22.9 106,68 81.6 9.8,9.2
-
3.5 5.0 0 119 0.1 140 .2 0.04 0.18 0.1 1 ••
---
Ewaporat.ed whole 100 13.7 llB 7.0 21.7 - 7.9 9.9 0 240 0.2 320 100 0.05 0.35 0.2 1
-
•••
SWftltneiJ (ondtnsed 100 27 320 8.1 10.8 8.' 54.8 0 293 0.2 330 100 0.05 0 ..43 0.2 1
•• 1.~
Powdtrtd whOle 100 506 2& 21.9 &9, &4 6.B,6.4 30 34 0 1m 0.7 320 0.24 1.31 0.7 4
Powdertci hkimmed> 100 360 36 '2.7 - - - 1 51 0 ,235 0.9 12 0.35 1.80 1.0 &
32. GOAT's MILK 100 8&.4 73 3.8 22.2 - - - 4.5 4.5 0 141 0.1 168 48 0.05 0.11 0.3 1 • I'
- - - •
len
3.3. CARABAO MILK 100 80 121 ~.B 20.5 9 4.4 0 (l2O) 10.21 (90) (27) (0.05) (0.10) 0.1 I
(Wlter buffalo)
)4. PORK~edium f.a1 100
100 69
~2 364
183
12.0
17.5
13.2
lB.2
81, &9
BO,M
-
6&.q
9.0,7.B
9.S, B.S
35.0
12.5
0
0 ---
& 6.5
10 2.6
0
0
0
0
0.58
0.08
0.14
0.16
3.l
'.2
0
0
•• go
35. BEEF-Iun
- - - 16.5 0 20 4.3 0 0 0.02 0.2' 3.' 0 ••
1=
36. BEEF--corned, eanned 100 68 22< 18.& 33.2
-- --
31. liVER-beef
.... 100
100
6U
72.3
136
134
19.7
19.7
57.9
58.&
65.0
-
3.2
'.8
6.0
1.7
0
0
7 6.6
10 18.0
'3.900
14,200
3.170
',260
0.2&
0.40
3.33
2.98
13.7
16.7
31
23
• ">
...
38. POULTRY &1 106 200 20.2 40.' 79,64 70.7 8.8,7.3 12.& 0 - 12 1.5 400 120 0.10 0.16 8.1 (01 • oZ
39. EGG, 'd, hen 89 7. 1&3 12.4 33.2 100 93.5 13.5 11.7 0.9 -0 50 2.5 1,000 300 0.10 0.30 0.1 0 •• rtfuse=sheil 0_
~~~
fmh,duek 87 71 189 13.0 29.4 - - - 14.5 0.5 57 2.8 1,200 360 0.15 0.30 0.1 0 muse-nil
40. FISH, fresh, fItly (sea)

fmh, othtr (sea)
fresh, (tilapaa)
50
45
39
68.6
77.2
77.3
176
104
107
20
19
17.5
'5.'
16.1
65.'
80,70
- -
....
79.5 14.5 10
2.5
'.1
0
0
0
--
- lB
28
77
1.2
0.8
0.1
(100)
k
100
(30)
k
30
0.08
0.06
0.03
0.21
0.08
0.10
2.7
2.2
'.2 0
II'
II' ••
•• "(;Q=
·Ot"
trtsll, f,ndtowits) 75 78 82 17.9 87.3 72,1:>7
.~~. 1.1 0 - 469 0.7 - - 0.01 0.08 3.7 0
.~tI!
I;
41. FISH, p'eserwd:
- •• ,l~t
--- -
canMd in all 100 51 314 22 28.0 24 1 0 44 1.3 (lOOl ()O' 0.06 0.20 2.' 0
-- .l"Jo.
canMCI, not In 011 (fltty) 100 ~ 188 20 '2.5 - 11 1 0 40 1.2 (l00) 00' 0.03 0.20 '.0 0
•• dried, salU!d
........ ;fIl
canned, not in all (other) 100 75 108 21 77.8 2 0 0 32 0.8 k It 0.03 0.06 U 0
0 0 80 (l00) 0.10 0.36 4.' 0
!~.:.
medlum·curf'd (faU,) b9 41 261 40 61.3 75, bb 10 2.' (33)
::::0
medlum-tured (other)
,ncltoYl", dried and powderl'd
"
100
37
5.2
223
351
46
82.0
82.5
9).' - - -
3
2.&
0
0
0 &9
2,29&
1.8
31.3
11
320
11
100
0.09
0.05
0.18
0.16
•.&
9.'
0
0 • ..
•
.""
It",
-.~
42. TURnE 30 80 82 16.0 78.0 - - - 1.0 2 -- 100 1.0 - 0.2 0.5 '.0 - • 2:0
43. MOLLUSCS (oysttn, m"ss.rll, clams, etd 25 83 71 10.0 56.3 Bl.71 - 7.1';;. 2.0 3 150 10.0 200 68 0.05 0.15 1.5 11 • ">i
44. CRUSTACEANS Uobstft, crab)
45. SHRIMP (larlf, fmll)
37
63
77
75.&
94
96
IB.O
19.&
71:>.6
81.7
78,60
-- -
- ....-
?4.5 1.5
0.8
2
2.5
-
-
100
146
5.0
1.1
k
250 7.
11 0.05
0.07 0."
0.10 2.5
).6 -
11
••
• 'g~
;1.2:
iO
4b. SHRIMP ISI'ItIlIi. frNJ (aales indicus) 100 79.1 78 160.6 85.1 - - 1.3 0 - 699 3.0 - - 0.07 0.15 2.4 --
47. SHRIMP (SIftIII, *ted) 100 21.6 28& 52.' 73.5 - - - 3.& 10.2 - 2,30& 21.4 115 34 0.06 0.19 5.5
••
~
48. FERMENTED SHRIMP PASTE 100 63.3 &9 1'.9 8&.' -- - -- 1.0 0.2 - 4&9 5.' - -- 0.01 0.10 1.' -
49.
SO.
FERMENTED FISH PASTE {Ancho,ies'
SNAIL (ri,er, pom"
100
100
49.0
78
12.
83
2&.7
12.0
B2.8
57.8 -
-
- -
2.5
2.0
0
4
- 280
1,500
8.3
·8.3
-- -
0
k
0.27
0.05
5.0
1.3
-
- •• ....,
51. SEA SLUG l8fc:h~ de mer) 100 7. 92 22.0 95.' - -- - 11 1 120 I.' - - !Y - -2.4 - •
S2. CATERPILLAR 100 80 81 12.0 59.3 - - ).0 1.5 2.0 61 6.3 -- - 0.08 0.43 - •
- - - 12 1.0 - - - - - •
..,
53. TERMITE 100 7. 148 10.0 27.0 12.0 0 1.2
54. LOCUST
55. SAGO GRUB
100
100
75
70.5
134
181
20.0
&.1
59.7
13.5
-
-
-- -
-
'.0
13.1
0
9
'.0
-
30
461
1.0 -
-
-
-
-
0.08
0.5
0.43
2.2
2.'
-
-
•,
• Set' pp. 206, 229 11 mean! "trace" - mfans "no cht.a anilable", not HCt'SSlrlly "0'
U TMs! figum rtClff'St'nt lolal vitamin A acti,it, (inelldlng prO'fltamln A portion). 1M ptrCtfIta", of this lotal vitamin A acliwil), which Is actually deri'e:! from tr-c:aroteM Is estimated (WHO 232A, Appendix 6J as fotlows:
milk. POUltry, e9gs - 30%; lish - 10% 13b 6 21
.... Breutmllk eontains on aYfl1llj", In addition,27 mcg Cl.roltnoids per 100 9 , of which about 6 meg IJ .-carOlf"" so t"t totll provitamin A actl'ity is about ( - - = 28 I.U. + --)
0.6 1.2
····Tht'st ,alun artificially low. Tht percentage ealeries derl,ed from proit'in is 50 hith that, wilen fisll
.~ of
The perc:entagt of caloti..s derived from prottin indicat" bt'tttr tM Iftl prCltein nllt!.
.10nt is I5ltl!fl, much of tile protein is used for 8It'r1)' production.
TABLE A.1.6
t-:)
SOME VEGETABLE SOURCES OF PROTEIN ~
Composition per lOOg of raw foodstnff, edible portion (E.P.) 0>
... .
PROfflN fAT CAlBOHYORA TE CALCIUM IRON PRO· "-CA.ROTENE THIAMIN RIBOF1..AVIN IACIN ASCORBIC
[.P. MOIS- CAl.
..,, ,.... IIIUMIH A ,..,... ,,,, ...
ACID
IS ,,_
"
".P.
TURE RltS
''''
100 \1) 100 ,
'Y.t;.iIl!•.
fro prot.
P,otfin
~"
NPU NOp
~~ ~. "
I~"
T,..,
(9/100 9) fibre
Untl. fibre '9/100,
."
1I:91 00 .,
I.U. pt.
100 gl
(mCi
"
100 9)
...
'"
100 gl
...
'"
100 9) 100 ,) 100 9)
REMARkS
Yield from 1 kg
•
..
56. SOYBEANS (GI,cillf max> whol! 100 8 335 38.5 4&.0 62,47 61.4 5.0,4.CJ 18 31.3 4.8 208 0.5 140 84 03 0.30 2.1 0 soybeans:
full·fat flovr (~coat
low·'at flour, grits, etc.
removed) 100
100
8
8
357
201
39
41>
37.9
01.2
-
--
-
-
-- 21
5
27.4
35.2
2.4
2.3
197
247
0.2
7.0
11>0
llO
% 0.77
0.7J
0.28
0.30
2.0
2.0
(0)
(OJ
a
a
Q,qs kg
084 kg
turd (tofu) 100 87.4 58 0.3 37.7 - - 3.1 2.5 0.1 41> l.l 20 12 0.05 0.04 0.4 (OJ
•a 3.5 kg
--- -
fermented (nattol 100 bl 153 17 38.& - 9 II 3 100 3.7 (40) (24) 0.09 (a.20l n.m (0) 2.0 kg
fft'mtntftl Hsiang) 100 oS 153 17 38.6 - - 10 0 3 100 3.7 40 24 (0.09) (0.20) n.OJ (0) a 2,0 kg
sprOtlls 100 80.3 4. •. 2 4&.8 - - 1.4 5.3 O.B 4B 1.0 lBO lOB 0.23 0.20 0.8 13 d
57. PUNUTS (Groundnutsl

(Arachis hypogilH)
71 5.2 541> 25 .• 1•. 3 69,43 42.7 B.B.o.O 43.3 23.4 3.3 52 1.9 30 lB 0.84 .0.12 1•.0 II a
58. GREEN GRAM (MUNG BEANS). with coat
(Pt\a5t'OIus aure-us) sprouls
100
100
12
92
336
31
22.0
2.5
22.7
19.7
32.22
-
48.5
35.0
5.5,4.3
-
1.0
II
61.1
5.5
4.7
0.5
100
10
B.O
0.0
40
e
24
II
0.45
0.2
0.2
0.2
2.0
0.5
II
30
••
59. KIDNEY BEANS (Pllaseoius vulgaris) dried 100 12.2 336 23.1 23.9 47,34 43.7 7.5,5.8 1.1 59.4 3.5 1.3 0.9 (OJ (0) 0.22 2.5 2 d
mature, moist. fresh 91 89.1, 35 2.4 23.B - - - 0.2 7.6 1.5
0.57
a
bOo LIMA BEANS (PhaWOIU5 lunatus) dried
61. HYACINTH BEANS (Field Beand dried
100
100
12
1l.B
338
338
20.0
22.2
20.5
22.B
50,41
37,27
51.5
59.9
7.4,6.4
6.2,4.8
1.5
1.5
63
61.0
5.0
b.B
90
88
•. 0
3.5 -
Jr
-
Jr 0.5
0.02
0.14
~.20
1.5
2.3 -
g
•
d
(Dolichos lablab) (Lablab niger)
62. WINGED BEANS, dritd
IP5OphOc.arpus tltra90nolo~s)
100 14 399 33.0 28.7 - - - 16.0 37 5.0 - - - - 0.08 - - II •
63. BROAD BEANS, dried 100 12.2 33B 25.4 26.1 041,28 .41.8 6.9,5.1 1.7 57.B 7.B 95 6.5 130 7B 0 .•0 0.26 2.5 5 d
IVitia labaJ
b4. PEAS (whole) dried 100 II .• 339 23.8 24.4 50.37 47,9 7.9,6:2 1.4 60.2 5.4 57 4.7 140 B4 0.77 0.28 3.1 2 d
(Pisum satiyuml
&5. CHICK PEAS, dried 100 10.6 359 20.8 20.1 53,40 52 7.7,6.3 4.7 1>0.9 5.3 162 8.4 90 54 0.49 0.18 1.0 II d
(Cim ariftinum)
66. COW PUS (whole) dried 100 10.6 342 22.9 23.2 57,41 45.1 B.7,6.6 I.' 61.6 4.2 77 0.5 30 IB 0.92 0.1. 2.2 2 d
IVigna ,iIteMis)
b7. PIGEON PEAS (husked) d~itd
(CaJanus aian)
100 13.1 333 21.9 22.8 39.27 - 6.4.4.8 l.b 59.9 1.5 92 4.5 140 84 0.47 0.18 2.0 5 d
68. RICE BEANS, dried

(PhUfOlus talcaraUl)
100 10.1 352 18.4 IB.l - - - 3.1 64.5 7.3 397 4.0 55 33 0.54 0.17 2.2 - •
69. SUNfllWER, PUMPKIN, WATERMELON
(Orircl Sftds, Sfe(fe04t remcwtd)
53 5 535 27.4 17.7 93.61
61,42
58.1 12.0,8.2
- 8.S, 6.2
43.0 19.7 2.7 48 9.3 70 42 0.23 O.IB 2.7 /l • Sunflower
Melon
70. SESAME SEEOS 100 ~ 574 18.1 10.'l 61,42 53.4 b.l,4.4 51.3 20.0 3.7 .200 9.0 /l /l 0.80 0.22 4.5 0 a
ISnamum ilHfieuml
71. CASHEW NUT
(A.cardlum oeci6entalel
100 5 5.0 17.0 10.5 - 57.B - 45.0 30.3 1.3 50 5.0 /l /l O. 0.2 2.1 0 •
72. PILI NU.r
(Clnarlum sppJ
I. 8.9 b44 14.2 7.0 - - - &8.5 5.5 3.2 ll9 2.0 45 27 ~.95 0.12 0.4 g ,
73. KAUWI NUT 8.B bOl 18.9 10.9 - - - 1>0.' 7.4 2.2 474 - - - - 0.08 - - j
(Macarilaga sppJ
74. PANDANUS NUTS 90 .B3 )).9 0.0 - - - ... 22.0 0.1 419 - -
L - - - ___
- - 0.36 - - I
, See pp. 206, 229

9" means "tr.ce"
- mHns "no data arailablr-", not nKessarily "0".
TABLE A.1.7
A. LEAVES
.....
E.P. 11015·
.l.P.
lUI[
i1U- ,
I",
100 I) '"
SOME OTHER VEGETABLES
Composition per lOOg of raw foodstuff, edible portion (E.P.)
PltOTEI.
% Gis.
.00 I fr. ,nt.
.....,
~.
..
.,u ..,
CiL '"I.
'AT
I,
.~"
WIOHYOU.Tl
~1
rota' ,I • '1••
(,/lOO
UIICI. lilnICt/lOO,
!we.u.
...
1:' .
.......
tJ 00 II
PRO-
.,'Utllll .....
I.U ....
lOa ,I
,.<MOT£NE
'''''
'"
100 II
.., ......
,,".AM••
•rE' ,I 100 II
..
RIIOIUYI IIIACIN
I.,
_IC
.....
I.....
100 II 100 ,)
, R'MOtes
-
•••
15. LEAVES, (al dark 91'ftn 80 SS 41 5.0 29.8 57,53 8.8,8.2 0.7 6.5 1.5 250 4.0 3000 1800 0.1 0.3 1.5 100
nwdium
(b)
(el IltIIt IrMfI
80
80
91
03
25
23
2.0
1.5
19.5
15.9 - -- -
-
0.3
0.2
4.8
4.8
O.S
0.8
80
40
2.5
0.5
1000
30
600
18
0_08
0.05
0.02
O.OS
0.5 50
0.3 '0
- _.
76. A8ElMOSCHUS MANIHOT
(Aibiu., NN Guinea)
82.1 41 5.1 29.6 - 0.3 8.6 1.8 580 - - - - - - - ;
77. AMARANTH US $pp. 11 86.9 36 3.5 23.7 88,62 - 13.0,9.5 0.5 6.5 1.3 2b1 3.9 60'10 3600 0.08 0.1& 1.4 80 ••
78. CABBAGE, CtmMOn
fBnnic.a ol.,.uo ~l.1)
PI. CABBAGE, Chineit t....ssici si~ls)
69
19
91.8
95
25
14
1.6
1.4
15.6
24,4
65,39
-
35.2 8.1,5.3
- -
0.1
01
5.7
2.6
1.0
06
50
100
D.'
2.0
100
3500
60
2100
0.06
0.06
0.05
0.03
0.3
0.'
50
25 •b dark gtftfl
§
BO. CASSAVA Iflm (Manlhot lfulcls) 82.0 55 7.2 31.9 59,51 - 8.8,7.7 1.9 6.1 2.' 175 2.0 2000 1200 0.33 1.07 1.7 275
8
lMori,. ,.i'...
81. HOR9£RADISH. TREE 1e.1J~
a;
bl 77.4 75 5.9 n.2 - - - 1.8 12.8 l.O 353 3.5 124SO 8470 0.20 0.73 3.1 232
• i(
Malunna" Philippines) ."
82. KALE
(Branica oIetarN ace,llala)
83. MUSTARD trftf'IS fl,assiea jaM'N)
b3 85.Cf 42 3.9 22.7 6O,~:
-
54.3
-
9.1 '.4
-
0.6 7.8 13 230 2.3 7600 '560 0.11 0.25 1.6 120 I
...
~
~
84. SAUROPUS ANOIIOGYNUS
OJ 92.2 23 2.2 23.J 0.3 4.1 08 108 3.0 5670 3400 009 0.25 0.7 100 • oz
(Sa"", manis, .....,s... )
85. SPINACH (SpiMCI Dleraca) n,bS -
86. SPINACH. PO",.,,,,
81 '2.1 22 2.2 24.4
- -
10.7,10.'
-
0.3 3.' 0.7 81 3.0 Cf420 5650 0.11 0.20 0.7 59 • ~
67 92.5 22 1.7 18.8 4.2 0.1 79
•
;
0.' 55 5255 3150 0.11 0.17 0.5 58
(TalillUm t' ......u&are'
87. SWAMP CAIIAGE/SPINACH
(Ipomoea a_Uu) (K.lIIIJk0nt'
60 8Cf.7 30
.,
3.9 31.7 73,44 - 10.5, 6.9 0.6 ••• 1.0 71 3.2 484:5 3000 0.09 0.24 1.3
•• •,
88. SWEET POTATO IMWts IIJlMloei
baLlla:sl
8S 3.5 18.2 - - - O.S 9.5 1.S 70 8.0 6000 3600 0.10 0.20 0.9 25
89. TARO 1."5 (Ctlteas" SllPJ
• lOOTS, lulbs, Itc.:
85 57 5.0 24.4 - - - 2.5 6.6 2.3 - - - - - - - - b
90. CARROT (Daucus urota) 92 88.6 40 1.1 6.7 79,40 5.1,2.8 0.2 9.1 1.0 34 0.8 2000
(·1000m
1200
(·6000)
0.06 D.O' 0.7 6
•
91. CHAVOTE (Sechlurn edule)
92. LEEKS and 9rffft DniDRS
(Alii..,. porrum, ocIonn, ctpI)
85
41
91.5 29
43
0.6 5.0 0.1 7.4 O.b 12 0.5 20 12 0.02 0.04 0.5 19
•
87.8 1.8 10.2
'93. ONIONS, matuFf (Allium ctpiIIl 93 88.8 40 8.5
0.2 9.4 1.2 80 1.0 50 30 0.06 D." 0.5 18 •
'94. RADISH 20
I.' 0.2 9.0 0.8 32 05 50 30 0.03 D." 0.2 9 •
-
pp. -'""",
56 93.7 1.1 13.4 0.1 4.2 0.7 37 1.0 30 18 0.03 0.02 0.3 2. •
PlK1lpkill IN'"
~malK "trace" ...... Turnil) (Branlta rapa) lea,,,
- ....ns "no eIIta l.allablr'; not nectssarll,. "0" ....NI
"'"
TABLE A.l.7 (continued)
SOME OTHER VEGETABLES ....
t>:)
00
Composition per lOOg of raw foodstuff, edible portion (E.P.)
,. .. ..
CALCIUM IRON
.. .. .. .. '.....
PROTEIN CARBOHVDRATE PRO· I CAROTENE THIAMINE RlBOFl.AV! NIACIN ASCORBIC
..... '" r
...,
[,PI, MDIS- CAL/)· VITAMIN A I.ero
,I TURf RI£S
I...
100 II
-I. call.
100 9 fr. prOI.
Prll!f'~
'COff
NPU NO,
Cal. eo
I,
100 ~l
TQt.;J1
(g/100 I)
(I"d. fibrt
Flbrt ...
I.,
1i/100, 100 gl
1m,
OIl "
I.U. ptr
100 gl
(meg
100 II)
1m,
100 9\
1m,
100 IJ\
I.,
100 ,) 100 ,I
g
REMARKS
C. VEGETABLE FRUITS:
95 BEANS snap, fresh, young, in pod
(PtlaS!OIU5 vulpris)
9. 8CU 35 2. 16.7 5&,39 7.4,5.5 0.2 7.6 1.5 57 .8 400 240 0.08 0.12 0.5 17 •
%. CUCUMBER (Cutumis §;Iliyus) 75 95.6 13 0.8 15.0 0.1 3.0 0.6 10 0.3" 0" 0" 0.03 0.04 0.2 8 •
(17 EGGPLANT <Solanum mtlongena)
98 MARROW (White) or Immature
82
83
92.7
95
24
15
1.2
0.8
]2.2
13.0
0.2
0.1
5.4
3.5
0 .•
0.•
15
18
.4
.6
30
100
18
60
0.04
0.06
0.05
0.04
06
0.5
5
20
•a
pumpkin (Cuturbita sppJ
99. MELON, biUer
(Momordica char.ntla)
100. OKRA (Hibiscus rscultnlus)
82
88
93.4
89.8
22
32
0 .•
1.8
10.0
13.7 85.36
0.4
'.5.4.6 0.2
4.6
7.4
0 .•
1.0
32
82
0.'
0.7
335
740
200
440
0.06
0.08
0.03
0.07
0.03
1.1
55
30
•
d
101. PEPPER, swtel., larQt, 9retn 82 92.8 24 1.2 12.2 0.2 5.3 1.4 6 0.8 2.0 170 0.04 0.05 0.' 103 a
(capsicum annuum)
102. PEPPER, cbili, small, TN
(capsicum frulescens;
87 72.2 62 4.8 18.9 2.2 '.0 1.4 65 2.3 7010 1200 0.31 0.25 I.B 6. ,
10). PUMPKIN (YElLOW SQUASH) 68 89.' 33 1.J '.6 0.3 7.7 1.2 18 0.6 400 240 0.06 003 0.4 11 a
(Cucurbita sppJ (malure) (·4 0001 (·2400)
104. TOMATO (Lycoperslcum esculentum) 80 93.8 20 1.1 18.5 66,21 8.4,4.1 0.3 4.2 0.6 11 0.6 700 420 0.04 0.04 0.5 24 a
105. TREE TOMATO
(Cyphomandta beLacea) 73 85.' 48 1.5 10.5 0.3 11.3 2.2 13 0.8 - -- 0.04 0.04 1.0 17 d
O. STALKS & STEMS:
10& SAMSOO SHOOT (8.ambuv. sppJ 2. '1.0 27 2.6 23.5 0.3 5.2 0.7 13 0.5 20 12 0.15 0.07 0.6 4 d
101. SETARIA PALMAEFOl1A, hearts
(Pitpit, New Guinea highlands) 92.4 27 0.5 4.5 0.2 6.8 1.1 21 - - - - - - - j
lOB. TARO, stalk
(Colotasia esculen\a) 93 21 0.5 5.8 0 5.5 1.6 218 - - - - - - 214 I
E. FlOWERS:
54 3b 1.6 0.4 8.0 ,

109. BANANA hezrt
110. PUMPKIN flowers 5.
B8.9
8'.8 2. 2.0
10.8
16.8 0.5 5.6
1.1
0.7
56
74
11
3.1
440
910
260
550
002
0.05
002
0.11
0.5
0.'
13
24 ,
111. SACCHARUM EDULE (efflorescence)
(Pitpit, New Guinea lowlands) 8. 37 4.1 27.0 0 7.6 0.7 10 - - - - - - - I
F. MISCELLANEOUS:
-•
112. MUSHROOM (Agaricul spp.l 91 91.1 23 2.4 25.5 42,18 72.4 7.0,4.2 0.3 4.0 0.' 1.0 0 0 0.10 0.44 4.' 5 d
113. "FUNGUS"
114. SEAWEEDS:
85 51 2.4 11.5 3.5 4.3 0.3 - - - - - - - b
-- -- --- •••
Cal Agar (Gel icliurn spp.l 100 17.8 2 101 0.2 (0) - - - - - -
Uti Kelp (lamin.aria SPPJ 100 23.6 9 (01 11 (0) - - - - - -
-
Icl Laver (Potphyra latlnlatal 100 16.9 5 (0) 0.' (01
- --
- - - - -
, Sa> pp. 206, 229
II means "trace"
- means "1'10 data available"; not necessarily "0"
•• Nrtd cucumllers
TABLE A.l.B
SOME FRUITS
Composition per lOOg of rsw foodstuff. edible portion (E.P.)
....
E.P. 111015-
r.U-
PROTEIN
... fAT CMIO"YDMTE ~,u, ,... ,...
... ....... ~C'ROT£N TMllIIIllII 111Of\.AVI IIIIAQN ASCOfIIIC
A.P.
of TURE
100 II
•
.... ,tt. .". Clis.
fr. prot.
' .....eln
"l"
••u
cal. ~.
e. 'tUl
,tt.> Unc•. flllr,1 ,,,100,
(1/100 " FIbn
, : tl DO .>
VI'''.IN''
I.U, per
100 II
...
e_
100 "
...
e..
100 II
...
Coo
100 ,)
...
e., AC'D
e",,..
.DO • ) 100 ,I
REMARKS
115. APPLE (Malus syIVt5iris)

11&. APPLE 'Malay" or "row'
(Eugenia NilCFtnsis)
84
n
84.0
85
58
51
0.3
0.6
·1.7
3.3
65," 1.0,0.5 0.4
II'
15.0
13.7
0.'
0.7
6
10
.3
.5
~
, 54
/I
0.04
0.03
0.0'
0.0'
0.2
0.3
5
15
I
•
117. •PP1£ "Star"
(ClwyMphylllIrI caimi\o)
87 80 80 1.0 4.2 2.0 16.5 1.5 15 0.5 10 6 0.03 0.02 1.0 s •
118. AVOCADO-low fat . 67 82.9 '18 1.4 4.8 8.3 6.5 1.5 10 .6 180 110 006 0.12 1.5 10 I
(Persll)-la"h fat 70 67.1 225 1.8 2.7 23.4 6.' 1.7 15' .9 340 200 0.10 0.44 1.5 10 I
11'. CITRIIS: DrIngt (C. sl ...~s) 72 87.1 45 0.9 6.7 57,28 4.0,1.' 0.2 1l.3 0.8 34 .4 170 100 0.08 0.03 0.2 50 (S~
~n
I
- Mandarin (C. reticula",)
- Lemon (C. llmonll)
- LIme, Stlllil (C. mlcrocarpa) ,.
71
62
87.3
88.7
8U
44
41
40
0.8
0.8
0.4
6.1
6.6
3.6
0.3
0.5
1.0
10.9
9.5
8.3
1.0
...
0.9
(33)
40
18
(0.4)
.6
0.8
(420)
0
0
250
0
0
0.07
0.04
0.02
(0.03)
;
0.01
0.21
0.1
0.2
31
50
45
d
•I
- pomelo {e, grandls osbecld 56 83.4 59 0.5 2.S 0.3 15.3 0.6 30 0.7 II II 0.03 0.01 0.1 42
•
120. OURIAN (Olltlo .ibecJll"" 24 62.9 144 2.5 5.8 3.1 30.' 1.7 , 0,' 30 18 0.24 0.20 0.7 24 d
o
:s:
...,
121.
122.
FIG (Flatl carka)
GUAVA (P.ldl. . "",.l
If1
78
81.7
80.6
65 1.2
..,
6.0 80,44 4.8,2.8 0.' 16.1 1.' 54 .6 80 48 0.06 0.05 0.5 2 •
• i
" 1.0 0.' 17.3 6.2 18 .9 180 110 0.03 0.04 1.2 160
~
123. MANGGO (&) rlpo 62 81.7 65 0.7 3.6 0.2 17.0 0.8 11 .4 1 '00 1140 0.05 0.06 0.6 48 I
(Mangl'. IndlCl) (b) grftn
124. MANGOSTEEN (GatClnla manpstana)
72
29
85.1 53 0.5 3.2 0.2 13.8 0.4 16 0.3 135
-
80
-
0.08 0.04
-
0.2
-
73
•
'"26
;
83.0 0.6 3.2 0.6 15.6 5.1 8 0.8 0.03 2 d
125. MEL~N, musk (Cantal0Uflt) 56 92.6 0.7 9.0 0.2 6,0 0.5 20 .4 1200 720 0.05 0.03
(CoKunI. II1II0) 0.6 30 I
126. MELON·WllII' (CKrullus 'Al1 ....1s) 53 92.9 25 0.5 6.3 0.2 6.1 0,2 6 .3 170 100 0.04 0.04 0.2 6 I
127. PAPAYA
(&1,1", papa,.)
(0) ,Ipo
(bl 0 -
66
6.
88.6
93.2
"
23
0.6
1.0
5.2
I'"
0.1
0.1
10.1
U
0.9
0,8
24
59
0.4
0.3
1000
0
600
0
0.03
0.03
0.04
0.02
0.4
0.2
64
22 ••
128. PAS$JONFRUIT (Granadlll.)
IH.
(PI55"'_ sppJ
P£RSIMMON, ..........
)) 80.0 70 0,6 2.9 (D) 18.9 (0) 11 1.1 10 6
• 0.10 1.3 16 I
( 0 _ ...11 80 7'-6 73 0.8 3.7 80,60 3.0,2.2 0.3 11.7 1.2 7 0.4 1900 1140 0.05 0,05 0 9 I
130. PINEAPPLE (Ana.....titus) 64 86.7 47 0.5 3.' 0.2 12.2 0.5 18 0.5 ~ 54 O.oa 0.03 0.2 40 I
131. PLUMS (Prunu. "",J 94 82.0 64 0.8 4.2 0.2 16.5 0.5 17 0.5 15O 210 0.06 0.04 0.5 5 I
132. POMEGRANATE (Punlca granatum) 48 8l.3 66 0.6 3.0 0.3 17.2 D.3 3 0,' 0 0 0.02 0.02 0.2 I I
13j. SOURSOP (AMonI ....1....) 66 80.2 71 0.8 3.8 0.4 18.0 1.0 20 0.5 20 12 0.06 0.06 1.0 19 I
134. TAMARIND 48 31.4 m 2.8 3.' 0.6 62.5 5.1 74 0.6 30 18 0.34 0.1. 1.2 2 I
135. TIESA (~ normal n 57.2 154 2.5 5.4 0.6 ".1 7.5 40 1.1 2060 1240 0.02 0.03 2.5 43 I
5tt ... 206, m
, ....ns "traer"
- mIIns ''no dlLa JYailable"; nGt neceuarily "0'" ....
~
tQ
t-:)
t-:)
Table A.1.9 <:>
SUMMARY OF NUTRIENTS SUPPLIED R" PRINCIPAL FOODS (per 100M)
"'l
Foodstuff calorits Protein calcium Iron Vitamin A Vitamin 81 Vilamln C
=
I!'.l
1. Tubers, Bananas
2. Rlct, WbNt
++
+++
+
++
+
+ ++
0·1++)' +
++
++ =
I!'.l
>
I:"
3. Saio, Sugar (refined) +++ 4- + 0 0 0 "'l
4. Milk 4- + +-r- :<:: :!::
±
j.+ + =
>
5. Meat .......... ++ +++ 4- ++ ++ r/l
"cI
6. FlslI + +++ +1++)' ++ .± H-+l' + 0 I!'.l
0
7. En ............. + j-+ + ++ ++ ++ "'l
r/l
8. Peanut!, Beans (dried',
I.e. pulses ... +++ +++ ++ ++1+)' o l.:Lr ++ 0 0
+++ +·,1+) ++ ++ + "il
9. Nuts ...... 0 00
-" H,) + "il
10. Coconut meat (mature) +++ + + ++ 0
+ 0
11. Coconut water -
+
+
- + 0 0 0 ++ II')
t::I
12. Leaves' + ++ ++1++)' +1-"+)' ++ + >
z
13. Bo.1n. (fresh) :!:: + ++ ++ + + ++
t::I
14. Yellow vegttables & fruils ± + + + ++ ±. ++
± + z
15. Other vegetables & fruits + + + ++ ++ c::
+- ~. + "'l
.±+ ++
16. Other fruits C ±+ 01++) 1+)++
..."'l
II;
Notes: I. Yellow and red-fleshed varirtj~$ f+ +) (5

b. Small fish, eaten whole Z
c. For differences between varieties, see Table A.IA--8
ANNEX II
NUTRITIONAL REQUIREMENTS
The following sections are mere outlines in order to assist in

the understanding of the nutritional problems described in the
main text. They should also facilitate an understanding of the
steps necessary to assess and prevent those problems and to ame-
liorate the nutritional situation generally. For a systematic
exposition of basic nutritional biochemistry and physiology,
standard texts should be consulted.
1. GENERAL COMMENTS
Minimum and optimum levels for energy and nutrient intakes
cannot be defined with exactness and certainty. Certain standards
are generally accepted for calories, protein, iron, and calcium.
Requirements depend on the age, sex, bodyweight, and the state
of pregnanc:\( or lactation, but even if these are specified, there is
a considerable range of individual variation. Dietary allowances
therefore usually represent a supposedly safe but arbitrary margin
above the average minimum requirement for a specified age, sex
and body weight. This margin means that the great majority
of a group will have sufficient intakes if they reach the "safe
allowance" level.
FAa/WHO publications cover the requirements for calories,
protein, iron and calcium, and m(lst vitamins. In the Western
Pacific Region, schedules for calculation of dietary allowances vary-
ing in their scope and comprehensiveness, are available for Austra-
lia, ,,; Japan, Malaysia,"7 and Philippines. 67 Other widely used stan-
dards are those of Canada,"8 the United Kingdom,16 and United
States of America. 6 "
While considering the requirements for calories and the
nutrients discussed below, it should be remembered that people
live on meals and mixtures of foods, not on individual nutrients.
The requirements for individual nutrients must be considered in
relation to the supply of requirements for other nutrients, and
ultimately interpreted in terms of mixtures of foods. For ins-
221
222 ,THE HEALTH ASPECTS OF FOOD AND NUTRITION
tance, protein requirements depend partly on protein quality, This

can only be assessed on the basis of an average or sample diet.
Such a diet may be formulated on the basis of household con-
sumption surveys, For particular groups, e,g" young children
who receive a more limited diet, this sample family diet may be
inappropriate, At the other end of the scale, when interpreting
average food production or consumption data for a population
group such as village or a nation, one has to take into considera-
tion that there is always some inequitable distribution of available
foodstuffs. Therefore, an average diet which apparently covers
group requirements may not do so in practice when it comes to
individuals or sectors within a group or population,
Certain nutrients are present in Rignificant amounts in the
normal adult body, e,g" fats, vitamins A and D, B12, iron, calcium,
and some minor elements, Temporarily, low intakes of these
nutrients may not be harmful. During growth, however, intakes
should be maintained continuously at the required levels, Some
nutrients, e,g" other B-vitamins and vitamin C, need to be taken
in more or less regularly each day, although ill effects may not
appear for a long time on deficient diets, During acute or chronic
infections, including parasitosis, there is likely to be catabolism
of various nutrients, and requirements are therefore elevated, On
mixed diets also, the absorption of some nutrients may be markedly
affected by the presence of other substances, e,g" phytates
apparently interfere with the absorption of iron, calcium and
possibly other nutrients, Foods taken singly may be less efficientl~
utilized than when a complete and balanced meal is taken, The
indications of requirements given below are therefore merely
guidelines to which many qualifications are necessary. The re-
quirements are in terms of nutrients ingested. Intakes are usually
calculated from tables of raw food composition, and some adjust-
ments for cooking losses are needed, if intakes are compared with
recommended allowances.
2. ENERGY 82b
Energy is measured in terms of the calorie, which is the amount

of heat required to raise 1 gram of water through l°C, Allowances
and intakes are usually quoted in terms of kilocalories (1 kiloca-
lorie = 1000 calories) *.
·On. kilocalorie is usually abbreviated 8S "Cal" (Capital C)
NUTRITIONAL REQUIREMENTS 223
Energy expenditures are of three main kinds:

(a) basal metabolism - energy expended to maintain body
metabolism during complete rest;
(b) additional energy expenditure, mainly muscular, involved
in performing physical work:
(c) specific dynamic actio.n - additional energy expenditure,
mainly metabolic, resulting from the consumption of food (amount-
ing to about 10% of basal).
Simple maintenance living usually needs about 33 % more calo-
ries beyond basal metabolism (Grade 0, see p. 225). Very active
persons, e.g., workers engaged in heavy industry, strenuous manual
work or exercise, need two or three times the basal requirements.
While energy requirements in both adults and children are closely
related to body weight or surface area, it should be noted that
chronically underfed persons may be 10'10 or more below .their
proper weight. A stable body weight and an energy intake which
just balances with energy expenditures does not necessarily mean
the diet is calorically adequate. Physical activity in either adults
or children may be reduced because of caloric inadequacy. Energy
intakes should ideally be calculated according to ideal body weight
rather than actual body weight.
Calorie intakes are usually regulated by appetite and food
availability. In adults, the appetite is so finely adjusted to bodily
needs, that a satisfied appetite and constant body weight are
normally achieved, indicating perfect caloric balance. Periods of
hunger, at certain times of the day in an individual, or at certain
seasons of the year, indicate caloric deficiency. This is probably
harmful in the case of children, who often have to go without
breakfast at certain seasons. of the year. Appetite however is not
a reliable guide to the requirements for essential nutrients; these
may not be adequately supplied in poor-quality, imbalanced diets
",hich nevertheless do meet the calorie requirements, prevent
hunger and satisfy the appetite.
Excess energy intakes causes accumulation of body fat (both
subcutaneous and internal). In affluent countries, the body weight
of adults commonly increases in successive decades until the age
of about 60 or 70 years, but in many developing countries, there
is either no increase, or a downward trend after the adult weight

is attained at about 25 years; this suggests deficiency of calories
and possibly protein and other nutrients. In children, calorie
restriction may be the principal cause of growth retardation.
The skinfold thickness is more directly related to caloric status,
than are body weight and height. Studies of skinfold thickness as
well as body weight are of the utmost importance in assessing
community nutrition status as regards energy.
The calculation of calorie requirements for various circums-
tances, age groups, population groups, etc., is explained and illus-
trated in an FAD publication,62h which should be consulted for
more details. The standards shown there are seldom attained, in
developing countries, except among privileged groups. In sum-
mary, the standards are:
1<'or men: E (energy requirements) = 152 WO. 73 Calories
For women (non pregnant, non-lactating) : E = 123.6wo.73
Calories
(W = body weight in Kg; this is raised to the 0.73 power, i.e.,
the logarithm of W is obtained, this is multiplied by 0.73,
and then the anti-logarithm of this number gives WO.73)
For infants, recommended allowances are:
1-3 months 120 Cal/kg body weight
For older children, requirements are specified for each year
of age S2h. For ready reference, allowances for several age group-
ings are summarized in Table A.2.1.
Populations in developing countries commonly do not reach
these body weight levels, due at least in part to chronic under-
nutrition. The reference allowances for adults and children of
specified ages are still theoretically desirable therefote. However,
to be more realistic, it is reasonable in developing countries to
take the existing body weight (for a given age, in children) as
the basis for calculating interim requirements.
It will be noticed that in developing countries the children
usually belong by weight in the age bracket one below, i.e., 7-9
year-olds weigh and 'need' much the same as 4-6 year-olds in
affluent countries, in relation to existing body weight.
225
TABLE A.2.1
RECOMMENDED DAILY CALORIE ALLOWANCES

A. Reference .tando.-d. (After F AO~2h)
Age (Yea,'.) A vemge weigh t
0- 1 110 Calories per kg body weight
1 - 3 13 kg 1300 Calories
4 - 6 18 kg 1700
7 - 9 27 kg 2100
10 -12 36 kg 2500
13 -15 49 kg 3100 (males), 2600 (females) Calories
16 -19 63 kg (male) 3600 Calories
54 kg (female) 2400
Reference man (65 kg) 3200
Reference woman (55 kg) 2300
Pregnancy (last trimester). Additional 20% of daily allowance, or
increase of 40000 Calories during the whole of last trimester, if
activity is not curtailed.
Lactation: Additional 800 calories daily throughout lactation.
I:!. fllt.dlll Rtullda.-ds (for developing We.te'·11 Pacific coulltrie.)

Age (Years) A verage 'weigh t
o- 1 110 Calories per kg
1 - 3 11 kg 1100 Calories
4 - 6 15 kg- 1500
7 - 9 20 kg- 1800
10 -12 26 kg- 2100
13 -15 39 kg 2600
Man 60 kg 3000
55 kg 2900
50 kg- 2600
Woman 50 kg 2050
45 kg 2000
40 kg 1800
Pregnancy/lactation: additional 10%.
TABLE A.2.2
CALORIE ALLOWANCE ADJUSTMENTS FOR

DIFFERENT ACTIVITY LEVELS
After NH &: MRC (Australia),';:!
Adjustment to "Reference" Calorie Allowance
for Activity Grade
Grade I
Body Weight Grade 0 (Reference
Kg ( Subract) individual) Grade II Grade III
41 - 50 - 536 0 + 360 + 810
51 - 60 - 610 0 + 390 + 870
61 - 70 - 690 0 + 400 + 900
71 - 80 - 760 0 + 410 + 930
Maintenance Clerical; Skilled Labourin~;
Activity only Home duties tradesman;
(At rest but Driver; Infantry; Minin~
not basal) typin~ Farming
The reference individual has:

Man Woman
Rest in bed 8 hrs 8 hra
Working activities 8 hrs 8 hra
Walking l'h hr. 1 hr
Washing and Dressing 1 hr 1 hr
Sitting 4 hrs 5 hra
Active recreation
and lor domestic activities II" hrs 1 hr
TABLE A.2.3
CALORIE ALLOWANCE ADJUSTJ\1ENTS FOR AGE OF ADULTS
Age (years) Percentage of "reference"

20 - 30 100.0
30 - 40 ~7.0
40 - 50 94.0
50 - 60 86.5
60 - 70 79.0
over 70 69.0
If nutritional improvement occurs and consequently growth

rates improve, standards evolved on this basis would automatically
adjust themselves upwards. Those given for developing coun-
tries are interim targets only.
The extra energy expenditure involved in work depends on the
body weight of the subject and on the type of work. This may
be classified as one of four grades. Sedentary activity is adopted
as Grade I; this is the basis for the standard reference man or
woman. Some adjustments applicable for Grade 0, Grade II and
Grade III activity are shown in Table A.2.2.
Further adjustments are needed for the age of adults (Table
A.2.3). Although further calorie allowances adjustments for envi-
ronmental temperature were previously recommended, no figures
for this have been included. because of changed opinions on the
subject.
It should be noted that recent revisions of calorie allowances
have shown a definite trend downwards in several countries, com-'
pared with the earlier standard (FAO):
Calories
Reference Reference
man woman
F.A.O.62h 3,200 (65 kg) 2,300 (55 kg)
Australia '53 2,900 (70 kg) 2,100 (58 kg)
United States of America66 2,800 (70 kg) 2,000 (58 kg)
Canada 28 2,850 (72 kg) 2,400 (57 kg)
Methods for calculating the calorie requirements of population
groups are explained and illustrated elsewhere62h. The needs for
calories and other nutrients have to be expressed ultimately in
terms of the foods actually available and consumed in a country.
Approaches along these lines are given by FAO.62h
3. PROTEIN
The WHO Technical Report Series No. 301282r replaces an
earlier publication62i , and should be studied for further details.
This document gives three levels:
(a) average protein requirement (which includes a margin of
10% for "stress")
(b) a 8afe practical allowance 20% above this, which is consi-

dered adequate for about 959'0 of persons of the specified age and
weight;
(c) a level 20% below the average, which is considered
inadequate for about 95 % of persons. Food supply targets should
be set at the highest figure, i.e., the safe practical allowance. The
requirements are stated in terms of "reference protein" which is
defined as a protein that is completely utilized for anabolic pur-
poses; whole egg protein is taken as the standard reference protein.
Protein quality is discussed further below, in relation to the dietary
calorie intake. The reference protein requirements, expressed in
relation to body weight, are summarized for age groups as shown
in Table A.2.4.
For developing countries, the problem of lower body weights
arises, as in considering calorie requirements. Again it is recom-
TABLE A.2.4
REFERENCE PROTEIN REQUIREMENTS OF CHILDREN

AND ADULTS
After WH0282r
g .... kg IIad, weigh!
AVMOt
Age group weight Averave -20% +20% N Up'
(kg) Indlvidllil (safe prilctlcal Col %
requlmnem. (lnsufflcientl allowance)
1· 3 years 13.5 0.88 0.70 1.06 7.0
4· 6 yors 18 0.81 0.65 0.97 5.9
7· 9 ,.. .. 27 0.71 0.&2 0.92 5.9
10·12 )ea.. 36 0.72 0.58 0.86
13 415 years 49 0.70 .0.56 0.84
1&·19 boy, &3 0.&4 0.51 0.77
girls 54 O.&~ 0.51 0.77
men b5 0.59 0.47 0.71 4.&
women 55 0.59 0.47 0.71 7.0
Additional allcwance for pregnancy: 6 9 per person per clay In second and third trimesters.
Additional allowance for lactation: 15 9 per penon per day.
For infants, adequate (safe practi4:a1) allowances In tenns of breastmilk or cow's milt proleln art:
Protein N Dp Cal %.
O· 3 months 2.3 9/kl) body weight 8.3
3· 6 months 1.8 ./kg IIad, weigh! 8.0
6· 9 montlu 1.5 g:kl body ...Igh'
9 -12 months 1.2 9/11.9 bed; weight 7.5
• 5te p. 230
mended for the meantime to base requirements on actual body

weight, recognizing that this is deficient, and this procedure is an
interim expedient. As with calories, it is a self· limiting interim
standard which will adjust itself upward as average growth per·
formances improve, and for individuals of reference-standard
weight the normal standard applies.
Protein requirements are not considered to vary greatly with
physical activity, although when increased physical activity is
begun, there is initially an increased protein requirement while
additional muscle, etc., is being developed.
The protein content of food is usually calculated from its nitro-
gen content, which is multiplied by 6.25, since most proteins con·
tain about 16% nitrogen. (For certain foods, other factors are
used, as shown in Annex I.) This protein content is termed
"crude protein", of which a part is true protein, made up of
amino acids, and a part is non-protein nitrogen; the latter· is a
small proportion in some foods, but a large proportion in others,
e.g., tubers. If not otherwise specified, "protein" refers to the
whole nitrogenous portion of a food, not merely the true protein,
since normally aU the nitrogen is utilizable.
The protein value of a diet depends on :
(a) The calorie content: if this is insufficient, protein will be
utilized to provide calories at the rate of about four calories per
gram. The "protein concentration" of the diet is the percentage
of total dietary calories which is derived from the protein com·
ponents, i.e.,
protein calories
protein concentration = X 100 (%)
total metabolizable calories
A diet should supply a sufficient percentage of its energy value as
protein, but also, its calorie content must be sufficient to avoid
the utilization of protein for energy purposes.
(b) The protein quality, which in turn depends on-
(i) its digestibility (D), which is the percentage of the
ingested nitrogen which is absorbed int.o the body,
when a food is eaten;
(ii) its biological value (BV) which is the percentage of
the absorbed nitrogen which is subsequently retained,
i.e., not excreted in the urine, or from the skin. etc.
The product D x BV expressed as a percentage gives the net

protein utilization (NPU), which is the percentage of ingested
food nitrogen which is actually retained in the body. This should
be measured under standard conditions (designated NPUst ), in
which the protein level is just sufficient to maintain nitrogen
equilibrium while the diet is adequate in all other respects 144 •
Under these circumstances, NPU has its maximum value.
Under the operative conditions when an actual meal is eaten,
the NPUop may be below NPU.. because the protein concentration-
in the diet is too high or too low. The protein value of a
diet is therefore obtained as the product of the two factors, protein
concentration and protein quality (NPU"p)' Since NPU is a
"percentage", this product is also a percentage, termed the net
dietary protein calories per cent (N Dp Cal %) ;*
protein calories
NDpCal'fo= ----~-.,...----- x NPU
total metabolizable calories op
In any ease, the requirement for protein should really be spe-
cified in terms of protein-calories Le. percentage of calories derived
from protein, rather than grams, since it is meals not nutrients
which are under consideration. A diet that provides less than
5% of the calories in the form of utilizable protein, (i.e. N Dp
Cal % below 5) is incapable of meeting the needs of the adult, even
when consumed at a level that meets the calorie requirements.
A diet that supplies less than 8% of calories as utilizable protein
(i.e. N Dp Cal % below 8) is ,incapable of meeting the needs of
an infant. The chart (Figure A.2.2) shows protein requirements
in terms of N Dp Cal '1'0 * *. Although this approach sounds
complicated, for nutrition specialists it is worth mastering. Some
examples for various diets are given in Table A.2.5.
Where data for NPU are not available, as is often the case,
an estimate of protein quality can be made from the amino acid
composition of foods, ** where the content of all the essential amino
.oTo calculate thia. one ehould know NPUop as determined experimentally. However. in
practice one can determine N Dp Cal % directly from a nomogramU4 (see Figure A.2.L).
If the protein concentration and NPU.t or the protein score (see p. 280) of the diet
is known. For instance. rice. with an NPU st of about 70%. and about 710 of ita caIoriet
derived from protein. has an N Dp Cal ~ of about 5. If extra susar wna consumed 80
that only 6% of the calorie. come from protein. then N Dp Cal % faJia to ..bout , (ftad
th., 8DPropriate line from nomogram where y axia = 70. x axis = 5). If extra protein
was eaten, aay In a variety of rice richer in protein. so that 10% of calories are derived from
protein. N Dp Cal ".. would be about 6.6 ('be4;wetm the parabolae for 6 and 7. at the point
where y = 70, x = 10) •
• -Elaborated further by Platt, Miller and Payne (Protein valuea of human food) In
81"Ock.18
acids is known. The amino acids are classed as "essential" and

"non-essential"; the former cannot be manufactured in the body
from other nitrogenous compounds .• There are probably ten
essential amino acids for humans. The absolute requirements of
these amino acids are usually met in any actual diets, but the
balance between the different essential and non-essential amino
acids and the non-protein nitrogen, all influence the protein quality
and utilization. The protein in some foods can be utilized better by
adding one or more amino acids. However, the interrelationships
are ve'ry complex and the results of such supplementation cannot
be predicted in advance.
This sort of analysis was used in the compilation of the second
portion ("calculated values") of Table A.2.5. Table A.2.6
shows our analysis of some sample rice, sweet potato and taro diets.
For purposes of assessing amino acid composition, a reference
pattern is needed. Wholt' egg protein is now considered the most
satisfactory from the standpoint of essential amino acid compo-
sition, in which it closely resembles human milk. Chemical scores
or protein scores are calculated as follows. The amount of each
essential amino acid in the protein or food is expressed as milli-
grams of that amino acid per gram of total essential amino acids,
and this amount is expressed as a percentage of the amount of
the same amino acid per g of total essential amino acids in the
whole egg (see Table A.2.7). The lowest of these percentages
is the chemical score, and the amino acid concerned is called the
limiting amino acid. In making these calculations, the sulphur-
containing amino acids are added together, and likewise phenyl-
alanine/tyrosine, since they are interconvertible.
Chemical scores for some proteins are shown in Table A.2.8,
and in the food composition tables in Annex 1. This score means,
for instance, that for milk, with a protein score of 60% the
sulphur-containing amino acids per g of total essential amino acids
in milk, are 6070 of 107 mg (see Table A.2.7), i.e., 64 mg, and
that all the other amino acids were more than 60% of the pro-
portion for the respective amino acids in whole egg (see Table
A.2.7). It will be noticed that for fish and corn, the limiting
amino acid is tryptophan; for most of the other common foods,
the sulphur-containing amino acids are limiting. There are few
foods which are rich in these; the most notable are egg, sunflower
seed, sesame seed, and taro. It is noteworthy also that animal
FIGURE A.2.1
PREDICTION OF PROTEIN VALUES - NDp CAL%
After Miller & Payne'"
tllorl.. p.rcnt.
100
90
80
70
t 60
.
I!
0
OIl 50
z
;;;
i... 40
30
20
10
0 10
FIGURE A.2.2
PROTEIN ALLOWANCES IN TERMS OF NET DIETARY
PROTEIN CALORIES %
After Miller & Payne'"
•,
L
,._---
I
I
rll-
til
P: I
C; I
U I
I
, 0
a.
I
6 I
I
:z
4
0 2 4 6 10 12 14 16 18 20
Age - Years
TABLE A.2.5 ~
....
COMPARISON OF THE PROTEIN VALUES OF SOME HUMAN DIETS AS DETERMINED BY
RAT ASSAY AND AS CALCULATED FROM FOOD TABLES
After WHO 232r 003
==
I!riI
Observed values Calculated values d
Protein ==
~
Total Protein
Additional effective no. of NPUop calories calories
Origin StaplnG source. of protein compo-- (0/. ) (% total NDpCal ~It Score e (% total NDpCal %
nents calories) calories)
Gambia Cassava Pulses 4 45 2.8 1.3 53 2.1 1.1 ==

Papua Sago Fish 3 75 3.5 2.6 ± 0.2 74 4.1 3.0 ~
'd
I!riI
Jamaica Sugar Cornmeal 3 66 4.9 3.2 ± 0.1 45 4.3 2.0 C')
003
65 4.0 0.3 rn
Gambia Cassava Fish 5 6.1 ± 64 8.9 5.3
o
14 59 9.2 5.4 0.2 69 9.3 5.9 "!I
E. Pakistan Rice Pulses, milk ±
"!I
Jamaica Maize Fish 4 60 10.0 6.0 ± 0.2 58 14.0 6.8 o
o
t;j
Britain Wheat Cheese 6 73 9.4 6.9 ± 0.3 76 10.7 7.1
12.5 7.3 0.4 72 12.5 7.7
>
Nigeria Sorghum Pulses, fish 12 58 ± Z
t;j
Gambia Maize Pulses, fish 6 57 13.9 7.9 68 14.2 8.0
Z
8.3 c:::
Persia Wheat Meat, eggs, milk 11 55 15.0 8.3 ± 0.3 76 13.0 003
13 63 14.0 8.8 0.3 76 15.1 9.0 ~
Nigeria Sorghum Milk fish ± 003
15.7 9.2 :5
TUlkey Wheat Meat, pulses 11 59 ± 0.2 71 15.3 8.7
z
Britain Wheat Milk 5 44 29.0 12.8 ± 0.2 80 29.0 11.8
I
a Chief source of calorie!
b Foodl (excluding the staple) contributing more tha,n 20Cf" of the protein in the diet.
~ The tbruru eiven are means, and the limits are standard errors.
d Food compofiiltion tables used were those of McCanCE & Widdowllon (1960). Orr and Watt (1967) and
Platt (19621.
e Calculated according to F AO 62i
(.~
" •
"
Table A.2.6
PROTEIN VALUES OF SOME SIMPLIFIED DIETS IN THE WESTERN PACIFIC
Amino acid content (mg), protein score and NDp Cal %
A. DIET L Rice/fish/vegetable
Food
Commodity
(E.P.)
Grams CalorieS Protein
(grams)
Calories
from
protein
Iso·
leucine
Leucine Lysine
Total
Sulphur-
contaifl-
Ing$
.
Total
Aromatic Thr~
nine
Trypto·
phsn Valine
Total
Essential
Amino Acids
(E)
Rice (brown) 160 575 12.0 41 480 1 036 478 427 1 090 491 157 693 4 852
Amaranth 10 5 0.46 1 22 36 23 17 43 20 7 26 194
leaves
Eggplant 30 7 0.36 1 16 22 19 /j 28 13 4 18 126
Fish 40 40 7.52 30 360 578 685 304 571 344 84 460 3 386
Total 627 20.3 73 878 1 672 1 205 754 1 732 868 252 1 197 8 558
diet 10.2% 19.5'1< 14.1 'I< 8.8% 20.2% 10.1% 2.9% 14.0%
whole egg 12.9'!o 17.2% 12.5t')i, '10.7% 19.5'7, 9.9% 3.1% 14.1 '7c
x 100 79 113 113 82 104 102 95 99
---
b
Limiting
amino
acid
Protein score = 79
73
Protein calories % = - - - x 100 11.6'10
627
N Dp Cal % = 8.0 (Read from nomogram, Fig. A.2.1)
*Sulphur-containing acid! ""'" methionine and cystine

Aromatic amino aeida -' Phenylalanine and tyrosine. ~
0.
Table A.2.6 I>:)
~
a>
PROTEIN VALUES OF SOM.E SIMPLIFIED DIETS IN THE WESTERN PACIFIC
Amino acid content (mg), protein score and NDp Cal %
o-,l
B. DIET II. Sweet potatolvegetable ==

J:<j
Sweet ==
J:<j
>
potatoes
Amaranth
500 570 15.0 41 240 355 226 135 406 250 110 296 2 016
~
leaves 50 24 2.3 6 109 179 117 85 213 98 34 128 963 ==
>
rn
47 534 342 220 618 348 'tI
Total 594 17.3 349 144 423 2 978 J:<j
oo-,l
(a) AlE ratios for diet 11.7% 17.90/< 11.5% 7.4'10 20.7% 11.7% 4.8% 14.2% rn
o
(b) AlE ratios for whole egg 12.9% 17.2% 12.6'1<. 10.7% 19.6'1< 9.9% 3.1% 14.1% "!l
"!l
Percentage scores ..'! x 100 91 104 92 69 106 118 156 101 o
b
o
t:I
Limiting
amino
acid
>
Z
Protein score = 69 t:I
Z
47 c:::
o-,l
Protein calories % = --- x 100 = 7.9%
....o-,lto
694
....
N Dp Cal % = 6.0 (Read from nomogram, Fig. A.2.11 o
Z
.;oSulphur.eontaining aeids = methionine and cystine

Aromatic amino selda == PhenYlalanine and tyro8ine.
.r ,.
Table A.2.6
PROTEIN VALUES OF SOME SIMPLIFIED DIETS IN THE WESTERN PACIFIC
Amino acid content (mg). protein score and NDp Cal %
C. DIET III. Taro/fish/vegetable
Food Calories Total Total Total
Commoditv Gramt Calories Protein from Iso- Leuein( Lysine Sulphur_ Aromatic Threo-- Trypto· E .....t1a1
(E.P.) (grams) protein leucine contain·
ing'"
• nine phan Valine Amino Acids
(E)
Taro 400 416 7.20 20 256 532 280 288 632 296 132 444 2 860
Amaranth
leaves 14 65 z
30 1.38 3 108 70 51 128 59 20 77 578 c
Fish 30 30 5.64 23 270 433 514 228 427 258 63 345 2 538 ~
.~
Coconut'· 30 108 2.0 7 92 157 82 74 169 80 25 127 806 8
z
Total 568 16.2 53 683 1 230 I 946 641 1 356 693 240 99'3 6 782 ~
(a) A/ E ratios for diet 10.1% 18.2,/', 14.0% 9.5% 20.0% 10.2% 3.5% 14.6%
g;j
.c
~i!::
(b) A/ E ratios for whole egg 12.9% 1~"l:'i'o . 12.50/r 10.7% 19.5% 9.9% 3.1 % 14.1%
Percentage scores!. x 100 78 106 112 89 102 103 114 104
b tzJ
Limiting
amIno ...
Z
rn
acid
Protein score = 78
53
Protein calories % x 100 = 9.3%
568
N Dp Cal % = 5.6 (Read from nomogram, Fig. A.2.1)
.Sulph~ntaining acida - methionine and cptine

Aromatic amino acidt -= Phenylalanine and t:rroalne. ~
··Amlno acid analysla in FA068 it for well-dried product with protein content 6.8 per 100 ana (molature ~
12.2~): calorie content (FAO) bu been adjuoted .eeorc!ln"ly.
TABLE A;2.7
WHOLE EGG AMINO ACID PATl'ERN

After WH0232r
AlE Ratio:
Amino acid mg per g of total
essential amino acids
1. Isoleucine 129
2. Leucine 172
S. Lysine 126
4. Total "aromatic" amino acids: 196
a. Phenylalanine 114
b. Tyrosine 81
6. Total sulphur-containing amino 107
acids:
a. cystine 46
b. methionine 61
6. Threonine 99
7. Tryptophan 31
8. Valine 141
TABLE A.2.8
CHEMICAL SCORE AND NPU OF SELECTED PROTEINS

After WH0232r (Table 9)
Score"
Food AlE AIT Limiting amino acid NPU"
Egg 100 100 93.5

Milk (cow's) 66 60 S" 81.6
Casein 59 58 S 72.1
Pork 81 69 S (84)
Fish 80 70 Tryptophan 83
Rice 76 57 Iso-leucine 57.2
Corn meal (maize) 55 41 Lysine (55)
Millet 67 53 Lysine (56)
White flour 52 32 Lysine (52)
Peanut 69 43 S 42.7
Soy 62 47 S 61.4
Sesame seed 63 42 Lysine 53.4
Sunflower seed 93 58 Lysine 58.1
Navy bean 47 34 S 38.4
Peas 50 37 S 46.7
Potato 53 34 S (71)
Sweet potato 82 51 S (72)
Spinach 71 68 S
Cassava 85 41 Arginine
.. S = Sulphur-containing amino acids (methionine and cystine)
.. Figures in these columns are taken from the more recent publication of
FAO,581 where available
proteins are not necessarily superior in quality to vegetable pro-

teins. Effective combinations are those between proteins having
different limiting amino acids, e.g., rice and fish; rice and pulses
or other vegetables; tubers and fish. The high score of spinach
is interesting; the protein quality of other leafy greens is not
known in detail. However, green leafy vegetables in general do
provide an outstandingly high percentage of calories from protein.
Therefore even though their protein concentration per· gram of
foodstuff is low, they tend to increase the N Dp Cal 7c in the diet.
Notwithstanding all the above remarks about protein, it has
been found that under conditions of marginal protein nutrition,
non-essential amino acids and even non-protein nitrogen are appa-
rently utilized with unexpected efficiency by the growing human
body. Therefore from the practical angle, the addition of any
source of protein or nitrogen to the usual low-protein diets should
be or' great value, irrespective of whether it is animal or vegetable
protein. In practice it may be difficult enough to increase the
supply and consumption of any nitrogenous food, and questions
of protein quality sh(lUld not therefore be considered paramount.
On the whole, the main p~oblem in the Region is to find any avail-
able low-cost protein sources which can be augmented in the family
and infant diets of low-income groups.
Observed protein intakes are commonly not far below recom-
mend.ed levels on a per caput basis where cereals form the staple.
With other staples such as tubers, intakes are usually far below
recommended levels. The staples commonly supply about half ·of
the protein intake, even though they are not rich in protein, be-
cause of the relatively large quantities of staple consumed.
Among infants and toddlers, protein intakes are liable to be
seriously deficient even with cereal as staple. Only careful sur-
veys among these vulnerable groups can determine the existence
and extent of this problem, which is probably second in importance
only to calorie restriction (in the same age group), among all the
public health nutrition problems. A degree of physiological
adjustment to these low protein intakes undoubtedly occurs,
probably including more efficient utilization of some non-protein
nitrogenous compounds. These adjustments evidently must be
particularly profound and efficient among women during pregnancy
and lactation.
When using food composition tables, these usually cite the com-
position of raw foods. Most protein-containing foods are cooked.

It is commonly overlooked that the losses of nitrogenous compo-
nents during cooking may be significant, especially if water used
for boiling is discarded (see Annex 1).
4. VITAMIN A
The requirements expressed in terms of retinol,~-carotene
and international units are given in Table A.2.9.
Human diets contain both retinol and carotenoids in widely
varying proportions. Of the carotenoids, (,-carotene ,has the
highest biological activity. The activity of other carotenoids
varies, some having no activity and others about 50 per cent of
that of ~-earotene. The activity of other mixed carotenoids (with
Vitamin A activity) should be taken as one-half of that of
jl-carotene, on average.
The efficiency of conversion or biological activity of 8-
carotene, after absorption, is only one-half that of retinol, i.e.,
0.6 meg jl-carotene=0.3 mcg retinol (aee p. 208). Absorption of
8-carotene is also only partial, usually ranging from one-half
to one-quarter of the ingested jl-carotene (see WH0232A, p. 24).
It was agreed by FAO/WH0232A (p. 24) to take the average
absorption or availability of ,,-carotene as one-third. Hence the
overall utilization of ,,-carotene is one-sixth that of retinol,
weight for weight, i.e., 1 mcg ,,-carotene in the diet;: 0.167 mcg
retinol in the diet.
The requirements as stated by WH0232A are given below,
in terms of retinol, ,,-carotene (in the diet) and international
units:
TABLE A.2.9
RECOMMENDED DAILY INTAKE OF VITAMIN A

AT VARIOUS AGES
Purely animal source Purely vegetable source
Age Retinol I. U. of (3-earotene 1. U. of
(meg) Vito A (meg) provitamin A
0- 6 months· • •
6-12 months 300 1000 1800 3000
1- 3 years·· 250 833 1500 2500
4- 6 years 800 1000 1800 3000
7- 9yeara 400 1833 2400 4000
10-12 years 576 1917 3450 5750
18 -15 years 725 2417 4350 7250
16-19 years 750 2500 4500 7500
Adults·· 750 2500 4500 7500
Note: for diets containing both carotene and retinol. adjuUDent mut be made .. deaeribed
ovprleat,
·For infanta 0.& montha breaatfeeding by a well-nourished mother fa the beat way to
IBtlsty the nvtritional requlremente for vitamin A. However, In thil Reaion maternal
c1teta and breutmllk are too &ow in vitamin. A.
"It would appeal' deairable to reeommend in this Re-gion;
(a) an additional 160 meg retinol daily durin&' ptelPlancy i
(b) an additional _ ...... retinol dally during lactation.
(.) JDaintainilnl' 800 me.. minol daily duriurr the critical toddler ap (1-8 yean)
rather tbim reducI.... to 260 m ....
This table is based on Table 3 of WH0232A (Page 22).
The recommended intake in accordance with the biological
activity of the vitamin A compounds in the diet is calculated as
follows:
Recommended intake of mixed

vitamin A-active compounds = Recommended intake of retinol
0.167 k + (1- k)
where k = proportion of ('-carotene in diet·
(3-earotene (meg)
- ~------~~------------
(3-carotene (meg) + retinol (mcg)
Contrary to previous teaching, it is now believed that dietary
fat has little effect on retinol absorption, but may have some
*Includlng half the weil'ht of other carotenoids tban ~.oC.rotene.
effect on carotene absorption. Evidently, however, even carotene

can be absorbed despite very low fat intakes, e.g., in New Guinea.
More important is the fact that inadequate protein intake has an
adverse effect on the efficiency of retinol absorption, its transport
in the blood, and its metabolism. In the case of carotene, protein
.'
deficiency markedly depresses the intestinal conversion of (3-caro-
tene to retinol derivatives.282A
In point of fact, the greater part of the vitamin A intakes in
most parts of the Region are derived from vegetable sources. The
recommended intakes should therefore approach those given for
(3 -carotene.
5. VITAMIN B COMPLEX
In general, these are related quite closely to energy require- "
ments and intakes, and the recommended intakes can be calculated
from the calorie requirements as follows:
Thiamine: 0.4 mg per 1000 Calories
Riboflavin: 0.55 mg per 1000 Calories
Niacin equivalents: 6.6 mg per 1000 Calories
These recommended intakes are set at a level 20% above

average minimal requirements,' since this level is estimated to
give a margin of safety sufficient to cover the requirements of the
great majority of people.
Tables A.2.l0 and 11 are ready reckoners for vitaminB require-
ments, on the basis of recommended calorie intakes. It is believed
that the same relationships to calorie intakes can be applied during
pregnancy and lactation.
The adequacy of actual diets in thiamine depends greatly on the
method of milling and cooking of rice and is usually marginal.
Riboflavin intakes are low in nearly aU the common diets in this
Region, whereas niacin intakes are usually relatively adequate.
Vitamin B12 and folic acid requirements, and the amount pre-
sent in various foods and the usual intakes, are not known accu-
rately, but current recommended intakes are given in Table
A.2.12.
Nl.1TRITIONAL REQUIREMENTS 248
TABLE A.2.10
RECOMMENDED DAILY INTAKES OF THIAMINE

RIBOFLAVIN. AND NIACIN
After WHOzaZA
Thiamine Riboflavin Niaein 1
A&, e Calories/ day (mg) (mg) equivalent.
o- S monthe2 12O/kg - - -
4- 6 monthe2 110/kg - - -
7-12 months 1000 0.4 0.6 6.6
1 year 1150 0.6 0.6 7.6
2 years 1300 0.6 0.7 8.6
3 years 1460 0.6 0.8 9.6
4- 6 yean 1700 0.7 0.9 11;2
7- 9 yean 2100 0.8 1.2 13.9
. 10 - 12 years 2500 1.0 U 16.6
13 - 16 (boys) 3100 1.2 1.7 20.4
(girls) 2600 1.0 1.4 17.2
16 - 19 (boys) 3600 1.4 2.0 23.8
(girls) 2400 1.0 1.3 16.8
Adultall (men) 3200 1.3 1.8 21.1
(women) 2300 0.9 1.3 .
16.2
-
1 A. niacin equivalent ia 1 DUr_ niacin or 60 -m&' ~tryptophan
For e b l _ 0 to • IDOIItbo it Ia accepted that _ {_na by a welJ-ilO1Il'Iabed
-.
' 10 tile _ ..." to aatiafy the nutritlolUll - W _ t . for tlWuallle. rIbofIDIll ...d
alaeln.
3 For recommended Intak. of thiamine. riboflavin and Dlaln for adaIt. of different
..... weiPlo. _ TaI>Ie A.l.ll.
TABLE A.2.11
RECOMMENDED DAILY INTAKES OF VITAMIN B FOR

ADULTS OF DIFFERENT BODY WEIGHTS
After WHOZI&A
Body weight Thiamine Riboflavin Niacin
(kg) (kg) (mg) equivalente
MEN
- -
45 1.0 1.3 16.3
50 1.1 1.5 lUi
55 1.1 1.6 18.7
60 1.2 1.7 19.9
65 1.B 1.8 21.1
70 1.4 1.9 22.3
75 1.4 2.0 23.5
80 1.5 2.1 24.6
WOMEN
85 0.7 0.9 11.0
40 0.7 1.0 12.1
45 0.8 1.1 18.2
50 0.9 1.2 14.2
55 0.9 1.3 15.2
60 1.0 1.4 16.2
65 1.0 1.4 17.2
70 1.1 1.5 18.2
6. ASCORBIC ACID. VITAMIN D. VITAMIN B12,

FOLATE ( WH0232H )
Ascorbic acid intakes of 10-20 mg are known to be enough

to prevent scurvy. Blood levIes and urinary excretion increase
with higher intakes but the supposed nutritional benefits are
not known with certainty. An intake of 30 mg daily is consi-
dered adequate for all children and adults except in pregnancy
and lactation.
Table A. 2. 12 summarizes the intakes recommended by
WHO.232H
TABLE A.2.12
RECOMMENDED DAILY INTAKES 01<' ASCORBIC ACID,
VITAMIN D, VITAMIN B12 AND FOLATE
Ascorbic Acid Vitamin D Vitamin B12 Folate

(mg) (meg) c (mclU (mg)
n
Infants, 0-6 months 20 10 0.3 40
7-12 months 20 10 0.3 60
Children, 1-3 years 20 10 0.9
4-6 years 20 10 1.5
J
7-9 years
10 12 years
20
20
2.5
2.5
1.5
2.0
roo
Boys ) 13-19 years 30 2.5 2.0 200
Girls )
Adults, men ) 30 2.5 2.0 200
women )
pregnancy 50d 10 d 3.0 400
lactation 50 10 25 300
a It is accepted that for infants aged 0-6 months brea't-feeding by a

well-nourished mother is the best way to satisfy the requirements of
ascorbic acid, Vitamin B12 and folate, but not of vitamin D.
b Adequate exposure to sunlight may partially or totally replace
dietary Vitamin D.
c 25 mcg of cholecalciferol are equivalent to '100 IU of vitamin D.
d For 2nd and 3rd trimesters.
7. IRON""2f.G.H
Many factors affect the absorption and utilization of iron.
Furthermore, iron deficiency anaemia usually arises only when
there is also excessive blood loss. Table A.2.12 gives recom-
mended allowances which are intended to apply under the most
favourable conditions for utilization; intakes at these levels may
not be at all adequate under the prevailing conditions.
TABLE A.2.13
RECOMMENDED DAILY INTAKES OF IRON
After WH()232H
Recommended intake
according to type of diet
-\bsorbed Animal foods Animal food. Animal food.
iron below 10% of 10-25% of bver 25% of
required calories calories calories
(mg) (mg) (mg) (mg)
Infants 0-4 mos. 0.5 a a a

5-12 mos. 1.0 10 7 5
Children 1-12 yrs. 1.0 10 7 5
Boys 13-16 yrs. 1.8 18 12 9
Girls 13-16 yrs. 2.4 24 18 12
Menstruating
women b 2.8 28 19 14
Men 0.9 9 6 5
Pregnancy) Same, ~rOvjded previous iron intakj" and present
Lactation ) iron stpres adequate!
a Breast-feeding is assumed to be adequate.
b For non-menstruating women the recommended intakes are the same
as for men.
8. CALCIUMz8z I
Large populations subsist on intakes of 200 to 600 mg daily

without ill-effect attributable to calcium deficiency. In the ab-
sence of any definite minimal requirements, WHO recommends
"practical allowances" as shown in Table A.2.14.
However, successful repeated pregnancy/lactation cycles are
widely achieved in this Region without any sigilificant increase in
calcium intakes above the normal adult intakes mentioned above.
As a rough approximation, 400-600 mg daily is adequate at all ages.
TABLE A.2.14
PRACTICAL ALLOWANCES FOR CALCIUM

After WH08ZZ1
0-12 months (not breastfed) 500-600 mg/day
1- 9 years 400-500 mg/day
10-16 years 600-700 mg/day
16 -19 years 500-600 mg/day
adults 400-500 mg/day
pregnancy (third trimester)
and lactation 1000-1200 mgl day
..
TABLE A.2.15
SUMMARY OF RECOMMENDED DAILY INTAKES
A. Reference Standards (FAO-WHO)
School Ate Adult
-
Femal.
Toddler ""-'1 P",..nt I
Inflnt 1.' )<I .. 406 JIll! 7.9 )<Irs l0012:;r 13-15 ::rrs Mole NPNL thin! I
0011 IIHInIhs (13 kg) (18 kg) 127 lit) (36 ) (49 ) (65 ktl 155 kt) trimester Ladall",
110
Calories (per kg body 1300 1700 2100 2500 M 3100 3600 2300 ·2760 3100
weight) F 2600
Protein (gram) 2.3-1.2 ~
(reference) (per kg body 14.3 17.5 24.9 31.0 41.1 46 39 45 54 il::
weight)
~
Vitamin A: rn
retinol (mcg) 300 250 300 400 575 725 750 750 750 1200 c::
or
~-carotene (mcg) 1800 1500 1800 2400 3450 4350 4500 4500 4500 4500 §
Thiamine (mg) 0.4 0.5 0.7 0.8 1.0 M 1.2 1.3 0.9 1.1 1.2
F 1.0 iil::
Riboflavin (mg) 0.6 0.7 0.9 1.2 1.4 M 1.7 1.8 1.3 1.6 1.8 OJ
F 1.4
Niacin equivalents 6.6 8.6 11.2 13.9 16.5 M 20.4 21.1 15.2 18.2 20.4
F 17.2
Ascorbic acid (mg) 20 20 20 20 20 30 30 30 50 50
Iron (mg) 5 5 5 5 5 ~1~ 5 14 14 14
500- 400-' 400- 400- 600- 600- 400- 400- 1~ 1~
Calcium (mg) 600 500 500 500 700 700 500 500 1200 1200
t-o
Vitamin D (meg) 10 10 2.5 2.5 10 10
10 2.5 2.5 2.5
~
Vitamin B" (meg) 0.3 . 0.9 1.5 1.5 2.0 2.0 2.0 2.0 3.0 2.5
Folate (meg) 40-60 100 100 100 100 200 200 200 400 300
- ---
B. Interim Standards (for developing Western Pacific countries) ~
School Age Adult "'"

00
Fem_lt
Toddler Pre-school Pregnant
Infant 1·3 years 4·6 yean 7.9 years 1()'12 years 13·15 years Male NPNL third o-,l
0·11 months III kg) (15 ttl (20 k91 (26 kg) 139 kg) ISS kgl (50 k,1 trlmelttr LactatlnCJ
==
l".l
Calories 110
(per kg body 1100 1500 1800 2100 2600 2900 2050 2250 2250 ==
l".l
weight) >
t"
o-,l
Protein (g) 2.3-1.2
(per kg body 11.7 14.6 18.4 22.4 32.8 39 35 38.5 38.5 ==
(reference)
weight) >
rn
'1:j
Vitamin A: l".l
Retinol (meg) 300 300 300 400 575 725 750 750
a
900 1050 o-,l
or rn
~-carotene (mcg) 1800 1800 1800 2400 3450 4350 4500 4500 5400 7200 o
"'l
Thiamine (mg) 0.4 0.4 0.6 0.7 0.8 1.0 1.1 0.9 1.0 1.0 "'l
Riboflavin (mg) o
0.6 0.6 0.8 1.0 1.2 1.4 1.6 1.2 1.3 1.3 o
tI
LNiacin equivalents 6.6 7.3 9.9 11.9 13.9 17.2 18.7 14.2 15.6 15.6
>
Z
I Ascorbic acid (mg) 20 20 20 20 30 30 30 30 30 30 !
tI
Iron (mg) 5 5 5 5 5 If!J 5 14 14 14 Z
c::::
Calcium (mg) 500 400 400 400 600 600 400 400 600 600 o-,l
~
Vitamin D (mcg) 2.5 2.5 2.5 2.5 2.5 25 2.5 2.5 2.5 2.5
....
~
o
Vitamin B" (mcg) 0.3 0.9 1.5 1.5 2.0 2.0 2-D 2.0 3.0 2.5 Z
Folate (mcg) 40-60 100 100 100 100 200 200 200 400 300
- - - - - - .- -
ANNEX III
SAMPLE NUTRITION SURVEY FORMS
A. General infant feeding and weaning practices"

B. Special feeding practices of mothers/infants·
C. Household survey"
D. Community survey·
E. School survey·
F. Nutrition Centre examination form*
A. GENERAL INFANT FEEDING AND WEANING PRACTICES·

(To be used only for any child under 3)
1. Village: ........................ Household Number: ............. .

2. Name of Child: ......... Ethnic Group: ........... Religion ...... .
Aite of Child: ...... yean ...... Months ...... Days ...... Sex ... .
3. (a) Name of Mother: ............ : .................. Age
(Last) (First) . Middle)
(b) Name of Father: ................................. Age ....... .
(Last) (Fint) Middle)
(c) Ages of other children in the family:
4. Pregnancy and lactation with this child:

A. Foods or drink: added to mother's diet
1. During pregnancy:
II. During lactation:
B. Vitamin/mineral supplements taken
1. During pregnancy:
II. During lactation:
• These forms are summary and sample fonna only. Tbey need adaptation to local
eircumatancee. For field use, some worken will need conliderable briefing on how to
fill them in. Others will need more expanded forms. of which samples· may be
obtaine<l from WHO. ManUa.
249
· ,
6. What was given to this child during the first three days after birth?
(Check one or more)
A. Water only ....•......... E. Milk formula ............ .
B. Sugar solution .......... . F. Castor oil ............... .
C. Rice water ......•........ G. Unknown ................ .
D. Put to breast ........... . H. Others (Specify) ........ .
6. Feeding of infant:
Duration
T1/'Pe Age Started (Dall', W.ek. or Month.)
Purely breastfed
Purely artificiallY-fed
Mixed-fed
7. If breastfed, by whom!
A. Mother .................... . C. Both ..........•..........
B. Wet nul'8e ............... . D. Others (Specify) ........ .
8. If not breastfed, state reasons:
A. Absence of milk ................. .
B. Inverted nipple ................... .
C. Cleft palate or harelip ........... .
D. Prematurity ..................... .
E. Others (specify) ................. .
9. If artificially fed, what kind of milk. was used?
Evaporated milk (Ex. Carnation, Alpine, Dutch Baby, Alaska)
Powdered whole or modified milk (Ex. Klim, Similac, Lactogen) ....... .
Condensed milk (Ex. Senorita, Dutch Baby) ....................... .
Fresh milk (Ex. carabao's, cow's, goat's) .......................... .
Others (Specify including brand) ................................... .
Was there a definite formula followed! yes ...... No ..... .
If yes, who gave the formula'
PhYsician or nurse .............. .
Read from book, pamphlet etc. . .... . Present formula:
Other (specify) ...................... . Milk ........ .
Water .•.•.....
Sugar ........ .
10. Regardless of whether baby was breaatfed, bottlefed or mixed fed, what
schedule of feeding was followed:
A. Strictly by the clock method .............. .
B. Fairly regular schedule •.................
C. No schedule, feeding was whenever baby showed signs of wanting .....
11. How was breastfeeding stopped, i.e. how was baby weaned!
A. Abruptly ............... .
B. Gradually ....... . ...... .
C. If gradually, at what age was weaning started?
SAMPLE SURVEY FORMS 251
12. What special customs did the mother follow during weaning?
(Check one or more)
A. Hiding from baby for one or more days ................. .
B. Painting nipples with (specify) ........................ .
C. Giving medicines such as sedatives, to baby
13. Reasons for stopping breastfeeding:

A. On part of the mother:
1. Another pregnancy
2. Difficulty of breastfeeding
Inadequate milkflow ........... .
Cracked nipple ........... .
Mother's illness ........... .
Mother working outside the home
Others (specify) ........... .
B. On part of the infant:

1. Baby's illness ........... .
2. Insufficient g~in in weight ........... .
3. Allergy to mother's milk ........... .
4. Others (specify) ........... .
C. Advice by physician or nurse ........... .
D. Advice by other than physician or nurse ........... .
E. Advice from no one but child was regarded old enough for
weaning ................. .
F. Others (specify) ........... .
14. Vitamin/mineral supplements given to the child? ..... . .... .

A. Reasons for giving: ........................................... .
B. Duration of giving vitamins: ........... .
15. Indicate foods given, other than milk, at these ages:

AGE KIND
1 - 2 months
3 - 4 months
5 - 6 months
7 - 9 months
10 - 12 months
1 - 2 years
B. SPECIAL FEEDING PRACfICES OF MOTHERS/INFANTS

(For instructions, see p. 253)
Questionnaire for the mother and the 1m' weaned child
1. Village: Councilman:
2. Name of mother: P/L ...... (duration in months)
4. Name of last weaned child: Sex: Birthday:
5. Age when breastfeeding stopped completely:
6. When did child begin full adult diet?
7. How often does the mother eat the following food.:
No. of If sea- Amount eaten in

times sona], Preg. & Lact.
in one which More (+) Duration of
month months Less (-) and reasons for
Same (=) restrictions
Preg. : Laet. (if any)
(1) (2) (3) & (4) (5)
Rice
Corn (Maize)
Sweet notato (white)
(yellow)
Wheat products
Peanut
Mung beans
Others dried beans
(specify)
Cassava leaves
Drumstick leaves
Pepper leaves
Bitter melon leaves
Amaranthus
Spinach
Sweet potato tops
Ipomoeaaquatica
Jute
No. of If sea- Amount eaten in

times 8Onal, Preg. & Laet.
in one which More (+) Duration of
month month. Less (-) and reasons for
Same (=) restrictions
Preg. : Lact. (if any)
(1) (2) (3) & (4) (6)
Other dark neen
leaves (specify)
.
Fresh beans
Carrots
Pumpkin
Papaya
Mango
Other yellow fruit
Banana
Fish ( dried)
(fresh)
Egg
Chicken
Pork
Liver
Snails
Other (specify)
8. Do you have facilities for storing any of the above foods (specify, e.g..
bamboo basket, small or large, wooden crate, etc.)
9. Do you have any existing store of any of the above foods (specify
quantity) ?
10. At what ages (in monthR) were the following foods introduced in the
child's diet? (If never eaten, indicate by -):
Age If considered bad
intro- Method Method for baby below any
duced of of age, specify reasons
(months) Cooking Feeding'l=
Rice
Corn (maize)
Sweet potato
f--- (a)white
--
(b) yellow
Wheat products .
Peanut
Mung beans
Other dried
beans (specify)
Taro leaves
Cassava leaves
Drumstick leaves
Pepper leaves
Bitter melon leaves
Amaranthus
Spinach
Sweet potato tops
Ipomoea aquatica
Jute
Other dark 2reen
leaves (specify)
Fresh beans
Pumpkin
i
Papaya ,
• (e) - cup. (8) - spoon. (rub) - mother'. hand. (eh) - child's hand, or others; specify;
plate. banana leaf. or other.
Age If considered bad

intro- Method Method for baby below any
duced of of age, specify reasons
(months) Cooking Feeding>
Mango
Other yellow fruit
Banana
Fish (fresh)
(dried)
Egg
Chicken
Pork
Liver
Snails
Other (specify)
11. Do you have facilities for preparing any of the above foods for infants?
(Specify material from which it is made e.g., stone, wood, bamboo, iron,
cloth) e.g.
mortar and pestle
grinder
sieve (specify type)
mashing (with what)
cloth (for straining)
grater
12. Have you ever tried introducing dried beans for your infant! If so, at
what age! . . . . . . . . . Were there any ill effects (specify)?
How were they prepared?
Have you tried other ways of preparing dried beans for infants?
Would you like to try other ways of preparing dried beans for infants
NOTES ON QUESTIONNAIRE ON FEEDING PRACTICES

OF MOTHERS
Before any field survey, the field workers need considerable briefing and
detailed discussion of each question, item by item, and how to fill in the
form, e.g.:
Q.6 - This means full adult diet apart from breastmilk.
(Some get full adult diet before stopping breastfeeding, others only
much later.)
Q.7 - Column 2 - give examples, e.g.:
Rice - 3 times daily means 90 times per month
Meat once weekly means 4 times per month, etc.
Column 2 - specify the months numerically, e.g. if eaten in June
to August, enter as '6-8'; or "all" if not seasonal.
Columns 4 and 6 - enter as U +" (means more than non-pregnant,
non-lactating)
U_" (means less taan non-pregnant.
non-lactating)
1I ==" (means same as non-pregnant,
non-lactating)
Column 6 - should be as wide a. pouible.
The whole questionnaire take. about an hour to fill in thoroughly. The
answers elicited seem to depend considerably on the interviewer. The inter-
viewer needs to be trained to reduce to the minimum the entry of his per-
sonal view.. Public health nurses were usually the best interviewers in the
rural health staff in our experience.
The analysis of the questionnaire answers is also a long and difficult job.
For the seasonal influences, the results are tabulated and the general trend
or trends picked out. For most of the other items totals and averages can be
worked out.
C. HOUSEHOLD SURVEY
1. DA'1:E: ........................ , 19 ..... .
2. TYPE OF HOUSEHOLD SURVEYED:
(a) Urban: .................. (b) Rural:

(c) Ethnic group: .................. (d) Religion: ............. ..
3. NAME OF HEAD OF FAMILY: ................................... .
4. OCCUPATION OF HEAD OF FAMILY: .......................... .
5. AGE OF HEAD OF FAMILY: ..................................... .
6. OCCUPATION OF MOTHER (if any):
7. AGE OF MOTHER: ............. ..
8. HOUSING:
(a) Type of dwelling:
(b) No. of rooms:

9. OCCUPANTS: Male Female Total
(a) Number of adults ........ . .........
.........
•• 0 •• ••• •
(b) Number of children . ·.··0·· . • ·0 ••• •• •
Total number of
occupants ........ . ........ . .........
10. KITCHEN FACILITIES: Yes No
(a) Proper indoor kitchen ........ . .........
(b) Outdoor kitchen ........ . .........
(c) Others (specify) : •••• • ••••••••••••••••••• 0 ..........
11. COOKING FACILITIES: Yes No

(a) Stone oven
(b) Wood oven
(d) Electric stove
(c) Gas stove
( e) Other (if yes, specify)
12. FOOD STORAGE FACILITIES: Yes No

Are they satisfactory for:
(a) Cooked food
(b) Raw food
(c) Bulk supplies
13. Is food stored in fly-proof
enclosure?
14. GARBAGE DISPOSAL: Yes No
(a) Is garbage burnt
(b) Is garbage buried
(c) Is garbage fed to animals
(d) Is garbage scattered
15. WASHING FACILITIES: Yes No
(a) Satisfactory water supply
(b) Fixtures satisfactory
(c) Draining satisfactory
16. LATRINE Yes No
(a) Is latrine available
(if yes, specify type)
(1) pit (dry)
(2) pit (water-sealed)

(3) septic tank
(b) Is water available in latrine?
17. GROUNDS:
(a) Is drainage satisfactory? Yes No
(b) Are grounds clean, free of
Htter and/or animal manure?
(c) Is litter and/or animal
manure properly composted? . .. . . . . . . . ........
18. WATER SUPPLY AND
SOURCE OF WATER
SUPPLY Yes No
(a) Is water supply adequate? ... . . . . .. . . . . . . .. .
(b) Is source of water supply:
(1) rainwater
(2) surface water (streams)
(3) well (dug)
(4) well (bored)
(c) Is water obtained by:

(1) pumps
(2) bucket
(3) tap
19. PESTS Yes No

(a) Is dwelling free of:
(1) rats
(2) mice
(3) snails
(4) cockroaches
(5) lice
(6) bedbugs
20. DOMESTIC ANIMALS
(a) Are domestic animals kept?
If answer is yes, specify
kind of animals kept, and
whether kept fenced in.
Fenced m:
Type of animals kept Ye. No
21. REMARKS
Specify any other remarks
concerning living conditions
D. COMMUNITY SURVEY
1. DATE: ........................... , 19 ..... .

2. NAME OF LOCALITY SURVEYED: .............................. .
3. MUNICIPALITY OR PROVINCE:
4. NAME AND DESIGNATION OF
COMMUNITY LEADER: .......................................... .
5. COMMUNICATIONS:
6. POPULATION:
(a) Ethnic group:
(b) Religion: ................................. .
(c) Number of families in locality
Number 01
Males Femal68
(d) Number of persons over 16 yean ....... .
(e) Number of infants in 10~a1ity
o through 11 months
(f) Number of toddlers in locslity,
1 through 5 years
(g) Number of children in locality,
6 through 14 years
(h) Total number of persons living
in locality
(i) Total area 01. locality
(j> density of population
per sq. km.
7. TYPE AND NUMBER OF SCHOOLS IN LOCALITY:

YeB No Number
(a> Private primary school ........ . ........ . .........
Private intermediate ........ . ......... . ........
Private secondary
(high school) ........ . .. , ...... ..... , ...
Private, others, speci1.y
( technical, vocational> ........ . ........ . .........
(b) Public primary school ........ . ....... .. .........
Public intermediate ....... .. ,,0 •••••• ........ -
Public secondary ...... ... ....... .. .........
(high school)
Public, others, speci1.y ........ . ........ . .........
( technical, vocational)
8. NUMBER OF CHILDREN ATTlj:NDING SCHOOL:

Male Female
(a) Private primary school
Private intermediate school
Private secondary (high school)
Private, others, specify
(technical, vocational) T1IfJe
(b) Public primary school

Public intermediate school ", ....... .
Public secondary (high school)
( c) Public, others, specify
(vocational, technical) Type
9. GENERAL HEALTH STATUS:

(To be completed from Health Department records)
(a) Birth rate (number of live birth Number
per 1000 population, within last
calendar year) per 1000
(b) Crude death rate (total number
of deaths per 1000 population,
at mid-year) ......... per 1000
(c) Infant mortality rate (number
of infant deaths under 1 year,
per 1000 live births, last
calendar year) . . . . . . . .. per 1000 livebirths
(d) Pt"evalent diseases Pr61lalent Diaeaaes
Among adults
Schoolchildren (6-15 yrs)
Toddlers (1-5 years)
Infants (0-11 months)
(e) Any epidemics in the last Yes No
3 years?
If yes, specify:
10. HOUSING
(a) Number of dwellings
(b) Type and number
of each type of State of repair
dwelling and state (Number
of repair TlIpe (SpecifY) Number Satisfactory )
Numb.,·.
Good Satis/actol'll POOl'
(c) Dwellings with safe

water supply
(d) Dwellings with satis-
factory excreta disposal
(e) General cleanliness
of dwellings
11. WATER SUPPLY
(a) Number of sources
and adequacy
Number of
adequate
Number 01 SOlirceB source
(1) fountain
(2) from ground
(3) from spring
( 4) from stream
(b) Dwellings directly
connected with public
water supply
Yes No
(c) Are there possible
sources of contamination
of water supply
( d) If answer is yes, specify source of contamination:
Source of contamination of water supply from:
(1) rain .......................................... .
(2) grounds ....................................... .
(S) spring ........................................ .
(4) stream ....................................... ..
(5) municipal water supply ......................... .
( e) Are sources of water No

supply supervised and
controlled for bacteriological
contamination!
(f) If answer is 1/88 by Authoriti.. 01 treatment
7'1/JIe
whom and type of treatment superviBt..g awdl tir proteetUm
and/or protection applied. wam suppl1/ appli.d
12. EXCRETA DISPOSAL Numb ...

(a) Latrines, pit (dry)
(b) Latrines pit
(water-sealed)
(e) Septic tank latrines
( d) Other types (specify)
(e) Dwellings without
facilities
13. GARBAGE COLLECTION AND DISPOSAL
(a) Households with sanitary
garbage storage (in bins
and covered)
(b) Is garbage regularly Yes No
collected by municipalities
(e) If all8Wer is "", which methods of dispoul are appli" by munici-
pality, (specify):
••••••••••••••••••• 0. 0 ••••••••••••••••••••••••••••• 0.
(d) If answer is no, which methods of disposal are applied by house-

hold, (specify):
14. OCCUPATIONS IN COMMUNITY Number8

(a) Farmers (land owners)
(b) Farmers (tenants)
(e) Farmer. (labourer)
(d) Self-employed (home indUBtry)
(e) Self-employed (shop keepen)
(f) Employed in domestic work ....., ....

(g) Employed in industry
('factory worken, etc.)
(h) Professionals, employed (teachers,
clerks, nurses, midwives, etc.)
(i) Professionals, self-employed
(nurses, midwives, lawyers,
doctors, etc.)
15. ORGANIZED GROUPS
(a) Endeavour to find the most
influential Of:
Nam~. and Occupation of leade ...
(1) Civic leaders in Names Occupa tion
community
(2) Religious leaders

in community
(3) Official leaders

in community
(b) Any voluntary health Yes No

agencies in community
If yes, specify the type or types of aetivities in which involved .
.................................................... .
.................................................... .
16. MISCELLANEOUS Kiruh of animal.• Number

(a) Kinds and number of
animals (including
domestic) kept in
community
(b) Number of families in community having home gardens with fruit

and/or vegetables
Fruit orrl1/ Vegetables orr ly Fruit & Vegetables
(c) Impression of
leadership
Good Fair Poor
(d) Remarks by investigator which may have a bearing on any ad-

verse condition in the community:
Signature of
Investigator
E. SCHOOL SURVEY
1. nate of Survey
(day) (month) (year)
2. Ethnic group:
3. R.P.ligion:
4. Name of School: ......... . ....................................... .
5. Location:
6. Name of Principal:
(7) Type of School: Yeo No

(a) Boys only ........ . ........
(b) Girls only ......... . ........
(c) Co-educational ......... . ........
8. Type of instruction given:
Yes No
(a) Primary .. . . . . . . . .........
(b) Intermediate ......... . ........
(e) Secondary (high schoo\) ......... . ........
9. Number of pupils: No. No.

Male Female
(a) in primary classes ........ . .........
(b) in intermediate classes .. , ...... .........
(c) in secondary classes
(high school) ........ . .........
Total ........ . .........
10. Yearly average number
19- 19-- 19--
of pupils during the
M F M F M F
last 3 years:
(a) in primary classes

(b) in intermediate
da.sea
( c) in secondary dasses
(high school)
Tot a II
11. CUusrooms No. of classroomB
(a) for primary dasses
(b) for intermediate dasses
(c) for secondary classes (high school)
12. Pupils p.... cUuBroom No. of pupil. per
classroom
(a) in primary classes
(b) in intermediate classes
(c) in secondary classes (high school)
Floo,' area per pupil
13. Floor A ...... (square met.... )
(a) in primary classrooms
(b) in intermediate classrooms
(c) in secondary classrooms (high school)
14. Teacher. No. 01 teachers
(a) for primary classes
(b) for intermediate classes
(c) for secondary classes
Total no. of teachers
16. Oth.... staff No. emplo1/ed
(a) guards
(b) cleaners
( c) gardeners
(d) Others' (specify):
Total no. of other staff:
.Except staff employed in aeboolkitchen i.e., food officer. cook. helper. etc.. and
permanent medical I!Itaft (i.e.. physician. dentist. nune. etc.).
16. Struct..... 01 b..ildings

(a) Walls
(b) Floors
(c) Roofs
17. Lighting and ..entilation Se..-.iceable U1l8' ....ic.ab

Yes No Ye8 N
(a) lighting
(b) ventilation
18. Waw S"P1lI"
(a) Souree or 80urees
Indicate 80....C. and
if mo... than one
(b) Quantity always

sufficient for Ye8 Not Alwall8
(1) handwashing
facilities
(2) cleaning of premises
(3) school gardens
(4) cooking of meals
(c) Potable groundwater Yes No
(1) I. potable ground-
water available
(2) Is the necessary
Improvement made to
make it safe and con-
venient to use
<d) Are washing facilities
satiafactory
19. Latri...... and uri_Ie
<a) Type
(1) pit (dry)
(2) pit (water-sealed)
(3) septic tank
(4) others, specify
~
. SAMPLE SURVEY FORMS· 267

Y •• No
(b) State of repair
(1) IlAtisfactory ? ......... . ........
(c) Sanitary conditions
(1) IlAtisfactory! ......... . ........
(d) Needs
(1) Would teachers
prefer other type
than the present ones? ' .......... . ........
(2) If yes, specify type of latrines or urinals preferred.
(e) Number of latrines Number

and urinals available
(1) for males
(2) for females
20. Grounds
(B) Drainage
No
(1) Does water stagnate
after rainfall?
(2) If yes, for how long?
Number of hour.
Number of days
No
(b) Refuse
(1) Is litter collected?
(2) Is there a compost pile 1
(3) Is animal manure composted L ...... .
(c) Mosquito problem
(d) Fly problem
21. Health services

(a) Are school health
services provided? ....... ' ...
(b) If yes, which type
(1) medical
(2) dental
(c) Are school health services

carried out by health staff Yes No
from:
( 1) Department of Education
(2) Department of Health
(d) Are all new school entrants
(first class primary)
subjected to:
(1) Medical examination
(2) Dental examination
J
(e) If yes, how often are pupils re-examined by the school health
team in: 1st yr 2nd yr. 3rd yr. 4th yr. 5th yr. 6th yr.
(1) primary
schools
(2) intermediate
schools
(3) secondary
schools
(f) If no, indicate kind of school health services provided for:
(1) primary schools
(2) intermediate schools
(3) secondary schools
(g) How often are schools

visited by school health Frequency of vi.it. by
team? Bchool health team
(1) primary schools
(2) intermediate schools
(3) secondary schools
(high school)
(22) School feeding

(a) Is supplementary feeding
provided in: Ye. No
(1) primary school
(2) intermediate school
(3) secondary school
(high school)
(b) If yes, which type of meals

are served? Yes No
(1 ) milk only
(2) C.S.M. only
(3) school snacks
(cooked food)
(4) schooi snacks (bread,
rolls, doughnuts, etc.)
(5) full supplementary meal
(breakfast or lunch)
(c) Which are the sources of food

supplies used in preparation
of school snacks or supplementary
meals? Yes No
(1) CARE supplies
(2) AID supplies
(3) other supplies
(4) school gardens
(5) school fishponds
(6) school livestock
(7) students contributions
(in kind)
(8) students contr.ibutions
(in cash)
2a. Food preparation:

<a) 18 food prepared:
(1) in school kitchen
(2) in individual classroom
(3) others, specify
24. Food pr6parliti01l in kitchen and

food storage
(a) Kitchen
Yes No
(1) Are kitchen facilities
adequate?
(2) Clean and tidy?
(3) Is food preparation
satisfactory from an
hygienic point of view?
Yea No
(") From a nutritional
point of view
(5) Are cooking facilitiee
adequate?
(6) Are cooking utensils
(pots, pans, etc.)
adequate and clean?
(7) Is water supply adequate"
(8) Are dishwashing facilities
adequate?
(9) Are cleaning equipment
and cleaning supplies
adequate!
(b) Food storage
(1) Is food store for
non-perishable
supplies adequate in size?
(2) Are food supplies properly
stored (raised from the
floor)?
(8) Is storeroom clean and
tidy!
(4) Are measures taken to
prevent insect infestation
of food supplies and to
control pests (rats mice,
cockroaches, etc.)!
(c) Kitchen stair
(1) Title of person or persons in-charge of feeding operations
(2) Number and title of other paid kitchen stair

(specify, cooks, helpers).
Title N ..mber
(3) Does kitchen stair No

receive cash payment ~
(monthly salary)
SAMPLE SURVEY FOIlMS, 271
(4). If yes, from which source or sources
i. the payment effected!
·Source or sources providing caah
for payment of kitchen staff
Department of Parents' and Pupils' contribution
Education Teacherti Association to cooking of meals
...............
No
(5) If answer is no, is staff·
paid in. kind?
(6) Do mothers of pupils assiet
in the preparation of
school meals on a
voluntary basis?
If yes, how many per day?
25. Food Preparation in individual

classrt)oms
Yes No
(a) Are facilities for food
preparation satisfactory from a
hygiene point of view? ••••• 0 •••
(b) Is equipment for food

preparation adequate?
(c) Are washing-up facilities
satisfactory?
(d) Is water supply adequate?
(e) Is food preparation equipment
clean?
(f) Is storage space for cooking
equipment and utensils
satisfactory?
(g) Is food preparation effected
by classroom teachers?
(h) If no, is food prep "ration
and consumption effected
under the supervision of
the classroom teachers?
~Check one or more.
(i) How often. are food supplies Yes No

from the stores issued to
the teacher?
(1) Daily
(2) Weekly
(3) Monthly
26. Food cOMUmption
(a) Place where food is consumed
(1) in classroom
(2) central dining room
(b) Type of eating utensils used
(1) Pupils' own eating utensils
brought from home
(2) Eating utensils provided by
UNICEF or other source ........ .
(3) Are the eating utensils
used satisfactorily!
(4) Are the available eating
utensils su1licient for
all pupils?
(6) Where is the washing-up
of eating utensils effected!
(a) Classroom .•.......
(b) Kitchen ........ .
If in classroom, are facilities
for washing-up of eating
utensils satisfactory?
(27) Hea.lth check on kitchen stal!
(a) Is kitchen staff (cooks and

kitchen helpers) medically
examined before being
employed?
(b) Is a periodic health check
carried out on kitchen staff?
(c) If answer is YB', were
records of the medictU
examination of the persons
working available!
(d) What was the time interval between the health check-up·
8 month, 6 month, 9 montks 1 yea.r
.'. •
C. NUTRITION CENTRE EXAMINATION FORM
I.,ocation ..................... '. . . . . . . . . . . . . . . . . . . . . . . . . . . . Date .•.........•..•.. .....••..•. .. Serial No............ .
Child's Name Ethnic group .................. Religion ................. .

Surname First name
Date of birth ......................... Sex. . . . . . . . . . . . . . . . Mother pregnant? No. of months .......................... .
Mother's name ............................................ Mother breastfeeding now? ............................... .
Father's name. .. . .. . .... .. . . .. .. . . . . .. .. . . .. .. .. .. . .. .. .. . Ages of living brothers & sisters ........................ ..
Father's occupation ...................................... Ages at death of dead brothers & sisters ..................•.
Child's weight (kJ.) ..................... ................... Mother's weight (kg.) ..................................... .
Child's height (em.)........................................ Mother's height (em.) .................................... ..

Child's skinfold thickness Triceps{mm.) ........•........... Mothel'S skinfold thickness T riceps( mm.)
Scapular(mm.) .................... . Scapular(mm.)
~
co
CLINICAL EXAMINATION
Put [±] if sign present B if sign absent ~
10. Gums 18. OEDEMA

""
1. THYROID
(a) Grade--
(a) Gingivitis 0 (a) Facial 0
(b) Adenomatous D
(b) Scorbutic 0 (b) Dependent 0
2. PAROTID
11. DERMATOSIS (c) Unilateral
D
ENLARGEMENT D (a) Kwashiorkor 0 "'l
(b) Pellagra 0 19. GENERAL
=
3. HAIR CHANGES 0 PALLOR CJ !.oJ
4. MOONFACE 0
12. FOLLICULAR
KERATITIS
20. GROSS ANAEMIA CJ
=
>
!.oJ
(a) Arms CJ ~
5. EYE SIGNS
(a) Xerosis
(b) Back
(c) Legs
0
D
21. MENTAL
CONDITION
=
>
rn
conjunctivae D "d
(b) Bitots spot CJ
13. MUSCLE WASTING (a) Apathetic D !.oJ
0
"'l
(c) XerophthaJmla D (a) Arms 0 (b) Irritable CJ rn
(d) Keratomalacia D (b) Buttocks 0 (c) Mentally deficient D 0
"!I
(e) Malnutrition (c) Legs 0 "!I
scar 0 14. POT BELLY 0
22. FRANK
MALNUTRITION
0
0
(f) Other scar D t::I
6. NASOLABIAL
15. SKELETON (a) Marasmus CJ >
Z
SEBORRHOEA
(a) Costochondral (b) Kwashiorkor 0 t::I
enlargement D (c) Rickets 0 Z
(b) Knock-knees CJ c::
7. ANGULAR (d) Other (Specify)
0 "'l
STOMATITIS (c) Enlarged
epiphyses CJ 23. NUTRITIONAL ......
l1li
"'l
(a) Active D CONDITION 0
(b) Scar CJ 16. CALF Specify one: Z
8. CHEILOSIS
TENDERNESS CJ Good D
9. TONGUE
17. REFLEXES just adequate D
poor
(a) Absent knee
D
(a) Papillary jerks D
atrophy D (b) Absent ankle 24. OTHER FINDINGS
(b) Magenta D jerks D (specify)
....--
ANNEX IV
SOME ANTHROPOMETRIC INDICATORS

OF NUTRITIONAL STATUS
1 Growth retardation is the commonest manifestation of mal-

nutrition in this region. Researches in almost all the countries
have shown that weight and height gains in infancy and child-
hood are retarded, most markedly after six montas of age
when breastmilk production becomes increasingly inadequate
to meet the infant's growing needs, and supplementary feed-
ing practices are usually inadequate. The retardation reflects
mainly lack of calories and protein, but also of vitamins and
minerals, and intercurrent illness. Usually anthropometric
indicators are more useful, sensitive, practical, accurate, and
reliable as indicators of nutritional status in communities,
than are clinical appraisals and (at the moment) vital and
health statistics.
2 Growth rates in different countries enable comparison of the
overall nutritional situation in different groups or areas with-
in a country and between different countries. Growth curves
can be obtained for different socio-economic and ethnic groups.
However, this is a major research programm~ which usually
requires proper sampling, comprehensjve field surveys and
rigorous statistical analysis of the results.
3 It is known that well nourished individuals grow and develop
at rather similar rates. For instance, well nourished
Africans,1S4 Japanese,l07 Chinese 30 and Filipinos27 approach
remarkably close to U.S.A. standards. This is illustrated by
the curves of body weight for Filipino children in Manila
coming from upper, middle and lower-income brackets 27 (see
Figure A.4.1). It is also noteworthy that in Uganda,134 after
trial use of well established local standards, these have been
abandoned in favour of USA weight norms, which appeared
275
FIGURE A.4.1
AVERAGE WEIGlfrS OF IIIFANI'S AIID TODDLERS OF DIFPEREm' SOCIO ECOII<JIIC GROUPS

( Mole. ond _ l e o COII!.btned )
..: M _ a
------
LEGEND MANILA (Upper Incaoe) _._.-.-.-.---
• (Middle Incaae)-----------
(Lower tnecae) + + +. + .. + .....
BAYAMBAIIG (Phillppin,,") _•••••• , ••••••••••••
• M - b
• M - c
• B
IOWA • I
22
• B
• M - b
AGE I R YEA R 5
SOME ANTHROPOMETRIC INDICATORS OF NUTRITIONAL STATUS 277
fully applicable for well nourished Ugandans!a. There are good

reasons therefore to use an accepted international standard
for growth In childhood, for comparative purposes.
4 • The development and use of local standards is of course to be
encouraged, and a suitable method of analysis is indicated
,elsewhere (po 144).
5. International standards
In the following pages, tables and charts based on accepted
international standards are given. Further details are given
by Jelliffe 103c.
278
TABLE A.4.1
WEIGHT FOR AGE. 0 TO 4 YEARS (SEXES COMBINED)
Derived from Jelliffe11Xl<: and Nelson l54
Weight in Kg
AGE Stan. 120% 110% 90% I!O% : 70% 60% AGE Stan. 121)% 110% 00% SOli>: 70% 60%
YeareMos. dard of atdof atd of 8td of stdiof!ltd of std Years MoB. dard ~f std of 8td of 8td of 8tdlo£ std of std
0 I
0 3.4 4.1 3.7 3.0 2.7 2.4 2.0 2 6 13.5 16.2 14.8 12.2 10.8 I 9.5 8.1
1 4.3 5.2 4.7 3.7 3.4 2.9 2.5 7 13.7 16.4 15.1 12.4 11.0 I 9.7 8.2
2 5.0 6.0 5.5 4.4 4.0 3.4 2.9 8 13.8 16.6 15.2 12.5 11.1 : 9.8 8.3
,
3 5.7
6.3
6.8 6.3
7.6 6.9
5.1
5.7
4.5
5.0
4.0
4.5
3.4
3.8
9 14.0
10 14.2
16.8 15.4 12.6 11.2 : 9.9
17.0 15.6 12.8 11.3 110.0
8.4
8.5
5 6.9 8.3 7.6 6.2 5.5 4.9 4.2 11 14.4 17.3 15.8 12.9 11.5 110.1 8.6
I
6 7.4 8.9 8.1 6.7 5.9 5.2 4.5 3 0 14.5 17.4 16.0 13.1 11.6 110.2 8.7
7 8.0 9.6 8.8 7.1 6.3 5.5 4.9 1 14.7 17.6 16.2 13.2 U.8 110.3 8.8
8 8.4 10.1 92 7.6 6.7 5.9 5.1 2 14.8 17.8 16.3 13.4 11.9 110.4 8.9
,
9 8.9 10.7 9.8 8.0 7.1 6.2 5.3 3 15.0 18.0 16.5 13.5 12.0 '10.5 9.0
10 9.3 U.2 10.2 8.4 7.4 6.5 55 I
18.2 16.7 13.6 12.2 ,10.6
4 15.2 9.1
11 9.6 11.5 lQ.6 8.7 7.7 6.7 5.8 5 15.3 1B.4 16.9 13.7 12.3 ,10.7 9.2
I
1 0 9.9 U.9 10.9 8.9 7.9 6.9 6.0 6 15.5 18.6 17.1 13.9 12.4 110.8 9.3
1 10.2 12.2 11.2 9.1 8.1 7.1 6.2 7 15.7 18.8 17.3 14.0 12.6 110.9 9.4
2 10.4 12.511.4 9.3 8.3 7.3 6.3 8 15.8 19.0 17.4 14.2 12.7 :Il.O 9.5
I
3 10.6 12.7 11.7 9.5 B.5 7.4 6.4 9 16.0 19.2 17.6 14.4 12.8 1112 9.6
4 10.8
5 11.0
13.0 U.9
13.2 12.1
9.7
9.9
8.7
8.9
7.6
7.8
6.6
6.7
10 16.2
11 16.3
,
19.4 17.8 14.6 12.9 111.3 9.7
19.6 18.0 14.7 13.1 ,11,4 9.8
I
6 1l.3 13.6 12.4 10.1 9.0 7.9 6.8 4 0 16.5 19.8 18.1 14.8 13.2 '11.5 9.9
I
7 11.5 13.8 12.6 10.3 9.2 8.1 7.0 1 16.6 20.0 18.3 15.0 13.3 ,11.6 10.0
8 11.7 14.0 12.9 10.5 9.4 8.2 7.1 2 16.8 20.2 18.5 15.2 13.5 IIL7 10.1
9 11.9 14.3 13.1 10.7 9.6 8.3 7.2

I
,
20.3 18.6 15.3 13.6 111.9 10.2
3 16.9
10 12.0 14.5 13.2 10.9 9.7 8.4 7.3 4 17.1 20.5 18.8 15.4 13.8 112.0 10.3
11 12.2 14.6 13.4 11.1 9.8 I 8.6 7.4 5 17.2 I
20.7 19.0 15.6 13.9 112.1 10.4
, I
2 0 12.4 14.9 13.6 11.2 9.9 I 8.7 7.5 6 17.4 20.9 19.1 15.7 14.0 ,12.2 10.5
1 12.6 15.1 13.9 11.4 10.1 , 8.9 7.6 7 17.6 21.1 19.3 15.8 14.2 :12.3 10.6
2 12.7 15.2 14.0 11.6 10.3 I 9.0 , 7.7 8 17.7 21.2 19.5 16.0 14.3 112.4 10.7
,
I
3 12.9 15.5 14.2 11.8 10.5 I 92 7.8 9 17.9 21.5 19.7 16.1 14.4 112.6 10.7
4 13.1 15.7 14.4 12.0 10.6 I 9.3 10 18.0 I
7.9 21.7 19.8 16.3 14.5 ,12.7 10.8
5 13.3 16.0 14.6
,
12.1 10.7 I 9.4 8.0 U 18.2 21.9 201 16.4 14.6 112.8
I
10.9
2 6 13.5 16.2 14.8 i

12.2 10.8 I 9.5 8.1 5 0 1M 22.1 20.2 16.5 14.7 1129
I . 11.0
279
TABLE A.4.2
WEIGHT FOR AGE. 5 TO 18 YEARS
Derived from Nel8on l S<
Weight in Kg
BOYS GIRLS
AGB Staa.- ll11~ 110% 90% 80%: 70~ 60% StaD- IlII~ 110% 90% 80%: 70~ 60~
Years dard of IItd of atd of atd of 8td I of atd of IItd dard of sld of .td of atd of 8td I of std of stet
I
I
5 19.4 23.3 21.3 11.5 15.5 I 13.6 11.6 18.8 22.6 20.7 16.9 15.0 13.2 11.3
5.5 20.7 24.8 22.8 18.6 16.6 I 14.5 12.4 20.0 24.0 22.0 18.0 16.0 14.0 12.0
I
I 25.3 23.2 19.0 16.9 14.8 12.7
6 21.9 26'3 24.1 19.7 17.5 I 15.3 13.1 21.1
6.5 23.2 27.8 25.5 20.9 18.6 I 16.2 13.9 22.4 26.9 24.6 20.2 17.9 15.7 13.4
I
7 24.5 29.4 27.0 22.0 19.6 17.2 14.7 23.7 28.4 26.1 21.3 19.0 16.6 14.2
7.5 25.9 31.1 28.5 23.3 20.7 18.1 15.5 25.0 00.0 27.5 22.5 20.0 17.5 15.0
8 27.3 32.8 00.0 24.6 21.8 191 16.4 26.3 31.6 28.9 23.7 21.0 18.4 15.8
8.5 28.6 34.3 31.5 25.7 22.9 20.0 17.2 27.7 33.2 30.5 24.9 22.2 19.4 16.6
9 29.9 35.9 32.9 26.9 23.9 20.9 17.9 28.9 34.7 91.8 26.0 23.1 20.2 17.3
9.5 31.3 37.6 34.4 28.2 25.0 21.9 18.8 00.4 36.5 33.4 27.4 24.3 21.3 18.2
10 32.6 39.1 35.9 29.3 26.1 22.8 19.6 31.9 38.3 35.1 28.7 25.5 22.3 19.\
10.5 33.9 40.7 37.3 00.5 27.1 23.7 20.3 33.8 40.6 37.2 30.4 27.0 23.7 20.3
11 35.2 42.2 38.7 31.7 28.2 I 24.6 21.1 35.7 42.8 39.3 32.\ 28.6 25.0 21.4
11.5 36.7 44.0 40.4 330 29.4 25.7 22.0 37.7 45.2 41.5 33.9 :11.2 26.4 22.6
12 38.3 46.0 42.1 34.5 :11.6 26.8 23.0 39.7 47.6 43.7 35.7 3\.8 I 27.8 23.8
12.5 40.2 46.2 44.2 36.2 32.2 28.\ 24.1 42.4 50.9 46.6 36.2 33.9 I 29.7 25.4
I
13 42.2 50.6 46.4 38.0 33.8 29.5 25.3 44.9 53.9 49.4 40.4 35.9 I 31.4 26.9
13.5 45.5 54.6 SO.O 41.0 36.4 3\.8 27.3 47.0 56.4 51.7 42.3 37.6 II 32.9 28.2
I
14 48.8 58.6 53.7 43.9 39.0 34.2 29.3 49.2 59.0 54.1 44.3 39.4 I 34.4 29.5
14.5 51.T 62.0 56.9 48.5 41.4 36.2 31.0 so.3 60.4 55.3 45.3 40.2 : 35.2 ao.2
,
IS 54.5 65.4 60.0 49.0 43.6 38.2 32.7 51.5 61.8 56.6 46.4 41.2 : 36.0 :11.9
15.5 56.6 67.9 62.3 SO.9 45.3 I 39.6 34.0 52.3 62.8 57.5 47.1 41.8 I 36.6 31.4
I I
16 58.8 70.6 64.7 52.9 47.0 I 41.2 35.3 53.1 63.7 58.4 47.8 42.5 I 37.2 31.9
16.5 60.3 72.4 66.3 54.3 482
. II 42.2 36.2 53.6 64.3 59.0 48.2 42.9 : 37.5 32.2
I I
17 61.8 74.2 68.0 55.6 49.4 I 43.3 37.1 54.0 69.8 59.4 48.6 43.2 I 37.8 32.4
17.5 62.4 74.9 68.6 56.2 49.9 I .3.7 37.4 54.2 65.0 59.6 48.8 43.4 I 37.9 32.5
I
I I
18 63.0 75.6 69.3 56.7 SO.4 : 44.1 37.8 54.4 65.3 59.8 49.0 43.5 I 36.1 32.6
For Weight-for Height for children of all ages and adults, see JelliffelO3c (Annex 1).
280
TABLE A.4.3
LENGTH FOR AGE, 0 TO 5 YEARS
Derived from Jelllffe10lk: and Nelaonl54
Length io em
1
AGE Stan. 120% 110S1S 90% 80% 170% 80% AGE Stan.. Iln% 110% 90% 90%; 70% ~
YearaMo.. dard ofatd of ltd of atd of atdlof at40f .tel YoanWoa. dard of etd of atd of atd of atd lof _td of .tel
0 0 50.4 60.5 55.4 45.4 40.3 : 35.3 30.2 2 6 9U! 110.2 101.0 82.6 13.4 64.2 55.1
I 54.8 65.8 60.3 48.7 43.3 I 38.3 82.5 7 92.6 IIJ.J 101.9 83.2 74.0 64.7 55.5
2 58.0 69.6 83.8 51.7 46.2 I 40.5 34.5 8 93.3 112.0 102.6 83.7 74.6 65.2 56.0
1
3 60.0 72.0 66.0 54.0 48.0 1 42.0 36.0 9 94.0 112.8 103.4 8U 75.1 65.7 56.3
4 62.3 74.8 68.5 56.3 49.5 : 43.3 :rT.3 10 94.7 113.6 104·2 85.0 75.7 66.2 56.7
5 6404 77.3 70.8 58.1 51.l I 448 38.5 11 96.3 11404 104.8 85.7 76.3 66.7 57.2
1
6 65.8 79.0 72.4 59.2 52.6 1 46.1 39.5 3 0 96.0 115.2 105.6 86.4 76.8 67.2 57.6
7 fIl.6 8J.J 74.4 60.7 54.1 1 47.2 40.5 I 96.6 115.9 106.3 87.0 17.3 67.6 58.0
8 69.2 83.0 76.1 I 2
62.0 55.3 1 48.3 41.5 97.3 116.8 107.0 87.5 78.0 68.1 58.3
9 70.7 84.8 77.8 83.6 56.5 : 49.5 424 3 97.9 117.5 107.7 88.0 78.4 68.6 58.7
10 72.2 86.6 79.4 64.9 57.7 I 50.4 43.2 4 984 118.1 1aJ.2 88.5 78.9 69.0 59.2
11 13.5 88.2 80.8 66.Q 58.8 I 51.3 44.1 5 99.1 118.9 109.0 89.1 79.3 69.4 59.5
I
1 0 74.7 89.6 82.2 '".2. 59.8 152.3 44.8 6 99.7 119.6109.7 89.7 79.7 69.8 59.8
1 76.0 91.2. 83.6 68.3 60.7 I 53.1 454 7 100.3 120.4 110.3 90.3 80.2 70.3 60.2.
2 77.1 92.5 84.8 89.3 61.6 : 54.0 46.2 8 10\.0 121.2 111.0 90.9 80.7 70.7 60.5
I
3 78.1 93.7 86.0 70.3 62.4 I 54.6 46.8 9 101.6 121.9 111.8 91.5 81.3 7L1 60.9
4 79.3 96.2 87.2 71.3 63.3 I 55.4 47.5 10 102.1 122.5 112.3 92.0 81.7 71.5 61.2
5 80.5 96.6 88.5 72.3 64.2 1 56.3 46.2 11 102.7 123.2 113.0 92.6 82.1 72.0 61.7
1
6 8l.4 97.789.5 73.2 65.1 : 57.0 46.8 4 0 103.3 124.0113.6 93.0 82.6 72.3 62.0
7 82.7 99.2 91.0 74.2 65.8 157.7 49.4 1 103.8 124.6 114.2 93.4 83.0 72.7 62.3
8 83.5 100.2 91.8 75.1 66.9 : 58.4 50.0 2 104.5 125.4 115.0 94.0 83.6 13.1 62.7
9 84.4 101.3 92.8 76.0 fIl4 159.0 50.7 3 106.2 126.2 115.7 94.5 8'-0 73.4 83.1
10 85.4 102.5 93.9 7&.9 68.3 : 59.7 51.3 4 105.7 126.8 116.3 96.1 8U 73.8 83.5
II 86.3 103.6 94.9 77.7 88.9 I 60.2 51.8 5 106.2 127.4 116.8 95.6 84.9 74.3 63.8
I
2 0 87.1 104.5 96.8 78.4 69.6 I 60.9 52.2 6 106.8 128.2 117.5 96.1 854 1 74.7 64.1
I I
1 88.0 106.6 96.8 79.1 70.3 161.2 52.7 7 107.3 128.8118.0 96.5 85.7 I 75.0 64.4
2 88.8 106.6 97.7 80.0 71.0 I 62.0 53.3 8 \07.9 129.5 118.7 96.8 86.Q 1 75.3 64.7
1 I
3 89.7 107.6 98.7 80.7 71.5 I 62.7 53.8 9 108.2 129.8119.0 97.2 86.3 175.7 84.9
1 I
4 90.4 108.5 99.4 81.3 72.2 I 63.2 54.2 10 108.5 130.2 119.3 97.5 86.7 1 75.9 65.1
5 91.3 109.6100.4 82.0 72.8 I 63.7 54.7 11 108.7 130.4 119.6 97.7 86.9 176.1 65.2
I I
6 91.8 110.2101.0 82.6 73.4 164.2 55.1 5 0 109.0 130.8 119·9 98.0 87.1 I 76.2 65.3
I :
281
TABLE A'«
HEIGHT FOR AGE. 5 TO 18 YEARS
Derived from NelllOD154
Height III em
AGE 81&D-
Year. dud
5
5.5
111.3
114.4
13)% 1l~ IIO~
BOYS
133.6 122.4 100;2

137.3 125.8 108.0
-:~
89.01
91.5 1
1
80.1
-
of old of al4 of ltd of ltd-I of ltd of old
I 71.9 66.8
68.6
St&.- 12Ol1i 1l~ !lOllS
109.7
1l2.8
131.6 120.7
GIR L S
135.4 124.1 101.5

-:~
I
-
dard of ltd of ltd of ltd of Itdlo! ltd of tid
98.7
I
87.8 1 76.8 85.8

1n21 79.0 87.7
1 I
6 117.5 141.0 129.2 U~.8 94.0 I 82.2 70.5 115.9 139.1 127.5 104.3 92.7 1 81.1 69.5
6.5 120.8 145.0 132.9 108.7 98.6 1 84.6 72.5 119.1 142.9 IS1.0 101.2 95.3 1 83.4 71.5
1
7 124.1 148.9 185.5 111.7 99.31 86.9 74.5 122.S 146.8 134.5 110.1 97.8 85.6 73.4
7.5 127.1 l52.5 139.8 114.4 101.71 89.0 76.3 125.2 150.2 137.7 1l2.7 100.2 87.6 75.1
I
8 130.0 156.0 143.0 117.0 104.0 1 91.0 78.0 128.0 153.6 140.8 115.2 10.2.4 89.6 76.8
I
85 132.8 159.4 148.1 119.5 106.2 93.0 79.7 130.5 156.6 143.6 117.4 104.4 91.4 78.3
1
9 135.5 162.8 149.0 122.0 1084 \ 94.8 81.3 132.9 159.5 146.2 119.6 106.3 93.0 79.7
9.5 137.9 185.5 151.7 l24.1 no.s l 98.5 82.7 135.8 163.0 149.4 122.2 108.6 95.1 81.5
I
-10 140.3 1689 154.S 126.3 112.2 I 911.2 34.2 185.6 166.3 152.5 124.7 110.9 1 97.0 33.2
10.5 142.3 170.8 156.6 1281 113.8: 99.6 35.4 141.7 170.0 1559 127.5 113.41 99.2 35.0
\ I
11 144.2 173.0 158.6 129.8 115.4 \ 100.9 885 144.7 173.6 159.2 130.2 115.8 1 101.3 86.8
11.5 146.9 176.3 161.6 132.2 117.8: 108.4 881 148.1 177.7 162.9 133.3 113.5 \ 108.7 88.9
I
12 149.6 179.5 184.6 134.6 119.7 I 104.7 89.3 151.9 182.3 187.1 136.7 121.5 : 106.3 911
12.5 152.3 162.8 187.5 137.1 121.8 108.6 91.4 154.3 185.2 169.7 1389 123.4 1108.0 92.6
I
13 155.0 136.0 170.5 139.5 124.0 108.5 98.0 157.1 138.5 172.8 14l.4 125.7 1110.0 IN.!
13.5 158.9 190.7 174.8 143.0 127.1 1ll.2 95.! 156.4 190.1 174.2 142.6 126.7 1110.9 95.0
I
14 182·7 195.2 179.0 1411.4 130.2 113.9 97.6 159.6 191.5 175.6 143.6 127.7 1111.7 95.8
145 165.3 198.4 181.3 148.8 132.2 115.7 99.2 160.4 192.5 176.4 144.4 128.3 : 112.3 98.2
I
15 187.3 201.4 134.6 151.0 134.2 117.5 100.7 161.1 193.3 171.2 145.0 129.9 \ 112.3 95.7
15.5 169.7 208.6 186.7 152.7 135.8 I 1188 101.3 161.7 IIN.O 171.9 145.5 129.4 I 113.2 97.0
I 1
16 171.6 205.9 188.8 154.4 137.3 1 120.1 108.0 162.2 IIN.6 178.4 146.0 129.8 1113.5 STT.3
1 I
16.5 172.7 201.2 190.0 155.4 185 2 I 120.9 103.6 162.4 1IN.9 178.6 146.2 129.9 I 113.7 97.4
I I
17 173.7 208.4 191.1 156.3 139.0 I 121.6 104.2 162.5 195.0 178.8 146.2 130.0 I 113.3 97.5
17.5 174.1 208.9 191.5 156.7 139.3 I 121.9 104.5 162.5 195.0 178.8 146.2 130.0 1113.8 97.5
I I
13 174.5 209.4 192.0 157.0 139.6 I 122.2 104.7 162.5 195.0 178.8 146.2 130.0 1113.3 97.5
282
TABLE A.4.5
SKINFOLD THICKNESS
From lelliffe103c
\
,
• Triceps skinfold thickness in Mm
MALE FEMALE
AGE Stau-
Year. dard
131% 110% 90% 80% : 10% 60%
of .td of ltd of 8t4 of 8td Iof ltd of 8td
Stan-
c1ard
131% 110% 90% Ill% 70% 60% i
of std of std of 8td of 8tdj of atd of std
I
I
0 6.0 7.2 6.6 5.4 4.8 I 4.2' 3.6 6.5 7.8 7.1 5.9 5.2 4.6 3.9
I
I
0.5 10.0 12.0 11.0 9.0 8.0 7.0 6.0 10.0 12.0 11.0 9.0 8.0 7.0 6.0
1
I
1 10.3 12.4 11.3 9.3 8.2 I 7.2 6.2 10.2 12.2 11.2 9.2 8.2 7.1 6.1
1
I
1.5 10.3 12.4 11.3 9.3 8.2 I 7.2 6.2 10.2 12.2 11.2 9.2 8.2 7.1 6.1
I
I
2 10.0 12.0 \1.0 9.0 8.0 I 7.0 6.0 10.1 12.1 11.1 9.1 8.1 7.1 6.\
I
3 9.3 11.2 10.2 8.4 7.5 1 6.5 5.6 9.7 11.6 10.7 8.7 7.8 6.8 5.8
I I
1
4 9.3 11.2 10.2 8.4 7.5 I 6.5 5.6 10.2 12.2 11.2 9.2 8.2 1 7.2
5 9.1 10.9 10.0 8.2

1
7.3 1 6.4 5.5 9.4 11.3 10.3 8.5
1
,
7.5 I 6.6
6.1
5.7
6 8.2 9.8 9.0 7.4 6.6

I
,
5.8 4.9 9.6 11.5 10.6 8.6
1
,
7.7 ' 6.7 5.8
1
I I
7 7.9 9.5 8.7 7.\ 6.3 5.5 4.7 9.4 11.3 10.3 8.5
,
7.5 I 6.6 5.7
8 7.6 9.1 8.4 6.8 6.1 5.3 4.5 10.1 12.1 11.\ 9.1 8.1 , 7.1
, 6.1
I
9 8.2 9.8 9.0 7.4 6.6 5.8 4.9 10.3 12.4 11.3 9.2 8.2 I 7.2 6.2
10 8.2 9.8 9.0 7.4 6.6 5.7 4.9 10.4 12.5 11.4 9.3 8.3 7.3 6.2
11 8.9 10.7 9.8 8.1 7.2 6.3 5.4 10.6 12.7 11.7 9.6 8.5 7.5 6.4
12 8.5 10.2 9.3 7.6 6.8 5.9 5.1 10.1 12.1 11.1 9.1 8.1 7.0 6.0
13 8.1 9,7 8.9 7.3 6.5 5.7 4.9 10.4 12.5 11.4 9.4 8.3 7.3 6.2
14 7.9 9.5 8.7 7.1 6.3 5.5 4.8 11.3 13.6 12.4 10.1 9.0 7.9 6.8
15 6.3 7.6 6.9 5.7 5.0 4.4 3.8 11.4 13.7 12.5 10.2 9.1 I 8.0 6.8
I
I
Adult 12.5 15.0 13.7 11.3 10.0 i 8.8 7.5 16.5 19.8 \8.1 14.9 13.2 iI 11.6 9.9
'IABI.E A4.6 283
ARM ~IRC.uMFERENCE
From Jelliffe 103<
Arm circumference in em
MAL E FEMALE
Yean MOL S.... 131% ll~ 110% 80%: 10% 60% stan 120% ll~ 110% 80% : 70% 60%
dard ~ otd of old of std of atd 1of .td of _ttl dud of .t4 of 8td of .td of atd:Of ltd of 8td
, I
0 1 11.5 13.8 12.65 10.3 9.2 : 8.0 6.9 11.1 13.3 12.1 10.0 8.91 7.8 6.7
2 12.5 15.0 13.75 11.2 10.0 8.7 7.5 12.0 14.4 13.2 10.8 9.6, 8.4 7.2
S 12.7 15.2 14.0 11.4 10.2 8.9 7.6 13.3 16.0 14.6 12;0 10.61 9.3 8.0
•
5
6
14.6
14.7
14.5
17.5
17.6
17.4
16.1
16.2
13.2 11.7 10.2
13.2 11.7 10.3
15.95 13.1 11.1; 10.2
8.8
8.8
8.7
13.5
13.9
14.2
16.2
16.7
17.0
14.85
15.3
15.7
12.1
12.5
12.9
10.81
11.11
11.5 1
9.4
9.7
10.0
8.1
8.3
8.6
7 15.0 18.0 16.5 13.5 12.0 10.5 9.0 14.6 17.5 16.1 13.2· 11.7 10.2 8.8
8 15.5 18.6 17.06 14.0 1U 10.9 9.3 15.0 18.0 16.5 13.5 12.0 10.5 9.0
\I 15.8 19.0 17.4 14.2 12.6 11.1 9.5 15.3 18.4 16.8 13.7 12.2 10.7 9.2
10 15.8 19.0 17.4 14.2 12.6 11.1 9.5 15.4 lS.5 16.9 13.8 12.3 10.8 9.2
11 15.8 19.0 11.4 14.2 12.6 11.1 9.5 15.5 18.6 17.06 14.0 12.4 10.9 9.3
1 0 16.0 19.2 17.6 14.4 12.8 lU! 9.6 15.6 18.7 17.2 14.0 12.5 10.9 9.4
3 16.1 19.3 17.7 14.5 12.9 11.3 9.7 15.7 18.8 17.3 14.1 12.5 11.0 9.4
6 15.7 18.8 17.3 14.1 12.5 I 11.0 11.4 16.1 19.3 17.7 14.5 12.9 11.3 9.7
9 16.2 19.4 17.8 14.6 13.0 11.3 9.7 15.9 19.1 17.5 14.3 12.7 11.1 9.6
2 0 16.3 19.6 17.9 14.7 13.0 U.4 9.8 15.9 19.1 17.5 14.3 12.7 11.1 9.6
3 16.6 19.9' 18.3 15.0 13.3 11.7 10.0 16.4 19.7 18.0 14.S 13.1 U.S 9.S
6 16.4 19.7 18.0 14.8 13.1 11.5 9.S 16.4 19.7 18.0 14.8 13.1 U.S 9.8
9 16.4 19.7 1..0 14.8 13.1 U.S 9.8 16.1 19.3 17.7 14.5 12.9 U.3 9.7
3 a 16.2 19.4 17.8 . 14.6 13.0 11.3 9.7 15.9 19.1 17.5 14.3 12.7 11.1 9.6
3 16.9 20.3 18.6 15.2 13.5 11.8 10.2 17.4 20.9 19.1 15.7 14.0 12.2 10.5
6 16.5 19.8 18.15 15.0 13.2 11.6 9.9 16.3 19.6 17.9 14.7 13.1 U.4 9.8
9 16.7 20.0 18.4 15.0 13.4 11.7 10.0 16.8 20.2 18.5 15.1 13.4 I ,
U.S 10.1
4 a 16.9 20.3 18.6 15.2 13.5 11.8 10.1 16.9 20.3 18.6 15.2 13.5 I 11.8 10.1
3 17.2 20.6 18.9 15.5 13.8 12.0 10.3 16.8 20.2 18.5 15.1 13.4 I U.S 10.1
6 17.5 21.0 19.25 15.7 14.0 12.2 10.5 16.6 19.9 18.3 15.0 13.31 U.7 10.0
9 17.2 20.6 18.9 15.5 13.8 12.0 10.3 16.8 20.2 18.5 15.1 13.4 11.S 10.1
1
5 17.0 2M 18.7 15.3 13.6 11.9 10.2 16.9 20.3 18.6 15.2 13.5 I 11.S 10.1
6 17.3 20.8 19·0 15.6 13.8 12.1 10.4 17.3 20.8 19.0 15.5 13.81 12.1 10.4
7 17.8 21.4 19.6 16.0 14.2 12.5 10.7 17.8 21.4 19.6 16.0 14.2 12.5 10.7
8 18.4 22.1 20.2 16.5 14.7 12.9 11.0 18.4 22.1 20.2 16.6 14.7 12.9 11.1
9 19.0 22.8 20.9 17.1 15.2 13.3 11.4 19.1 22.9 21.0 17.2 15.3 13.4 U.S
10 19.7 23.6 21-7 17.7 15.8 13.8 11.8 19.9 23.9 21.9 17.9 15.9 13.9 U.9
11 20.4 24.5 22.4 18.4 16.3 14.3 12.2 20.7 24.8 22.8 18.6 16.5 14.5 12.4
12 21.2 25.4 23.3 19.1 16.9 14.8 12.7 21.5 25.8 23.65 19.3 17.2 15.0 12.9
13 22.2 26.6 24.4 20.0 17.7 15.5 13.3 22.4 26.9 24.6 2Q.2 17.9 15.7 13.4
14 23.2 27.8 255 20.9 18.6 16.3 139 23.2 27.8 25.5 20.9 18.5 16.2 13.9
15 25.0 30.0 27.5 22.5 20.0 17.5 15.0 24.4 29.3 26.8 22.0 19.5 17.1 14.6
16 26.0 31.2 28.6 23.4 20.8 18.2 15.6 24.7 29.6 27.2 22.2 19.7 17.3 14.8
17 26.8 32.2 29.5 24.1 21.4 18.8 16.1 24.9 29.9 27.4 22.3 19.9 17.4 14.9
Adult 29.3 35.2 32.2 26.3 23.4 20.5 17.6 28.5 34.2 31.35 25.7 22.8.i 20.0 17.1
284 TABLE A.4.7
HEAD AND CHEST CIRCUMFERENCES
Derived from Neison l54
Circumference in em
MALE FEMALE
AGE Head Cheat Head Chest
Yean Mos.
Stan- 110% 90lIii Stan- 110% 90lIii Stan- 110% 90lIii Stan- 110% 90%
dard of otd ofstd dard of atd of aId dard of old of old dard of std of std
0 0 35.3 38.8 31.8 33.2 36.5 29.9 34.7 38.2 31.2 32.9 36.2 29.6
3 40.9 45.0 36.8 40.6 44.7 36.5 40.0 44.0 36.0 39.8 43.8 35.8
6 43.9 48.3 39.5 43.7 48.1 39.3 42.8 47.1 38.5 43.0 47.3 38.7
9 46.0 SO.6 4!.4 46.0 SO.6 41.4 44.6 49.1 40.1 45.4 49.9 40.9
1 0 47.3 52.0 42.5 47.6 SO.4 42.8 45.8 SO.4 41.2 47.0 5J.7 42.3
- 3 48.0 52.8 43.2 48.6 53.5 43.7 46.5 5J.1 41.8 47.9 52.7 43.1
6 48.7 53.6 43.8 49.5 54.4 44.5 47.1 51.8 42.2 48.8 53.7 43.9
2 0 49.7 54.7 44·7 SO.8 55.9 45.7 48.1 52-9 43.3 SO.1 55.1 45.1
6 SO.2 55.2 45.2 51.7 56.9 47.5 46.8 53.7 43.9 51.2 56.3 46.1
3 50-4 55.4 45.4 52.4 57.6 47.2 49.3 54.2 44.4 51.9 57.1 46.7
FIGURE A.4.2 285
CHILD'S RECORD
Family No. I I I I I Case No. I I I I I I
N8ID8 ••••••• • ................................... .
Address ••••••••••••••••••••••• ••••••••• •• BIRTH •••••••• single ••••• (*) multiple •••••••••• (*)
................................................... Gestation •••• full-term •• ( ) premature ••••••••• (
Date of birth ••••••••••••• Sex M() F() Asphyxia ••••• yes •••••••• ( no •••••••••••••••• (
BlrthweIght ••••••••••••••• Blrth order •••• Blrthpl&ce ••• ho.pital ••• ( ) home •••••••••••••• ( )
NO. of sIbling. llvlng •••• D1ed ••••••••••• Attendant •••• doctor ••••• ( ) nurse/midwife ••••• ( )
Father's J18IIIe ............................... . tradi tiono.l ( other ............. ( )
Oooupation ••••••••••••••••••••••••••••••• DEVELOPMENT: .itting •••• ( ) walking ........... ( )
Mother's name ............................... . talking •••• ( ) No. of teeth •••••••••
Ocoupation ........................................... . FEEDING: •••••breast ( ) artifiCial ( ) mixed (
Education •••••••••••••••••••••••••••••••• semi-solid.( ) solid ••••••••••••• ( )
IJIMlIIIIZATIONS , CHILD'S PAST DISEASES:
Primary Boosters
BCG
DPT I I
FAMILY IUMllSSES,
poll0 I
~lp""
Iotners
Il'IRST MEDICAL EXAMINATION (h1st017 and findings)
Signature:
DI\'lE ~ wt. PROGRESS (INCLUDING DIET) J FINDINGS All'IICE AND TRFA'lNBNT
'PlaCe a t1Ck \ VI wnere appropr1au>.

286 FIGURE A.4.3
Enter tbe MONTH of birth aDd the appropriate calendar

year. in the first black rectangle at bottom of chan.
WEIGHT IN KILOGRAMS
Then flU in aU the months lD chronologie &equence, BIRTH TO FOUR YEARS INCLUSIvE
like this.:
Iglll ~~~ ~4~~ U~

(This is tbe appropriate entry for .. child bom in Oct. 19'10.) Kg Kg
w.igh tbe child. ·Place !aIle dot In appl'Opmrc column Ior 21 2
"e19ht (to ne.t.rest 0.1 kg) each time chUd is welghed. 20 2
Connecl tbis dot to previous dot. Enter illaesset on chan.
Ki
IS 1S
18 1
Ki
17 17
16 16
Ki
15 15
14 14
Ki
13 13
12 12
11 1
10 1
,/
V
8
V i--"
.....
,/ four yean
L LV
v' ,,- .- f- f- "
fWO ears
/
4
3
~ ,,-
,.".
V
~
--- ODe ea.r
2
,,-
Infant
t BlnbmoDth
DATE 'i! 1ft. PROGRBSS (INCllJDING Dmr); FINDINGS ADVICE AND TREADIENT
FIGURE A.4.4 287
SCHOOLBOY'S WEIGHT RECORD

Kg IN KIL08RAMS Kg
65
50
35
30 30
20
15 15
10 10
6 10 11 12 13 14
AGE-IN- YEARS
School
Grade:
288 FIGURE A.4.5
SCHOOLBOY'S HEIGHT RECORD

Cm IN CENTIMETRES em
170
160 160
150 150
140 140
130 130
120 120
]]0 ]]0
100 100
90 90
80 80
• 10
AGE-tN-YEARS
11 12 13
"
School
Grade:
FIGURE A.4.6 289
SCIIOOLCIIILD'S I1BCOID
lebool
C1dldO, Name: lebool<bI1d No. II

ratber', Name: family lID. I I
(lleallb Cenae)
_.lpoIlty
DATE J"IHC IQIiTORT, fINDINGS

6. Procedures
Using these charts and tables, for surveys made at a particular
time, several types of comparisons are possible:
(a) Malnutrition scores in different age groups
(b) Malnutrition scores in the two sexes
(c) Malnutrition scores in different areas
If analyses are repeated at suitable intervals, other types of

comparisons can be made:
(a) Malnutrition scores in different seasons
(b) Malnutrition scores in successive years
(c) Malnutrition scores as periodic evaluation indices during
an applied nutrition, nutrition education or supplemenatry
feeding programme.
For the last purpose, baseline surveys using this method are
made at the outset and are repeated in the same season at suit-
able intervals, e.g. after 1 year. 2 years, 4 years, etc.
7. Hazards
These scores should be interpreted with caution for many
reasons:
(a) A score at a given age represents both the .cumulative
life experience of the community. and recent events. For instance,
adolescent children in Korea or school age children and toddlers in
Vietnam might show results affected by wartime disturbances in
those countries, and the score might vary perceptibly in different
seasons.
(b) For progress scoring, an index based on weight might
show some change (by supplementary feeding, for instance) while
an index based on height or other indicators might show no change.
Therefore at least weight and height should be assessed, and if
possible arm circumference and skinfold thickness.
(c) Miscalculation: Ages are often inaccurately recorded or
miscalculated from the birthdays; individuals may be compared
with the standard for the opposite sex. Even percentages are
often miscalculated.
(d) Inaccuracies of measuring: The procedures outlined must

be closely followed especially the careful maintenance of scales
and correctly setting them at zero.
(e) Small samples: Percentage scores based on numbers less
than 100 for the group can be misleading.
(f) Not every child above the malnutrition line or standard
is necessarily well nourished. But the malnutrition line is deli-
berately not set too high, in order not. to discourage the commu-
nities and individuals involved.
8. Praetieal appUeation in routine work
Despite all the limitations this system has been found of prac-
tical use and. appeal in the following ways:
(a) In health centres, the younger patients can be weighed
•and checked against the standard, and when below the malnutri-
tion standard for weight, height or other indicators, a red mark
is attached to the record to call the physician's attention to a possi-
ble malnutrition factor. Of course, tuberculosis, diabetes or other
chronic disease could also be responsible for weight loss.
In the appraisal of nutritional status of individuals, however,
it is even more important to observe the growth of children at
regular intervals, at least monthly during the first year and
quarterly thereafter. A steady rate of gain should be seen, and
a slowing-down is the most sensitive indicator of malnutrition or
undernutrition - whether primary, or secondary to infection, etc.
This is emphasized by Morley148a. It is also equally important to
consider the general clinical condition of the child, as appraised
by a physician.
(b) In schools and preschools, kindergartens, nurseries, etc.,
the teachers or school nurses can "score" their children and refer
to the physician those who are underweight, and can also see that
these children get special priority for supplementary feeding (e.g.
second-helpings! )
(c) In communities at large: to identify localities of particu-
larly poor nutrition by rapid survey.
The main asset of these indicators is that they are relatively
simple for medium-level personnel to use in the field. They enable
these workers to evaluate nutritional baselines and programmes in

their own area, and so can powerfully motivate community action
towards self-improvement. Of special concern is the fact that
not only physical but also mental development is commonly re-
tarded. This association should be stressed, because it is the
strongest incentive towards better nutrition for children.
NUTRITIONAL STATUS OF POPULATIONS

A Manual on Anthropometric: Appraisal of Trends
Recently, a global study of long-term trends in anthropo-
metric status (indicative of changes in nutritional status over a
period of decades) has been launched by WHO headquarters in
several countries in the Western Pacific Region. The procedures
to be followed, including the sampling procedures and number
of subjects to be measured in several selected age groups, and
the analyses and presentation of the data, are spelled out in Ii
Manual of the above title (WHO/NUTR/70.129). This study
aims to establish anthropometric indicators of trends, to be
considered along with other data such as vital statistics, food
balance sheets, food consumption data, etc. WHO assistance to
investigators participating in this study includes the provision
of standard equipment, recording forms and computer-proce-
ssing of the data. Further details may be obtained from the
Regional office.
TABLE A.4.8
CONVERSION OF LBS TO KILOGRAMS
Lb, 0 1/4 1/2 3/4 Lb, 0 1/4 1/2 3/4
1 0.454 0.~7 0.680 0.7'14 &5 2</.484 2</.597 2</.710 29.824

2 0.907 1.020 1.134 1.247 66 29.937 30.051 30.1&4 30.277
3 1.361 1.474 1.588 1.701 67 30.391 30.504 30.618 30.731
4 1.814 1.928 2.041 2.154 68 30.844 30.qs8 31.071 31.184
5 2.208 2.381 2.4qs 2.608 oq 31.2q& 31.411 31.525 3J.638
0 2.722 2.835 2.948 3.002 70 31.751- 31865 3J.W8 32.0q2
7 3.175 l.2B'1 3.402 3.515 71 32.205 32.318 32.432 32.545
8 3.029 3.742 3.850 3.%9 72 32.059 32.712 32.885 32.999
9 4.082 4.1% 4.309 4.423 73 33.112 33.226 33.339 33.452
10 4.530 4.049 4.763 4.876 74 33.566 3}.679 33.793 33.906
11 4.990 5.103 5.210 5.330 75 34.019 34.133 34.246 34.360
12 5.443 5.557 5.670 5.783 76 34.473 34.586 34.700 34.813
13 5.897 0.010 6.124 6.237 77 34.q27 35.040 35.153 35.267
14 6.350 6.404 6.577 6.690 78 35.380 35.4'14 35.607 35.720
15 0.804 6.917 7.031 7.144 79 35.834 35.947 30.061 36.174
16 7.258 7.371 7.484 7.596 80 36.287 36.401 30.514 36.628
17 7.711 7.824 7.938 8.OS1 81 30.741 30.854 30.968 37.081
18 8.1&5 8.278 8.391 8.5OS 82 37.1qs 37.308 37.421 37.535
19 8.018 8.732 8.845 8.qs8 83 37.&48 37.762 37.875 37.988
20 9.072 9.185 9.299 9.412 84 38.102 38.215 38.329 38.442
21 9.525 9.039 9.752 9.861> 85 38.555 38.669 38.782 38.8%
22 9.979 10.0q2 10.200 10.319 86 39.009 39.122 39.236 39.349
23 10.433 10.546 10.&59 10.773 87 39.463 39.570 39.08'1 39.803
24 10.886 11.000 11.113 11.226 88 39.910 40.030 40.143 40.256
25 11.340 11.453 11.507 11.680 B'I 40.370 40.483 40.597 40.710
20 11.79} 11.907 12.020 12.134 90 40.823 40.937 41.050 41.104
27 12.247 12.360 12.474 12.587 91 41.277 41.390 41.504 41.017
28 12.701 12.814 12.q27 13.041 92 41.731 41.844 41.qs7 42.071
29 13.154 13.208 13.381 13.4'14 93 42.184 42.298 42.411 42.524
30 13.608 13.721 13.846 13.948 '14 42.638 42.751 42.865 42.978
31 14.001 14.175 14.288 14.402 qs 43.091 43.205 43.318 43.431
32 14.515 14.628 14.742 14.855 % 43.545 43.658 43.772 43.885
33 14.%9 15.082 15.1qs 15.309 97 43._ 44.112 44.225 44.339
34 15.422 15.530 15.t49 15.702 98 44.452 44.5&5 44.679 44.7q2
35 15.876 15.m 16.103 16.216 99 44.900 45.019 45.132 45.246
30 16.32</ 10.443 16.556 16.670 100 45.359 45.473 45.586 45.699
37 16.783 16.8% 17.010 17.123 101 45.813 45.926 46.040 46.153
38 17.237 17.350 17.463 17.577 102 40.266 46.380 46.493 46.607
39 17.690 17.804 17.917 18.030 103 46.720 46.833 46.947 47.060
40 18.144 18.257 18.371 18.484 104 47.174 47.287 47.400 47.514
41 18.597 18.711 18.824 18.937 105 47.627 47.741 47.854 47.%7
42 19.051 19.1&4 19.278 19.391 106 48.081 48.194 48.308 48.421
43 19.504 19.618 19.731 19.845 107 48.534 48.648 48.761 48.875
44 19.qs8 20.071 20.185 20.298 108 48.988 49.101 49.215 49.328
45 20.412 20.525 20.638 20.752 109 49.442 49.555 49.668 49.782
46 20.865 20.979 21.0q2 21.205 110 49.895 50.009 50.122 50.235
47 21.319 21.432 21.546 21.&59 III 50.349 50.462 .50.576 50.689
48 21.772- 21.886 21.999 22.113 112 50.802 50.916 51.029 51.143
49 22.226 22.339 22.453 22.566 113 51.256 51.309 51.483 51.5%
50 22.680 22.793 22.906 23.020 114 51.710 51.823 51.930 52.050
51 23.133 23.247 23.360 23.473 115 52.163 52.277 52.390 52.503
52 23.587 23.700 23.814 23.927 116 52.617 52.730 52.844 52.qs7
53 24.040 24.154 24.267 24.381 117 53.070 53.184 53.297 53.411
54 24.494 24.607 24.721 24.834 118 53.524 53.637 53.751 53.864
55 24.948 25.061 25.174 25.288 119 53.W8 54.091 54.204 54.316
56 25.401 25.515 25.628 25.741 120 54.431 54.545 54.&58 54.77i
57 25.855 25.968 26.082 26.195 121 54.885 54.998 55.112 55.225
58 26.308 26.422 26.535 26.&49 122 55.338 55.452 55.~5 55.678
59 26.762 26.875 26.989 27.102 123 55.7q2 55.905 56.019 56.132
60 27.216 27.329 27.442 27.556 124 56.245 56.359 56.47.2 56.586
61 27.669 27.783 27.896 28.009 125 56.699 56.812 56.q26 57.039
62 28.123 28.230 28.350 28.463 126 57.153 57.266 57.379 57.493
03 28.576 28.690 28.803 28.917 127 57.606 57.720 57.833 57.946
64 29.930 29.143 29.257 29.370 128 58.060 58.173 58.287 58.400
TABLE A.4.8 (conl'd I
u's 0 1/4 1/2 3/4 U.s 0 1/4 1/2 3/4
129 58.513 58.b27 58.740 58.854 IbS 74.843 74.95& 75.070 75.183
130 56.%7 59.060 59.194 59.307 166 75.2% 75.410 75.523 75.&37
131 59.421 59.534 59.647 59.7bl Ib7 75.750 75.8b3 75.977 7b.09O
132 59.874 59.988 bO.l01 bO.214 1&8 7&.204 7b.317 76.430 76.544 .
133 &0.328 bO.441 bO.555 60.bb8 1~9 76.bS7 76.771 76.884 76.997
134 60.781 60.69S 6LOOS 61.122 170 77.111 77.224 77.338 77.451
135 &1.235 61.348 b1.462 bl.575 171 77.564 77.678 77.791 77.905
136 bl.b89 61.602 61.915 62.029 172 78.018 78.131 78.245 78.358
137 62.142 62.256 62.369 62.482 173 78.472 78.585 78.698 78.812
138 62.5% 62.709 62.823 62.936 174 78.925 79.039 79.151 79.2bS
139- 63.049 63.163 63.276 63.390 175 79.379 79.492 79.606 79.719
140 63.503 63.bl6 63.730 63.843 176 79.832 79.94& 80.059 80.173
141 63.957 64.070 64.183 64.297 177 80.286 80.399 80.513 80.626
142 64.410 64.524 64.637 64.750 178 80.739 80.853 80.966 81.080
143 64.864 &4.977 65.091 65.204 179 81.193 81.306 81.420 81533
144 bS.317 bS.431 65.544 bS.658 180 81.647 81.760 Bl.873 81.987
145 65.771 65.884 65.998 66.111 181 1!2.1oo 82.214 82.327 82.440
146 66.225 66.338 66.451 66.565 182 82.554 82.667 82.781 82.894
147 66.678 66.792 66.905 67.018 183 83.007 83.121 83.234 83.348
148 67.132 67.245 67.359 67.472 184 83.461 83.574 83.&88 83.801
149 67.585 67.&99 67.812 67.925 185 83.915 84.028 84.141 84.255
150 &8.039 &8.152 68.266 68.379 186 84.3&8 84.482 84595 84.708
151 &8.492 68.bOb &8.719 &8.833 187 84.822 84.935 85.049 85.162
152 &8.946 69.059 69.173 &9.28b 188 85;275 85.389 85.502 85.616
153 69.400 69.513 69.626 &9.740 169 85.729 85.842 85.956 86.069
154 69.853 b9.%7 70.080 70.193 190 8&.183 86.2% 8b.409 86.522
155 70.307 70.420 70.534 70.1147 I'll 8&.636 86.750 86.863 8b.97b
15& 70.760 70.874 70.987 71.101 192 87.090 87.203 87.317 87.430
157 71.214 71.327 71.441 71.554 193 87.543 87.657 87.770 87.884
158 7l.bb8 71.781 71.894 72.008 194 87.997 88.110 88.224 88.337
159 72.121 72.235 72.348 72.461 195 88.451 88.564 88.677 88.791
1&0 72.575 72.b88 72.802 72.915 1% 88.904 89.018 89.131 89.244
161 73.028 73.142 73.255 73.3&9 197 89.358 89.471 89.585 69.698
1&2 73.482 73.595 73.709 73.822 198 89.811 69.925 90.038 90.152
163 73.93& 74.049 74.162 74.276 199 9O.2bS 90.378 90.4'12 90.605
164 74.389 74.503 74.616 74.729 200 90.719 90.832 90.945 91.059
TABLE A.4.9
CONVERSION OF INCHES TO CENTIMETERS
Inches 0 1/4 1/2 3/4 Inche5 0 1/4 1/2 3/4

18 45.7 46.4 47.0 47.6 43 109.2 109.9 110.5 111.1
19 48.3 48.9 49.5 50.2 44 111.8 112.4 111.0 1B.7
20 50.8 51.4 52.1 52.7 45 114.3 114.9 115.6 116.2
Zl 53.3 54.0 54.6 55.2 46 116.8 117.5 118.1 118.7
22 55.9 56.5 57.1 57.8 47 119.4 120.0 120.& 121.3
23 58.4 59.1 59.7 60.1 48 121.9 122.& 121.2 123.8
24 &1.0 61.6 62.2 62.9 49 124.5 125.1 125.7 126.4
25 63.5 64.1 &4.8 65.4 50 127.0 127.6 128.3 128.9
2& 66.0 66.7 67.3 67.9 51 129.5 130.2 130.8 131.4
27 &8.& 69.2 69.8 70.5 52 132.1 132.7 133.3 134.0
28 71.1 71.8 72.4 73.0 53 134.6 135.3 135.9 136.5
29 73.7 74.3 74.9 75.6 54 137.2 137.8 138.4 139.1
30 76.2 76.8 77.5 78.1 55 139.7 140.3 141.0 141.6
31 78.7 79.4 80.0 80.6 56 142.2 142.9 143.5 144.1
32 81.3 81.9 82.5 83.2 57 144.8 145.4 146.0 146.7
33 83.8 84.4 85.1 85.7 58 147.3 148.0 148.6 149.2
34 86.4 87.0 87.6 88.3 59 149.9 150.5 151.1 151.8
35 88.9 89.5 90.2 90.8 &0 152.4 153.0 153.7 154.3
36 91.4 92.1 92.7 93.3 61 154.9 155.6 156.2 156.8
37 94.0 94.6 95.2 95.9 62 157.5 158.1 158.7 159.4
38 965 97.2 97.8 98.4 63 1&0.0 1&0.7 161.3 161.9
39 99.1 99.7 100.3 101.0 64 162.6 163.2 163.8 164.5
40 101.6 102.2 102.9 103.5 bS 165.1 165.7 166.4 167.0
41 104.1 104.8 105.4 IOb.O 66 167.6 168.3 1&8.9 169.5
42 106.7 107.3 107.9 108.6 67 170.2 170.8 171.4 172.1
ANNEX V
MORTALITY DATA IN THE COMPARATIVE
ASSESSMENT OF COMMUNITY
NUTRITIONAL STATUS
1. AGE·SPECIFIC MORTALITY RATES AMONG TODDLERS AND
ONE·YEAR·OLDS BASED ON REGISTERED DEATHS
A correlation between high mortality in toddlers (1-4 years old
inclusive) and poor nutritional status in various communities was
noted."'" More recently, studies have indicated that the mortality
rate in the second year of life (one-year-olds) is a more specifically
sensitive i.ndicator of nutritional status.
TABLE A.5.l
AGE-SPECIFIC MORTALITY RATES AMONG TODDLERS AND
ONE-YEAR-OLDS
No. of deaths Mid·~ear p::.pula- Age-spttific
during a tion of §arne mortalit~
ANNUAL DEATHS calendar year age grtlup rate
One-year-olds (12·23 months inclusjve) , b -

b
y
, 1000
I
Toddlers (1-4 years inclusive) I c - , 1000
c
The age-specific mortality rates are thus expressed as deaths

of a given age group during one calendar year per 1000 living
population in that age group as known oy the middle of the year.
The death registrations and population data may be used for a
geographical unit of any size, e.g. a whole country, a province,
district, city, or village, etc.
The principal difficulty is that age·specific mortality rates are
often not readily available for toddlers or one-year-olds separately,
either because the ages at death are not known, or because popula-
tion data for a specific area under close study are not known.
For many developing countries, age-specific mortality rates can-
not at present be calculated. Also, their reliability is often question-
able, because of under-registration of deaths. For these reasons it
is not possible at the moment to set out complete comparisons be-
tween different countries in this Region or between different al·eag
within one country. Nevertheless, the above-defined age-specific
mortality rates, based on official registrations, give the best and
orthodox approach, and all efforts should be made to collect com-
plete and reliable data on deaths and population. Table A.5.3
summarizes the information currently available.
295
2. PERCENTAGE 01" REGISTERED DEATHS WHICH OCCUR

Al\fONG TODDLERS AND ONE.YEAR-OLDS
For the time being, a supplementary approach which may be
useful is to express the number of toddler deaths and one.year-old
deaths as a percentage of all deaths. In this way, the relative
frequency of mortality among toddlers and one·year-olds can be
compared with overall mortality. It is believed that these per-
centages. like the age-specific mortality rates. do give an indication
of the general nutritional status or the amount of malnutrition in
the community, particularly in respect of protein-calorie deficiency.
However. these percentages are affected by the age distribution
of the population. and therefore they must be interpreted witll.
caution.
It is essential to know the total number of deaths, and the age
at death (in number of completed years) for children below five
years. Tabulate as in Table A.5.2
TABLE A.5.2
DEATHS AMONG TODDLERS AND ONE·YEAR·OLDS AS % OF ALL
-
REGISTERED DEATHS
No. of dattlS In As -10 of all
ANNUAL MORTALITY RAnos ta_, ,.or _UK
1
O.yar-olds (12·23. months Inclusive) 1 - x 100
T
I
.."
Toddlers -(l·4 rean IMlusl,,) I -.100
T
All T 100
The avallabl~d for z and T from some countrIes In ASia
and the Pacific ar" presented in this way in Table A.5.S. which also
includes data/ elating to postneonatal/neonatal deaths (sec
section 3 be'low).
"",.,. Yur
_1....."
Doo~'
at.U
'I.
TABLE A.5.3
VITAL STATISTICS INDICES OF NUTRITIONAL STATUS
...
.....
,D_ ...... .....
Death. among toddlers and pofillooDa\a.l/neonatal death ratloe
1-11 mol
(poo-
111m!)
G-27 do.
(tte1;IIIII,I)
Deaths '11l0III
toddIdl.
,*unt 01
_1:':1.11 -""
_.
1~. ~
(/lOOO} -"',
,-,
t? n_tli
.....,
AStAN OOUNTRIES
_....
(I) (2)
,,,... ,,.,
(3)
. . (4) (5)
. (6) (7)-413 (8)-4/2 (9) ... S/6
B_. >t.,
.. , ..." '" I..,
69 1.33
~(hiWln)
""
"., '''28 •1180m
Ii '12
12301
'.8
140
108
.., ,.. D."
"
"" ..
1 " ' ... 71 1J61
.
6.1 0.62
"" '" '" '"''''D
196" '.8
,..
.."
." 30D 1 '" 1.1,
""" ,," '"1Q'"
2 622 171 251 IZ9 lli.5
..
lneti,
.113Il
""In
..
12482 13 0'"
RtpIMiI:
.....
MItIO
M.t.,sja
01' "'_
""
,''' ,.
138 ' "
" ..."
1 :;76 UI
"".. ", ... ..

12.1 1.16
"" '"
'" , 13. '"
10.8
Sarl"'~
Welt M.I'1Sia ""
"" 63'" 1 712 '.0 5.4· 0"
Pakistan
Rlpullhe 01
"",lippin"
,l1li
"..
"" ,430
"""".,
'"
"'", "'".....
..... .
. . .61
17.•
11.4
,"..
(9,6)-
,,,
1.01
R1UkJu Islandl
$i• •pore
Thai"nd ..
,."
""" '"
10 S21
236 lU
.'",
)28 113
ZS ' "
9 471 15.5 (114)-
D."
2.1.
.
"'blitOf~ 15.9
"" 61 144
,.
MOH-ASlAN tXlUMtIllES
AmClrieln.SlmoII
Australil
,'"
"" "55'"
1Z.
... , '34 '",
102 103
..
340 13
18
18
11
39
O•
'.8
D9
I."
0."
0.46
Gu.m
"" • ,
"" '" ... " """ ".,
1.01
Hlurll
141'111 Zu .. ncI
'966 8 16.7
,..
1.1 10
( '.110
"'~
Unlled SI.,.. of Americ. ""
"" "'"
1 Ir.il 323 ZD 90' 58 127
. Indian. 7.6
D1 D-"
MORTALITY DATA 297
3. AGE D1STRlBlITION OF REGISTERED DEATHS IN INFANCY

If it is possible to identify the age at death in each of the first
six months of life (in number of completed months), it should be
possible to detect any important incidence of infantile beriberi.
Normally the number of deaths is smaller at each successive month,
but if beriberi is a major problem there will be a peak after the
second month.iT'
The actual number of deaths may be used, or the percentage of
infant deaths for each completed month as in Table A.5.4.
TABLE A.5.4
PERCENTAGE OF ALL INFANT DEATHS OCCURRING IN MONTHLY
AGE GROUPS
-, ..... ,
-
CoI_ No. W (2) 0' 141 151
'-11-
IN•• 01......-
....,
Iller....' ...., IM...- -,
um·,., PtlfllC"
II
o_ (0.28 ...,.,
1 ? ? I
1 _ (28.59 do,., 5.6 7.0 21.6 7.'

2_ 10.8 5.2 15.2 5.5
4_.
3 ."...tln 16.2
8.0
6.2
4.6
8.8
5.8
4.5
3.9
5_ 5.2 4.6 !>.I ).I
TIlt '...... I. coI_ 2, , and 4, as read ,.... tlw dian 01 .,....,.. ....
blgllIJ a........
Kr_....... 706. . . OM
The data in columna S, 4 and 5 are not luggestive of beriberi.

In addition, it has been found that the ratio postneonatal/
neonatal deaths is a useful indicator of nutritional status!.
Where this is poor or marginal, relatively more deaths occur
in the latter half of infancy, and the ratio of postneonatall
neonatal deaths is greater than 1 In better-nourished com-
munities it is less than 1. This is illustrated in Table A 5.3
4. NON-SURVIVAL RATES AMONG TODDLERS AND ONE-YEAR·
OLDS, ACCORDING TO MOnIER-INTERVIEW
In an effort to avoid the inaccuracies of official records and to
enable the collection of data from a small area, many field workers
have adopted the practice of interviewing all the mothers concerned

(say in a health centre or a village) about the survival of their
children.
The mothers questioned should include all those in a population
sector, not only those who still have living children. Each mother
is asked the number of children ever born alive to her (by the
present or previous husband); the number who are now living
and now dead; and the age at which the latter died. The age at
death should be ascertained if possible at the last completed month
for the first year of life and thereafter at the last completed year
up to five years of age.
This interview should be held under quiet, unhurried conditions,
preferably in the home. It may be easier to start with the )ast-
born, and proceed to the next, and so on. Mothers may sometimes
withhold some information wilfully or' by oversight. Therefore it
may be helpful to have another knowledgeable person in the com-
munity on hand.
The data are tabulated as deaths among toddlers and one-year-
olds, as a percentage of all the deaths among the children born to
those mothers. It should be noted that these death ratios are those
reported among all the children born alive to the mothers inter-
viewed, during no specific time span. Therefore they are not
actually "death rates", which refer to an interval of one specific
year.
There will be relatively few deaths of adults and older child-
ren, among children born to those mothers, because relatively few
will have reached maturity, or because there has been no time for
the surviving children to become adults. Therefore, toddler deaths
and one"year-old deaths, as percentages of total number of deaths,
will automatically be higher than the deaths among toddlers and
one-year-olds as percentages of the total deaths in a community
as calculated in section 2.
Data from selected field studies are cited by way of example
in Table A.5.5.
MORTALITY DATA 299
TABLE A.5.5
DEATHS AMONG TODDLERS AND ONE-YEAR-OLDS AS
PERCENTAGE OF ALL DEATHS
(By mother-interview)
% of toddler deaths -t. of one-yar-old

among all reported
....1'" ~m~"
Mala,.:
--
Malacca kampong 27
Perot iramponv 31
Philippines:
(Tococ District -
pliOl ora of appllod
OIII,llIon prolt<O 3'l 28
The inherent weakness of this method is the possible unreliabi-

lity of the mother's answers to questions about the number of her
children who have died and their age at death.
Nevertheless the method does afford an approach to the pro-
blem of assessing mortality patterns in small areas, for comparing
different areas, and for assessing the effect of a nutrition pro-
gramme on these vital statistics.
Another situation in which this method can be applied is in
health centres. The data and analysis will reflect only the situa-
tion as found among the mothers in attendance, and it is very
likely that these will be a selected sample of the population in an
area: the more health-conscious, possibly the more well-to-do and
sophisticated, those who live nearest to the centre; and mothers
with young living children. Nevertheless, it could be a useful way
of assessing the severity of nutritional and other problems among
the populations actually served by centres in the areas studied.
This sort of analysis can be done quickly and cheaply.
5. AGE DISTRIBUTION OF DEATIIS AMONG INFANTS,

ACCORDING TO HOTIlER·INTERVIEW
The same remarks as in section 3 apply, -if the mother can
specify the age at death in each of the first few months of life (in
number of completed months). The data for the pilot area of the
Philippine applied nutrition project (Tococ District) were as fol-

lows:
Age at dealh Number of dellhs
o months 31
1 month 2'1
2 months 10
l months 8
4 months 3
5 months 4
6·11 IIIOtIlhs 43
These cia", do not _ beriberi.
6. CONCLUSION
It should be pointed out that in vital health statistical report-
ing, priority among different ages is usually given to infant mor-
tality. The toddler (1-4) and one-year-old mortality rates have
equal importance with infant mortality, and it is desirable wherever
possible to consolidate the data for each year of life singly up to
five years, or at least for the groups 0-11 months, 12-23 months,
and 1-4 years (inclusive).
It is very desirable that all of the foregoing methods of analysis
be undertaken if possible. The type of analysis based on officially
registered deaths may be mainly undertaken by vital health statis-
tics units at central or intermediate levels. The type of analysis
based on mother-interviews may be more often feasible in some
types of field operations. It would be appreciated if copies of any
analyses done along these lines could be forwarded to the Western
Pacific Regional Office of WHO. .
FOOD FOR INFANTS
ANNEX VI A sample pamphlet 301
~
f~ I'
PROPER SUPPLEMENTARY FOOD
MAKES YOUR BABY HEALTHY I
PILOT APPLIED NUTRITION PROJECT

I
•
MOTHIR~S MILK
IS THE BEST FOOD FOR BABIES I
PLEASE CONTACT
YOUR HEALTH CENTRE
fOR MORE INfORMATION
FOOD FOR INFANTS 303
9 MONTHS MONTHS
....""---
~......
4 ~ 5 l\f()Nl11S
6 MONTHS
10-12 MONTHS
1'f(1IITS - 1-8 Tbtsp.
o
J- WHOL£ see
@ MEAT
~
(ct:~
FAMILY RICE
J-CIIP~ ~
12 MONTHS
SNAKE All TNE FAMILY I'OOD

ANNEX VII
SAMPLE RECIPES
A. FOR INFANTS (AND TODDLERS)
Quantities are specified for 1 serving (for home use) and for 10 servings
(for use in group feedilllt, village nutrition station, etc.)
Some useful equivalent measures are:

1 tsp. = 5 grams (water) 1 tbsp. =15 grams (water)
_ 10 grams dried beans or rice
3 level teaspoon (tsp.) make 1 level tablespoon
8 level tbsp. make! breakfast cup (large) (approx. 120 ee.)
1 cup = 240 ec.
2 cups make 1 pint (approx. 500 ce.)
2 pints make 1 liter (1000 cc.)
8 pints or 4 liters make 1 gallon
4 cups make approx. 1 liter (volume) or 1 kg. (weight)
1 ganta = approx. 2.2 kgs. of solid foods (e.g. rice, dried beans)
1 liter of water weighs 1 kg. = 2.2 lbs.
1 large breakfast cup holds 200 ee. water (as drunk)
1 large breakfast cup holds 250 ce. water (brimful)
1 large breakfast cup brimful holds 170 - 180 g of cereal or small grains
(green gram, other dried beans)
1 condensed milk can holds 300 ce. water
1 evaporated milk can holds 400 ce. water
1 small beer bottle bottle holds 300 ce
1 large pineapple juice can = 1 liter
1 small ice cream can = i gallon (2 Quarts)
1 large ice cream can = 1 gallon (4 quarts)
1 small petroleum (kerosene) can = 1 gallon (4 quarts)
1 large petroleum (kerosene) can = 5 gallons
Skimmed milk powder nowadays is often enriched with vitamin A.

No allowance has been made for this' in the figures shown for the Nutrient
Content. Note: In markets and stores, a small can is sometimes miscalled
a ·'liter".
309
St)fne suitable com...on, low-cost lIegetable foods rich in nutrients

Protein and B-vita...i1&B (someti..... calcium)
Mung beans or green gram (PlLaseoltu au,.etu)
Lima beans (Pha.eolus lunatus)
Hyacinth beans (Dolieho. /ab/ab)
Winged beans (Psophoca7"pUB tetragonolobus)
Pigeon peas (Ca;anus ca;an)
Peas (Pisum .ati1lUm)
Fish flour (home-made) (S.e tezt p. 110).
Carou..e, vita...in C, iro1l (so ....time. calcium)
Horse-radish-tree leaves (Moringa olei/era)
Amaranthus and other types of spinach
Swamp cabbage (Ipomoea aquatica)
Taro leaves (Colocasia epp.)
Pechay, Chinese cabbage (Braaaica chinensU)
(dark green varieties)
Sweet potato tops (Ipomoea batataa)
Carrot, pumpkin, yellow sweet potato
Manggo, papaya, banana with yellow core
Preparation 0/ {i.h flour
This can be made from large dried fish as follows: Remove the skin
land head and shred the tlesh from the bones. Toast very lightly in a pan,
then pound to a fine flour, removing any bones missed. Repeat the toasting
and pounding if necessary. Store in an air-tight container. Small dried
fish and shrimps can be handled in the same way - without removing bones,
etc., if they are small and loft enough. Instead of pounding, a grinder
such as that used for legumes (see illustration, p. 104) can be used.
PreparatWn of in/tJftt foods in grn.eral
(a) Grinding. Fine pounding or grinding or mashing and sieving is
often necessary. For home use, a mortar and pestle may be used. For
quantity preparation of dried beans and cereals, a grinder made of stone
(traditional style) or iron (commercial) is convenient. (See p. 104.)
(b) Mashing and Bieviftg. For older infants (7-12 months) many foods
can be thoroughly mashed with a fork. For younger infants (4-6 months)
they should be mashed and then sieved or strained.
(c) Pulpiftg. For IIOf~ked vegetables, cheap light-weight vegetable
mills or grinders are available and very efl'ective.
NOTE
The recipes which follow are intended only as guides and samples. In
each country, further recipes based on a wider variety of locally available
foods should be compiled, using local names for these foods.
SAMPLE RECIPES
INDEX TO INFANT RECIPES
(To be used once, twice or three time. dally)
Larger infants can take double these quantitie&
A. Dried IIeGU CGlon.. p,.ot.itt Vitamin A

(g) (I.U.)
1. Dried beans/rice porridge 140 (170)' 6.1 (8.0) • 20
2. Dried beans gruel 60 (80)' 3.9 (6.8)' 20
8. Boiled dried beans with milk 70 (100)' 8.9 (6.8)' 20
4. Dried bean mash with yellow 90 (120)' 4.0 (6.9) • 160
sweet potato, or tubers or sago
6. Mixed vecatable/drled beans 80 (110)' 4.4 (7.3)' 900
puree
B. SOJIlleGu
6. Soybean/rice porridge 120 (160)' 7.3 (10.2)' 20
7. Soybean soup 60(90)' 6.2 (9.1)' 400
8. Soybean puree with coconut 260 9.4 20
milk
9. Ground soybean with fish 86 10.0 20
10. Mixed vegetable/soybean puree 90 (120)" 6.6 (9.6)' 900
C. PeGtltde
11. Ground peanut ball 170 8.3 10
12. Peanut/banana mash 240 8.8 300
13. Ground peanut with mlk 220 11.2 10
D.Fnflu
14. Scraped papaya 15 0.2 130
16. Scraped mango 15 0.1 760
16. Scraped ripe banana SO 0.4 190·
E. Egg
17. Soft boiled egg 80 6.2 660
18. Soft egg custard 120 9.1 660
19. Egg/sweet potato maeh 200 7.6 1640
20. Egg/rice soup 140 (170)' 7.3 (10.2)' 660
F. T.II.". GM _go
(See recipe 4 above.) Also:
21. Tuber/ftah porridge 60 (110)' 6 (8) • 200
22. Baked .tuber with ftsb or dried 80 (110)' 5 (8)' 200
beans
28. Sago/ftsh porridge or dried 100 (170)' 4 (7)' 200
beans
·U milk or tlah flour q Included. CSM may be a.ed inltead. If ued in the lame
QUaIlUt7. ·the ealorle content wiU be the aame, but the protein eontent II mld-WIQ' W ....
til. two ...... .pealfled.
811
G. Dowaf41d 11M loeAl lood. CIlltnW8 P1'Of4Iill VitlltRita A

(I) (I.U.)
24. Rolled wheat porridge 80 (110)· 2.0 (4.9)·
26. Rolled wheat porridge/egg 160 (190)· 8.2 (11.1)·
26. Rolled wheat porridge/liver 100 (130)· 4.7 (7.6)· 6700
27. Rolled wheat porridge/dried 130 (160)· 6.1 (8.0)·
beans
28. Rolled wheat porridge/pumpkin 80 (110)· 3.3 (6.2)· 380
29. Rolled wheat porridge/mixed 80 (110)· 4.6 (7.4). BOO
vegetable
80. Yellow sweet potato/milk 120 6.0 300
INFANT FEEDING RECIPES
(For infants 4-12 month.)
The left-hand column gives the quantity for one serving (home use). The
right-hand column gives the quantity for ten servinp (feeding stations).
1. DRIED BEANS-RICE PORRIDGE
For lI'Re For t...
Dried beans 2 tbsp. a cups
Rice 2 tbsp. n cups
Water 1 cup 8 cup. U gallon)
·Milk powder or fish flour 1 thsp. I cup
Brown sugar 1 tbsp. I cup
1. Prepare dried bean flour and rice flour from well-dried beau and
rice by pounding or grinding (with reeommendedcereai grinder).
If thorough drying in sunlight i. not pouib1e, heatinc gently over
a low fire helps to yield a fine flour.
(Flour of dried beans or rice may keep for one month in an air-
tight container, if the grains are first slowly toasted for fifteen
minutes until golden brown, then ground or pounded and quickly
stored in the air-tight container.)
A flour which is more readily soluble in water can be made by
boiling the beans for 30 minutes, then dr)'ing thoroughly and finally
pounding or grinding.
2. Blend dried bean flour and r,ice flour in ama1l amount of cold water.
3. Boil remaining water and add mixture, stirring constantly to prevent
scorching.
4. Add sugar and milk, or fish flour.·
6. Cook for fifteen minutes more to a soft custard consistency, adding
more water if necesaary.
6. Serve warm- to infants four months of ace and over.··
(The stool may be more bulky and softer than usual but this ia not
harmful.)
• If available
"Althouwh this mixture is in general recommended to bMfn onl,. alter 4 mona.. In elr-
cumstancet. where no breast milk or artificial milk I. .•• allable. It is known that it can be
tolerated by infante even in the first monthl of lift. if besu.n Initially In email Quantities.
SAMPLE RECIPES 313
2. DRIED BEANS GRUEL For 01WI For c.t&

Dried beans 2 tbsp. 1l cups
Milk powder or fish flour 1 tbsp. I cup
Salt l tsp. 1 tbap.
Water 1 cup 8 cups or 2 quarts
1. Prepare dried bean fiour as in Recipe 1.
2. Stir this flour into boiling water to make gruel of desired thickneu
and boil fifteen minutes.
3. Add milk 01' fish Sour, and salt to taste.
4. Serve warm to infants four months and over.
3. BOILED DRIED BEANS WITH MILK

Dried beans or ftah ftour 2 tbsp. 16 cups
Milk powder or fish 'f1our 1 tbsp. I cup
(or any milk available)
Sugar j tbsp. i cup
Water 1 cup 8 cups
1. Clean, wash and cook the dried beans in enough water until pulpy
(one hour or more).
2. Add the sugar and milk (diuolved in remaining water) and boil for
15 minutes; alternatively, add fish flour and a little salt; omit lugar;
boil.
3. Pau the mixture through a lieve or crlnder for infants 4-6 months;
for infants 7-9 months, mash only.
4. Serve warm.
4. YELLOW SWEET POTATO/DRIED BEANS MASH
Sweet potato (yellow) 0 2 tbsp. u cups
DrIed beans 2 tbap. U cups
Milk powder (or any milk available)" 1 tbsp. I cup
Sugar 1 tap. i cup
Water 1 cup 8 cups
1. Boil dried beans until soft (1/2 - 1 hour); mash.
2. Boil sweet potato until soft (10-20 minutes); remove skin and mash.
3. M.ix these ingredients. For infants 4-6 months, pass through a sieve.
4. Mix the sugar and milk with water, add to other ingredients, and
simmer 5 minutes more, atirrlug constantly.
5. Serve warm to Infants and toddlers (6 months and over).
*Taro. yam or cooking banana Dla)" be a.ed Inltead. but theM supply no vitamin A. They
ORally need to be gnted rather than .....- (_ f _ to lleclpe II). For Infaula
over 6 montha. aratI... the oookad tuber (or _ n c ) will ...alee. For Infanta 4-6 montha.
Ileve abo. CUiava IDQ' also be UIIed but la poorer tIum an7 of thoIIe mentlcmed above.
··U aVallable.
6. MIXED VIlGETABLE/DRIED BEANS PUREE

Forou For en
Sweet potato (:re1low) (maabed) 2 tbap. 1t cup.
Dark leafy greeDB l cup 2i cup.
Dried beau 2 tbap. 1l cup.
Water 1l cup 12 cups
Salt 112 tap. 1 tbsp.
Milk powder· (or any milk available) or ftah ftour
1. Boil dried beans until soft U - 1 hour); maah.
2. Boil sweet potato until soft (10-20 minutes); remove skin and mash.
3. Boil the dark leafy greeDB with a little water and salt for 6 minutes.
Mash.
4. Mix all these incredienta and paaa throqh a sieve (for infants 4-6
months).
6. Add the milk (dlaaolved In ODe-half cup water) and cook for another
6 minutes. Btirrill&' constantly.
8. Serve warm to infanta four montha and over.
• If available.
II. SOYBEAN/RICE PORRIDGII
Soybean II thsp. i cup
Rice 2 tbap. i cup
Salt I tap. 1 tbap.
Water 1l tbap. 12 cups
Milk powder. (diuolved In 1 tbap. I cup
small amount of water) or
any milk available or ftah ftour
1. Prepare rice f1~ur as In RecIpe 1. or acid washed rice in step 3.
2. Put soybeans in excess water. Remove the Imperfeet beau (which
float). Soak overnight or about twelve hours. Drain··.
3. Boil in clean water until tender (1-2 hours).
4. Pound or pass soybeans throueh a grinder. Boil agaiu for five
minutes. after addill&' rice ftour if this waa prepared separately
(atep 1).
6. Serve warm to infanta (over 8 months) and toddlers.
"If awallablf, SU9I' may bf added as In Reel.. 1.
··Th.e water uaed for aoaklna JII&7 haye .. IU.ht bitter and bea.ay teate. therefore chan. .
the water before c()oltinl'.
7. SOYBEAN SOUP
Soybeans II tbap. 16 cups
Salt l tap. 1 tbsp.
Water 1 cup 8 cup.
Any dark leafy creens l cup 2i cups
1. Prepare soybeans .as in RecIpe 8. stepa 2 and I.
2. Boil the dark leafy greens in a ama11 amount of water (three minutes).
I. Paaa cooked soybeans and leaves throueh grinder.·
.. Cook for five minutes more.
6. Serve warm to Infants six months and above.
• As uaed for maize, made of atone (traditional style) or metal (com .
mercial) (p. 104)
,
SAMPLE RECIPES 816
8. SOYBEAN PUREE WITH COCONUT MILK

FtWcm. FtW Uta
Soybean. Z tbap. 16 cup
Coconut milk l cup 26 cup.
SaIt t tsp. 1 tbap.
1. Prepare IIOJ'beans (ground) .. in Recipe 8, .tepa Z to 4.

2. Add coconut milk to lOybeans.
8. Cook for five minutes. Add salt.
4. Serve warm to infants six months and above.
9. GROUND SOYBEAN WITH FISH
Soybeans Z tbsp. a cup
Water U cup 12 cupa
Fish flakes with broth Z tbsp. Zt cups
SaIt j tap. 1 tbap.
1. Prepare IOYbeans (gronnd) as in Recipe 8, steps 2 to 8.
2. Add the salt and flaked fish.
8. Mix we\l, and cook five minutes more.
4. Serve warm to infants six months and over.
10. MIXED VEGETABLE/SOYBEAN PUREE
Same .. in Recipe 6, but use soybeans instead of dried beans.
1. Prepare soybeans .. in Recipe 6, steps 2 to 8.
2. Boil the yellow sweet potato until tender. Remove the skin.
8. Boil the dark leafy greens with a little water (8 minutes).
4. Mash and sieve, or p&88 the SOybeans, sweet potato and dirk leafy
greens through the grinder.
6. Add milk (diBBOlved in smaIl amount of water) or fish flour.
6. Cook for another five minutes, add salt and stir constantly.
7. Serve warm to infanta six months and over.
11. GROUND PEANUT BALL
Peanuta, shelled t cup 2t cups
1. Slowly bake or toast selected mature well dried peanuts (without
moulds) until golden brown (at least half hour). Do not allow to
bum.
2. Remove the skin (optionsl).
3. Pound or grind finely, using pestle and mortar or com grinder. • Wash
hands and form ground peanut into balls.
4. Feed one whole ball daily to infanta over six months, or toddlers, along
with any other food.
(Divide into Z or 3 portions, if not all consumed at once.)
Note: Ground peanuts should be stored in clean, tightly covered con-
tainers, when preparation is not consumed In- one serving.
Commercial peanut butter is not recommended for infants because
the ingredients (coconut oil, etc.) and the quality can not be con-
trolled.
• See p. 104
12. PEANUT/BANANA MASH"" For 0118 For e.a

Peanuts, shelled
Bananas, ripe"
1 cup
1 piece
2. cups
10 pieces
1. Prepare ground peanuts as in Recipe 11.
2. Peel the bananas and IIULIIh smoothly with a fork.
3. Blend with the finely ground peanuts.
4. Serve to infants five months and above in divided portions if neces-
sary. (For infants below five months, add a little boiled water to
make a creamy consistency.)
"Preferably a variety with yellow core (containing provitamin A) .
•• Although this mixture is in general recommended to begin only after
4 months, in circumstances where no breast milk or artificial milk is
available. it is known that it can be tolerated by infanta even in the
first months of life, if begun initially in small quantities.
13. GROUND PEANUT WITH MILK
Peanuts, shelled 2 tbsp. u cups
Water 1 cup 10 cups
Milk powder (or any 1 tbsp. I cup
milk available)
1. Bake and pound or grind as in Recipe 11.
2. Dissolve the milk in warm water. Mix with peanuts.
3. Serve to infants five months and over.
14. SCRAPED PAPAYA
Ripe papaya 4 tbsp. 2t cups (l papaya)
Scrape briskly with back of spoon and feed the resulting puree directly
to infanta three months and above with or without lugar.
15. SCRAPED MANGO
Ripe mango 4 tbsp. 6 pes.
Cut one slice of mango from each side of the core.· Scrape, as for ripe
papaya. Avoid the fibres.
16. SCRAPED RIPE BANANA
Yellow ripe banana 1 pc. 10 pcs
(As for ripe papaya)
17. SOFT BOILED EGG
Egg 1 pc. 10 pca
1. Boil the egg for three minutes.
2. Remove and place in cold water.
3. Feed yolk to infants four months and over; the whole egg to infanUl
six months and over.
18. SOFT EGG CUSTARD
En" 1 pc. 10 pea.
Milk powder (or any mUk 1 tbap. I cup
available)
Water t cap Ii CUJIII
Supr 1 tap. t cup
·Use yolk only, for infants 4-6 months old.

SAMPLE RECIPES 317
1. Stir the yolk aDd white of the en tboIouchI7.

2. Disaolve the milk and auaar in warm water. Add this mixture to
the en.
3. Strain into a cup and steam until ann over water that is gently
boiliilg.
4. Serve warm to infanta four mouthe and over.
19. EGG/SWEET POTATO MASH

For em. For tft
Yellow sweet potato mashed i cup 6 cups
Eee 10ft cooked 1 pc. 10 pea.
Salt t tap. 1 tbap.
en until ftne
1. Blend the ..-.hed sweet potato, ..It and 8Oft.cooked
in conaiatellC7.
2. Serve warm to infanta IIix IIIOnths aDd over. Strain for infanta
4-6 monthe.
20. EGG/RICE SOUP

Rice 2 tbap. Ii cups
Chicken or meat broth • cup 6 cups
Eft yolk lpe. 10 pea.
Salt t tap. 1 tbap.
Milk powder (or any milk 1 tbsp. I cup
available) ctiaIOlved ill
small amount of water
(or tiab ftour)
1. Boil the rice until tender.
2. Add the chicken or meat broth.
3. When the rice becomes pulpy, pau through a strainer and cook . . .in.
4. Mix en, salt aDd milk together, add to rice _Po
6. Cook tive minutes more.
S. Serve to infanta four IIIOnthe aDd over.
21. TUBER/FISH PORRIDGE

Taro or yam (cooked; 2 tbap. 111 cup.
mashed or crated)
Taro leaves (cooked; _hed) 2 tbap. 111 cups
-Flab (a) fresh edible portion 6 tbep. I cup
or (b) canned
Coconut cream 2 tbap. It cu~
(or: llkimmed milk powder
if available, mixed with
a little water) 1 tbap. I cup
·AlternaU~: _ dried be:ma - _ d willie dr7 (add _ III otep 1). or ....11ecI
ODd _hed (add _ III otep I).
\
1. Boil the taro (with fresh fish" if this is used) until soft; mash or
grate.··
2. Boil taro leaves and coconut cream (and canned fish· if this is used)
5 minutes, mash. Mix with other above ingredients.
3. PaBB through sieves for infants 4-6 monthll and simmer again.
4. Serve warm.
22. BAKED TUBER (WITH FISH)· For OM For t..

Taro or yam (raw) 2 tbsp. H cups
Coconut cream 2 tbsp. H cups
• Fish (canned or fresh,
edible portion) l tbsp. i cup
Taro leaves (washed,
finely chopped) 2 tbsp. U cups
Skimmed milk powder if
available, mixed with a
little water 1 tbsp. I cup
1. Grate the taro or yam raw; as shown below."
2. Mix with eoeonut cream. Add fish· and taro leaves (finely chopped).
3. Moisten a clean banana leaf with coconut cream. Place a suitable
amount of the above mixture on the leaf, wrap and place in a hot
stone or other oven for ~ hour.
Alternatillelll: such bundles may be slowly steamed or boiled with a little
water in a billy-ean, kettle or saucepan.
Suitable for infants 4. months and over. The traditional methods do
not include fish and leaves but these are very desirable additions.
4. Serve warm.
·Alternati1l8ly: use dried beans - ground while dry; or boiled or mashed.
•• A suitable grater is made by opening out an empty can of medium size,
punching lots of holes through it from the inner side with a two-inch
nail, then placing it in an arched position as shown:
The product is finer if the tuber is grated when raw rather than when
cooked.
SAMPLE RECIPES 319
23. SAGO/FISH" PORRIDGE Fur one Fur len

Dried sago 1 tbap. I cup
Coconut cream 2 tbep. U cups
Water 1 cup 10 cups
Fish" (canned, or cooked
fish, mashed) i tbep. l cup
Taro leaves (washed, edible
portion) 2 tbep. H cups
(boiled 6 minutes, mashed;
sieved for infanta)
Skimmed milk powder (mixed 1 tbsp. I cup
with a little water)
1. Mix the sago with an equal quantity of cold water to form a smooth
paete.
2. Boil the quantity of water indicated. Pour in the sago paste. stir
and mix till jelly-like.
3. Add the coconut cream, fish" and taro leaves, mix well.
Suitable for infanta 6 months and over; sieve the leaves and fish first
for infanta 4-6 months.
"Alternatively, use dried beans - boiled and mashed.
24. ROLLED WHEAT PORRIDGE
Rolled wheat 4 tbsp. 21 cups
Milk powder" (or any milk 1 tbsp. I cup
available) dissolved in B
little water, or fish fiour
Salt· 1 tap. 1 tbsp.
Sugar" 1 tap. t cup
Water H cups 12 cnps
1. Toast the rolled wheat until light yellow and pass through grinder.
2. Boil water and add flour until thick consistency.
3. Add milk and salt or sugar to taste.
4. Serve warm to infants over four months .
• Optional
26. ROLLED WHEAT PORRIDGE WITH EGG
Rolled wheat 4 tbep. 2i cups
Egg 1 pc. 10 pes.
Milk powder" (or any milk 1 tbsp. t eup
available) or fish flour
Sugar 1 tbsp. I cup
Water Ii cups 12 cups
1. Prepare rolled wheat fiour as in Recipe 24, item 1.
2. Mix the milk (dry) with sugar, add a little water, mix to
creamy consistency.
3. Mix the milk and the previously beaten egg together and add to cooked
wheat.
4. Cook for five minutes longer, constantly stirring.
6. Serve warm to infanta four months and over.
26. ROLLED WHEAT PORRIDGE WITH LIVER

For one: For ten:
Liver (make aure this is tresh) 1 inch 150 grams
or one chicken liver cube
Rolled wheat 4 tbsp. 26 cups
Salt t tsp. 1 tbsp.
Water U cups 12 cups
1. Prepare rolled wheat porridge as in Recipe 24.
2. Boil the liver over slow heat for ten minutes. Pass through strainer
or grinder and add to porridge.
3. Return to lire, add salt and continue cooking for live minutes.
27. ROLLED WHEAT PORRIDGE WITH DRIED BEANS

Dried beans (any variety) 2 tbsp. H cups
Others as in Recipe 24
1. Prepare dried bean Iiour as described for dried beans (Recipe 1).
Add to wheat Iiour prepared as in Recipe 24.
2. Add to other ingredients and boil for fifteen minutes.
3. Serve warm to infants over four months.
28. ROLLED WHEAT PORRIDGE WITH SQUASH (PUMPKIN)
Squash (mashed) or 2 tbsp. U cups
yellow sweet potato
Others as in Recipe 24
1. Boil and mash the squash.
2. Add to rolled wheat porridge, prepared as in Recipe 24.
29. ROLLED WHEAT PORRIDGE WITH MIXED VEGETABLES
Rolled wheat 4 thsp. 21 cups
Sweet potato (yellow) or squash 1 tbsp. i cup
Dark leafy greens 1 cup 21 cups
Water 2 cups 15 cups
Milk powder (or fish fiour) 1 tbsp. I cup
Dried beans 2 tbsp. U cup
Salt 1 tsp. 1 tbsp.
1. Boil dried beans first until soft.
Z. Boil sweet potato (or squash) until soft. Peel.
3. Add dark leafy greens for last five minutes ot step 1 or cook separately.
4. Mash, and pass mixed vegetables through sieve or grinder to make
puree.
6. Prepare porridge (Reeipe 24).
6. Add vegetable puree and cook five minutes more.
7. Serve to infants four months and over.
SAMPLE RECIPES 321
30. YELLOW SWEET POTATO WITH MILK OR FISH FLOUR

Yellow sweet potato (boiled) 4 tbsp. 26 cups
Milk powder (or fish fiour) 2 tbsp. 11 cups
Water U cups 10 cups
1. Boil the yellow sweet potato in excess water until tender.
2. Remove the skin. Maah well.
3. Add the salt and milk diasolved in small amount of boiled water, or
fish fiour. Mix well.
4. Serve warm to infanta six montha and over. Strain for infants 4-0
months.
B. FOR SCHOOLCHILDREN
<and for pre-school children 1-6 years)
The quantities specified are for 100 (school 1Ue) or 10 (practice, or
smaller groups). For other numbers, multiply by the appropriate factor.
Some equivalent meaaurea are:
1 tsp. = 5 grams water; 1 tbsp. = 15 grams water or
10 grams rice or dried beans
3 level teaapoon (tap.) make 1 level tablespoon.
S level tap. make t breakfast cup (large) (approx. 120 ce.)
1 cup = 240 ce.
2 cups make 1 pint (approx. 500 ce.)
2 pinta make 1 liter (1000 cc.)
8 pinta or 4 liters make 1 gallon
4 cups make approx. 1 liter (volume) or 1 kg. (weight)
1 ganta = approx. 2.2 kg. of solid foods (e.g. rice, dried beans)
1 liter of water weighs 1 kg. = 2.2 Ibs.
1 large breakfast cup holds about 200 ce. water (as drunk)
1 large breakfast cup brimful holds 250 co. water
1 large breakfast cup brimful holds 170 g. of cereal or small grains (dried
beans, soy)
1 condensed milk can holds 300 co. water
1 evaporated milk can holds 400 ce. water
1 small beer bottle holds 300 cc.
1 large pineapple juice can = 1000 ce.
1 small ice cream can = 6 Irallon (2 quarts)
1 large ice cream can = 1 gallon (4 quarts)
1 small petroleum (kerosene) can = 1 gallon (4 quarts)
1 large petroleum (keroaene) can = 5 gallons
Skimmed milk powder nowadays is often enriched with vitamin A.
No allowance has been made for this in the figure. shown for the Nutrient
Content. .
801M mta"". _"""'. loto-ooet vegeta",. looda riell. in 1lut.w..te

Proe.i1l aRd B-tntamiu (.ometim .. caleillm)
Mung beans or green gram (Phaaeolus aureus)
Lima beans (Pll.aseolUB lU1latUB)
Hyacinth beans (DolfeMe labia")
Winged beans (PBopMcarpua tetmgonolobUB)
Pigeon peas (Ca;a1lUB ca;a1l)
Peas (Puum Batit>um)
Cowpeas (Vigna BiMMiB)
Carotene. vitami1l C, iron (Bometi_ caleium)
Horse-radish-tree leaves (Mon"ga olei/..... )
Amaranthus and other types of spinach
Swamp cabbage (Ipomoea aquatfea)
Taro leaves (Colocaaia Bpp.)
Pechay, Chinese cabbage (BrIlBBica chi1lensU)
(dark green varieties)
Sweet potato tops (Ipomoea batatllB)
Carrot, pumpkin, yellow sweet potato
Mango, papaya, bananas with yellow core
NOTE
The recipes which follow are intended only as guides and samples. In
each country, further recipes based on a wider variety of locally available
foods should be compiled, using local names for these foods.
INDEX OF RECIPES FOR SCHOOL CHILDREN (AND PRE-SCHOOL)

Approximate nutrient contents per sertling
Calories ProtBin Vitamin A
(g) (l.U.)
A. Dried beans
1. Dried beans with leafy 280 (350') 16 (23') 1200
vegetables
2. Dried bean soup 260 11 400
3. Dried bean stew 220 (260) 9 ( 10 ) 450
4. Dried bean pudding with milk' 370 (440') 12 (18') 40
5. Dried bean/ sticky rice pudding 370 12 40
6. Boiled dried beans with milk' 180 (250') 8 (1S') 40
or fish
7. Dried beans and egg soup 270 12 540
B. Soybeans
8. Boiled soybeans (with milk) 130 (200*) 12 (19') 40
9. Soybean soup 190 (260') 12 /19*) 330
10. Soybean stew (with milk or 140 (216') 10 (17' ) SO
fish)
11. Fried soybeans (with milk) 210 (280') 10 (17") 40
SAMPLE RECIPES 328
Appro:rimcot. "1&m.ttt _WItt. pe............./1
CaWries Pf'Oun.. VitamitlA
((I) (I.U.)
12. Savory soybeans (with milk) 180 (250 0 ) 10 (17 0 ) 50
18. Toasted soybeans (with milk) 150 (220 0 ) 10 (17*) 40
14. Soybeans with coconut (with 230 (300 0 ) 11 (18*) 40
milk)
15. Sprouted soybean stew 140 (210*) 9 (16*) 40
(with milk)
16. Soybean pudding 330 12 30
17. Soybean cocktail 250 (320 0 ) 10 (17*) 80
C. Pea....t.
18. Boiled peanuts in shell 270 (340*) 13 (20*)
(with milk)
19. Fried peanuts (with milk) 250 (320*) 8 (16*)
20. Boiled decorticated peanuts 180 (250*) 8 (16*)
(sweet)
21. Peanut soup (with milk or 190 13 600
fish lIour)
22. Peanut dumplings (with milk 200 6
fi.h lIour)
D. MiseeU,,/neoWl
23. Corn soup (with milk) 230 (800*) 5 (12') 610
24. Chicken/rice soup (with milk) 880 (400*) 9 (16')
26. Pumpkin soup (with milk) 280 (360*) 7 (14*) 200
26. Tubers, etc.
E. D01UJ,ted and local !ooda
27. Banana milkshake 120 6 800
28. Molasses milk drink 130 11
29. Rolled wheat porridge 120 (190*) 5 (12*)
(with milk)
30. Bulgur wheat porridge 120 (190 0 ) 5 (12*)
(with milk)
31. BuIgur wheat, vegetable 250 10 760
and &blimp
32. Cream of vegetable soup 220 (2900 ) 6 (13*) 800
with bulgur
SS. BuIgur wheat soup with clam 200 (270*) 6 (13*) 400
84. Bulgur wheat, vegetables 240 6 960
and snails
36. Bulgur wheat and rice 220 (290*) 5 (12*)
(with milk or fish Bour)
36. Toasted bulgur wheat 220 (290*) 5 (12*)
(with milk or fish Bour)
37. Bulgur wheat/maize with tripe 270 (340') 8 (15*) 100
-If milk powder or fish flour is ineluded. CSM may be tlIIed instead. U ueed in the
earne quantity. the calorie content will be the l&DIe. but the protein content mid-way between
the two level. specified.
RECIPES FOR SCHOOLCHILDREN (AND PRESCHOOL)
(Quantities to serve 100 or 10 persons)

1. DRIED BEANS WITH LEAFY VEGETABLE (1 cup)
For 100 For 10
Dried beans 20 cups 2 cups
Rice 20 cups 2 cups
Dark leafy greens (cleaned) 30 cups 3 cups
Water (or rice washing) 6 gallons 10 cups
Dried fish (10 em long) or 100 pes. 10 pc•.
snails
Ginger 10 pcs. 1 pc.
Fish sauce or fish paste 1 cup 1 tbsp.
Powdered milk" 10 cups 1 cup
dissolved in a little water (46 Ib pkt)
1. Clean and wash the dried beans and rice.
2. Heat the water, add washed dried beans and cook until nearly soft.
3. Add rice, ginger and fish or snails. Cook twenty minute. longer.
4. Add dark leafy greens and milk." Cook five minutes more.
·U aVallable.
2. DRIED BEAN SOUP (1 cup)

Dried beans 20 cups (1* gantas) 2 cup.
Rice 20 cups (.. ..) 2 cups
Mixed vegetables (diced) 10 cups 1 cup
(Yellow sweet potato, squash,
okra)
Dark leafy greens 20 cups 2 cups
Water 6 gallons 10 cups
Oil or fat 2 btls. (600 g.) 6 tbBp.
1. Wash the dried beans, cover with cold water and bring to a boil
2. When tender, add the oil, salt, washed rice and diced veptablea.
3. Continue cooking until the mixture becomes pulpy.
4. Add the leaves three minutes before removing from tire. If desired,
pass through sieve or grinder to obtain creamy collSlateuey.
3. DRIED BEAN STEW /1 cup)

Dried beana 20 cups (11 gantas) 2 cups
Water 4 gallona 8 cups
Banana (coolrlllC variety) 60 pc... (6 kg. as 6 pc•.
pnrchalled )
Sweet potato (,..now) 60 pea. (5 kg. as 6 pc..
purehaaed)
SAMPLE RECIPES 325
For 100 For 10
Rolled wheat or wheat flour' 10 cups 1 cup
Salt 1 cup 3 tbsp.•
Meat 1 kg. 1 cup (160 g.)
1. Toast the dried beans lightly and grind llnely.
2. Chop the meat finely.
3 Put the beans and the chopped meat into water and· bring it to boil.
4. Add the diced banana and yellow sweet potato, rolled wheat and salt.
Boil for 16-20 minutes.
4. DRIED BEAN PUDDING (1 cup)

Glutinous rice 10 cups 1 cup
Ordinary rice 10 cups 1 cup
Coconut milk (6 coconuts) U coconut)
thick milk 6 gallon 1 cup
thin milk 26 gallons I>cups
Sugar, brown 10 cups (1.1> kg.) 1 cup
Powdered milk" di880lved in 10 cups (1 pkt.) 1 cup
small amount of water
1. Toast the dried beans until brown. Grind them into halves or if there
is no grinder, put the toasted dried beans on a winnowing basket and
roll a bottle on them so as to divide the dried bean grains into several
pieces; then winnow.
2. Grate the coeonutand extract the milk by adding a little water and
aqueesing. Save this thick milk. Pour mora water through coconut
and sieve and collect thin milk in the kettle (or saucepan).
3. Boil the dried beans in this for 16-30 minutes. Add the ordinary and
glutinous rice and boil it until 80ft (16 minutes). Stir several times
during the cooking.
4. When almost done, add sugar to taste.
6. Serve hot with the thick coconut milk lint extracted (or with milk·
mixtura).
'Powdered milk (if available) could take the place of thick coconut milk.
6. DRIED BEAN/STICKY RICE PUDDING (1 cup)
Glutinous rice 20 cups 2 cups
Sugar (brown) 10 cups (1.6 kg.) 1 cup
Coconut, grated from 6 coconuts 20 cups (2 kg.) 2 cups
1. Wash dried beans and put in a kettle(eaucepan)with two gallons/4cups
water. Cook until 80ft in consistency (about one hour).
2. Wash the glutinous rice and put in a kettle (saucepan)with 2lrallou/ 4
cup. water. Cook for 20-26 minutes.
3. Mix cooked rice and dried beans and pack to one-half cup fnll to mould.
4. Put moulded mixture on a tray or plate and gamish with grated
coconut and sugar.
6. BOILED DRIED BEANS WITH MILK (!I cup)

For 100 For 10
Dried beans 20 cups (U gantas) 2 cups
Fat or cooking 011 600 grams (2 btl.. ) 5 tbsp.
Salt 1 cup 3 tbsp.
Milk powder" 10 cups (1 pkt.) 1 cup
diBlJOlved in a little water;

or flah flour, o.r small dried
flab or shrimps.
1. Clean and waah the dried beans thoroughly through Beveral changes
of water.
2. Drain off water and put dried beans, aalt and fat into a kettle
(saucepan) with 4 gallons/8 cups water.
3. Boil vigorously for one hour or until soft in consistency, adding more
water as necesaary. Add milk or fish. Boil for 5 minutes.
4. Serve it in individual bowls.
7. DRIED BEANS AND EGG SOUP (I cup)

Ingrediente aa for Recipe 2 20 pes. 2 pes.
with eggs
1. Prepare dried bean soup as in Recipe 2.
2. Beat the raw eggs. Add Into the soup by pouring down a 30-cm
chopstick held nearly vertically and passed in spiral faahion over the
mixture so that the egg i8 thinly distributed throughout the whole.
3. Mix and simmer for one minute.
8. BOILED SOYBEANS (with milk) (iI cup)

Soybeans ,dried 20 cups 2 cups
Salt I cup 2 tbsp.
Milk powder" diBlJOlved in water 10 cups (I pkt.) 1 cup
1. Soak the beans overnight.
2. Wash the beans once or twice and add to the water.
3. Boil gently with cover for 1-2 hours. Add salt. Serve hot with one
cup of milk"
·11 available.
SAMPLE RECIT J!:S 327
9. SOYBEAN SOUP U cup)

For 100 For 10·
Soybeans dried 20 cups (Ii gantas) 2 cups
Water 5 gallolUl 12 cups
Oil 2 btls. (600 ee.) I) tbsp.
Tomato (chopped) 10 cups (1 kg.) 1 cup
Salt >,{, cup 2 tbsp.
Yellow sweet potato or squash, 10 cups (1 kg.) 1 cup
carrots (diced)
Any leafy greens 20 cups 2 cups
Garlic 20 cloves 2 cloves
Flour 1 cup 3 tbsp.
Onion (chopped) 20 pcs. 2 pcs.
Milk powder· dissolved in 10 cups (1 pkt.) 1 cup
water: or fish flour or small
dried fish or shrimps .
1. Soak soybeans in water overnight.
2. Wash and cook 1 - 2 hours.
3. Dissolve milk in warm water. Set aside.
4. Saute the garlic, onions and vegetables. Add the soybeans, salt and
flour.
S. Make thick or thin soup according to one's taste. Add the milk or
fish and leafy greelUl five minutes before removing from fire.
6. Serve hot.
10. SOYBEAN STEW (with milk) (t cup)
Soybeans 20 cups (Ii gantaa) 1 cups
Meat, or fish or s""ils 1 kg. 1 cup
Salt I cup 2 tbsp.
Milk powder" dissolved in 10 cups (1 pkt.) 1 cup
1. Boil the soaked soybeans for 1-2 hours, then add meat or fish and
boil until tender (for snails, 15 minutes).
2. Season with salt.
3. Add the leafy vegetables five minutes before removing from fire.
4. Serve hot with 1 cup of milk· for each pupil.
11. FRIED SOYBEANS (with milk O ) (t cup)
Soybeans 20 cups (Ii gantas) 2 cups
Oil (cooking) 3 btIs. (900 ee.) i cup
Salt i cup 2 tbsp.
Water (warm) I) gallons 10 cups
.U available.
1. Soak soybeans overnight, and boil 1 - 2 hours. Drain off the water.
2. Add salt.
3. Fry in vegetable oil until soybeans are light yellow and crispy.
4. Eat fried soybeans with milk· (1 cup).
12. SAVOURY SOYBEANS (with milk·) U cup)

FOT 100 FOT 10
Soybeans 10 cups (1 gal.) 1 cup

Onions, minced 2 cups ~ cup
Tomato sauce· 5 btls. 1 cup
Sweet pepper (red) to pcs. 1 pc.
Cooking oil 2 btls. (600 cc.) S tbsp.
Salt ~ cup 2 tbsp.
Milk powder" dissolved in 10 cups (1 pkt.) 1 cup
1. Soak soybeans overnight, add salt and boil 1 - 2 hours.
2. Heat the oil and add the onion and pepper. Cook for five minutes.
3. Add the boiled soybeans and. tomato sauce. Allow to simmer over
the low fire until thoroughly heated. Serve warm or hot with milk"
(1 cup).
13. TOASTED SOYBEANS (with milk·) (I cup)

Soybeans 20 cups (16 gantas) 2 cups
Salt l cup 1 tbsp.
Oil 1 btl. 3 tbap.
1. Soak soybeans in watel" overnight.
2. Wash, drain and add salt. Boil for 1 - 2 hours.
3. Toast in vegetable oil until the soybeans are light yellow and crispy.
4. Serve with one cup milk."
14. SOYBEANS WITH COCONUT (t cup)

Soybeans, dried 20 cups (a ganta.) 2 cups
Coconut, grated 20 cups 2 cupe
(5 cocon,uts)
Salt i cup 2 tbsp.
Sugar (white) 5 cups (~ kg) 6 cup
o:IU avall.ble.
SAMPLE RECIPES 329
1. Soak beans overnight. Drain and cook in boiling water until tender.
2. Add the salt. When done remove from fire, drain and set aside to cool.
3. Place in a platter. Make a ring around the soybeans with grated
coconut.
4. Serve with one cup milk."
15. SPROUTED SOYBEAN STEW (with milk) (1 cup)

For 100 For 10
Soybeans. dried 20 cups (1~ gantas) 2 cups
Shrimps, shelled 5 cups j cup
Fat (oil) 2 btls. (600 cc.) 5 tbsp.
Onions. diced 10 pes. 1 pc.
Garlic, minced 10 pCB. 1 pC.
Powdered milk" dissolved in 10 cups (1 pkt.) 1 cup
1. Soak the soybeans overnight. Drain of\' water and place in a con-
tainer with holes. Cover the soybeans with cloth to keep warm.
2. Sprinkle water on the soybeans twice a day until the soybeans have
a sprout of 2-3 cms. long (about 2-3 days).
3. SauM garlic, onions, shrimps in oil. Add five gallons/10 cups of water.
When water boils add the soybean sprouts and cook until tender.
4. Serve with milk" (1 cup).
Note: Soybean sprouts could also be cooked for soup.
16. SOYBEAN PUDDING (1 cup)

Soybeans, dried 14 cups (1 ganta) a cups
Bulgur wheat or glutinous rice 10 cups 1 cup
Ordinary rice 10 cups 1 cup
Thin coconut milk 2 gallons 5 cups
(5 coconuts) (I coconut)
Thick coconut milk 10 cups 1 cup
Brown sugar 10 cups (1.5 kg.) 1 cup
1. Toast the soybeans in medium heat for twenty minutes until golden
brown.
2. Grind the toasted soybeans to break them into halves, 6r in the
absence of a grinder, place toasted soybeans in a winnowing basket
and roll a bottle on them to break them into halves. Winnow to remove
the husks.
3. Extract the milk by "'Iueezing the grated coeonut. Strain and set
aside thick extract. Repeat the proceu by adding excess water to
get 2 gallons/5 cups thin coconut milk.
4. Boil the soybeans 1-2 hours in excels water.
·If available.
5_ Add wheat, rice and thin coconut milk. Stir the mixture to prevent
scorching until it thickens.
6. When the rice is cooked, add sugar and cook for five more minutes.
7. Serve with the thick coconut milk.
17. SOYBEAN COCKTAIL (0 cup)

For 100 For 10
Soybeans 14 cups (1 ganta) H cups
Cooking bananas 100 pes. 10 pes.
Papaya- (large) 5 pes. l pc.
Grated coconut 20 cups (5 coconuts) 2 cups
o coconut)
Sugar (brown) 5 cups (;I kg) ~ cup
Powdered milk" dissolved in 10 cups 1 cup
1. Soak the soybeans overnight, boil 1 - 2 hours; drain.

2. Boil the bananas (in skin); peel and dice.
3. Dice the papaya.
4. Mix all ingredients together and serve cold.
18. BOILED PEANUTS IN SHELL (with milk*) (A cup)

Peanuts in shell (dried) 7i kg. ~ kg.
Salt 1 cup 2 tbsp.
Water 10 gallons 1 gallon
Water 5 e-allons 10 cups
1. Boil washed peanuj;/I -in water (plus salt) for about an hour, adding
more water as necessary.
2. Remove from fire and dr.ain olf the water. Serve warm with 1 cup
of milk per pupil.
19. FRIED PEANUTS U cup)

Peanuts, shelled! 3.3 kg 2 cups
Cooking oil· 1 gallon H cups
Garlic 10 cloves 1 clove
Salt 1 cup 2 tbsp.
1. Soak the shelled peanuts overnight. Remove the skins and dry the
peanuts under the sun for an hour.
2. Heat the cooking oil, add the garlic and peanuts.
3. Stir constantly to _prevent scorching. Add salt.
4. Remove from the fire when the peanuts are golden brown.
*Most of this can be recovered and used again.
·U aVB.llable.
lOne kg. of peanuts in shell yields 8'10 I(1'UII8 of eheIled peanula (6 eupa).
SAMPLE RECIPES 331
20. BOILED DECORTICATED PEANUTS WITH SUGAR (l cup)

For 100 For 10
Peanuts, ahelled1 3.3 kg. 2 cups
Sugar (brown) 5 cups 6 cup
1. Soak shelled peanuts in water overnight.
2. Remove the skin and boil in fresh water for 211 hours with sugar.
3. Remove from fire and serve warm or cold.
21. PEANUT SOUP (1 cup)

Peanuts, shelled! 3.3 kg. 2 cups
Dried shrimps 10 cups (1 kg.) 1 cup
Sweet pepper, sliced 10 pea. 1 pc.
Onions 10 pea. 1 pc.
Salt 1 cup 2 tbap.
1. Boil the peanuts until soft (20-60 minutes).
2. Add washed shrimps and prepared vegetables. Simmer for five
minutes.
3. Serve warm.
Note: If fine consistency is desired, pass all ingredients through grinder
and simmer again.
22. PEANUT DUMPLINGS (with milk·) (5-10 pea.)

Glutinous rice 20 cups 2 cups
Peanuts, shelled! 1.6 kg. 2 cups
Sugar 10 cups 1 cup
Milk powder· dissolved in 10 cups 1 cup
1. Soak glutinous rice in equal quantity of water for 2-3 hours.
2. Put it through a grinder and grind finely. Add enough water to
make a dough.
S. Form amal\ balls of dough and flatten to around 1 cm in thickness
and 5 cm long.
4. Drop the circular doughs in the boiling water five or more at a time.
5. Cooked dough rises to the top 80 they could be taken out of the boil-
ing water.
6. Toast the peanuts lightly and pound or grind finely. Add sugar.
Roll each cake in the peanut flour/sugar mixture.
7. Serve the cakes with a cup of milk.·
lOne ka. of peanut. In shell )'ields 870 graml!l of shelled peanuta (6 cu'P')'
-If available. -
23. CORN SOUP WITH LEA YES (and milk·)

For 100 FOT ten
Corn (mature fresh) 10 large cobs 1 cob
Cooking oil 1 btl. (300 cc.) 3 tbsp.
Garlic, minced 10 cloves 1 clove
Onion, sliced 10 pes. 1 pc.
Shrimps, dried 5 cups ~ cup
Salt 1 cup 2 tbsp
Rice washing or water 3 gallons 5 cups
Milk powder" dissolved in water 10 cups (1 pkt.) 1 cup
1. Shred corn grains from cobs.

2. Saut' garlic, onion, corn and washed shrimps.
3. Season with salt or fish sauce. Cover and cook for 10 minutes.
4. Add rice washing, leaves and the milk dissolved in warm water.
5. Stir and boil for 5 minutes.
6. Serve hot.
24. CHICKEN/RICE SOUP WITH MILK' (1 cup)

Whole chicken 2 pcs. t pc.
Cooking oil 1 btl. (300 ce.) 3 tbsp.
Garlic, sliced 10 cloves 1 clove
Onion, sliced 10 pcs. 1 pc.
Ginger, sliced 10 pcs. I pc.
Rice (ordinary) 6.6 kg. 3 cups
Rolled wheat or 20 cups 2 cups
Bulgur wheat 10 cups 1 cup
Fish sauce or 80y sauce 1 btl. 4 tbsp.
Monosodium glutamate 1 tbsp. 1 tsp.
(Vetsin, Ajinomoto)
Green onions (chopped) 10 cups 1 cup
Milk powder" dissolved in 10 cups 1 cup
Water 10 cups 1 cup
1. Cut the chicken into small plecee.

2. Sauto! garlic and onion until lirht brown and add chicken, ginger, rice
and wheat. Cook for about 10 minutes.
3. Add half of the water and boil until chicken is nearly done.
4. Add remaining water and milk· and continue cooking until well done,
stirring occasionally. Seuon with f1ah aauee or soy aauee.
5. Garnish with green onions.
6. Serve hot.
·If available.
SAMPLE RECIPES 333
26. PUMPKIN SOUP (with milk·) (1 cup)

For 100 For 10
Pork 1 kg. 1 cup
Garlic, crushed 10 cloves 1 clove
Onion, alieed 10 pcs. 1 pe.
Riee wa.hing 5 gallons 10 cups
Salt 1 cup 3 tbsp.
Rice 6.6 kg. 3 cups
Pumpkin 20 cups 2 cups
Monosodium glutamate 1 tbsp. 1 tap.
(Vetsin, Ajinomoto)
Milk powder· dissolved 10 cups 1 cup
Water 10 cups 1 cup
Onions, greens, chopped 1 cup 2 tbsp.
1. Cook pork and when tender cut into small pieces and extract the fat.
2. Saute garlic, onion and pork.
3. Cook rice and pumpkin in rice washing and meat stock. Season with
salt, pepper, vetsin.
4. Add milk to mixture. Cover and boil for five minute•.
5. Serve hot with chopped ereen onions.
26. TUBERS, etc.

Yams, taros, cooking bananas and callBva, are usually cooked in bulk
(boiled, baked or steamed). Cassava is poorer than the others. The prin-
cipal objectives are (i). to provide a suftlcient quantity and (ii) to ensure
that this is taken with some animal or vegetable protein supplement
and some green leafy or yellow vegetable.
Tubers may be as follows:
(a) Replacing rice in many of the reci)1811 (1, 2, 4, 7, 24, 26). The tubers
may need to be cut into smaI\ piecea (diced) before or after cooking.
(b) With lOybean. (reci)1811 9, 10, 11, 12, 18, 1", 16, 16, 17) (whole or
diced).
(c) With peanuts (reci)1811 18, 19, 20, 21) - whole or diced.
(d) Added to other soups and stew (e.g. recipe 23).
(e) Replacing sweet potat.oe.. (reci)1811 2, I, 81, 12, 8").
(1) With leafy vqetablea aDdJor other nptablea and/or ftah, meat, etc.,
as indicated in the recipee of Section C below (p. 340).
The ....ht of taber which Ia equivalent calorically to a given weight of
dry eereal Ia about three tl.-the - m of eereal.
·It .ftl.....
1'1. BANANA SHAKE (with milk·)

(1 cup) F0'I"100 FO'I" 10
Banana, yellow, ripe 100 pea. 10 pea.

Milk powder dill80lved in 10 cups 1 cup
Water 5 galIo... 10 cups
Salt 2 tbsp. t tsp.
Supr 5 cupa A cup
(I kg.)
1. Mash the banana or force through a sieve.

2. Add other ingredients and mix well.
28. MOLASSES MILK DRINK (1 cup)
Mtlk powder dlBBOlved in 10 cups (1 pkt.) 1 cup
Water 5 pIlons 10 cupa
MoJaa.. 10 cups 1 cup
1. Milk and water should be cold.
2. Mix together and stir in the mol_.
S. Drop of vanilla may be added to each serving if desired.
29. ROLLED WHEAT PORRIDGE (with milk·) (U cups)
Rolled wheat , pntu (50 cups) 5 cups
Milk powde~ 10 cups (1 pkt.) 1 cup
Salt 1 cup 2 tbsp.
Supr· 15 cups t cup
1. Bring to a boil eight 18110... /12 cups of water.
2. Add the rolled wheat to the boiling water. Stir to avoid scorching.
Add salt.
S. DiBBOlve the powdered milk and sugar· in about ten cups/1 cup of
warm water. Add the mixture to the rolJed wheat.
4. When done remove from 1Ire and sene warm.
SO. BULGUR WHEAT PORRIDGE (with milk·) (I cup)
Bulgur wheat '0 cups 4 cups
Water , gallons 8 cups
Milk powder 10 cups 1 cup
Sugar 5 cups 6 cup
1. Soak the buigur in one gallon/2 cups of water for two hours.
2. Add two gallons/' cups of water to the soaked bulgur and boil for
live minutes.
S. DiBBOlve the milk powder and sugar in one gallon/2 cups of water.
.&. Add the milk and sugar to tho bulgur. Cook three minutes longer.
5. Remove from fire and sene warm or hot.
SAMPLE RECIPES 335
31. BULGUR WHEAT WITH VEGETABLES AND SHRIMP (1 cup)

For 100 For 10
Bulgur wheat 40 cups 4 cups
Oil 1 btL (300 ce.) 3 tbsp.
Dried shrimps 10 cups 1 cup
Garlic, minced 10 clov~s 1 clove
Onions, sliced 10 pes. 1 pc.
Rice washing 4 gallons 10 cups
Pumpkin and yellow sweet 10 cups 1 cup
potato - diced.
Dark leafy greens cut into strips 20 cups 2 cups
Salt 1 cup 2 tbsp.
1. Heat oil. Saute garlic, onions, washed shrimps and bulgur. Add rice
washing gradually. Add salt and cover.
2. When the bulgur mixture simmers, add the yellow vegetables and
cook until tender. Add leaves and cook five minutes longer.
3. Remove from fire and serve warm.
32. CREAM OF VEGETABLE SOUP WITH BULGUR (1 cup)
Bulgur 40 cups 4 cups
Corn yellow (shredded) 100 large cobs 10 cobs
Pumpkin, diced (or yellow 10 cups 1 cup
sweet potato)
Dark leafy greens (cleaned) 20 cups. 2 cups
Garlic, minced 10 cloves 1 clove
Onions, diced 10 pcs. 1 pc.
Rice washing (or meat stock or 4 gallons 10 cups
fish stock)
Oil 2 btls. (600 cc.) 6 tbsp.
1. Shred grain of corn from cob.
2. Cut the pumpkin (or yellow sweet potato) into cubes.
3. Wash and pick the dark leafy greens.
4. SauU! garlic, onions, bulgur and the vegetables together. Add salt,
and the rice washing. Cook until tender.
5. Dissolve the powdered milk into ten cups/l cup of water. Add this
mixture and the leaves five minutes before removing from fire.
33. BULGUR WHEAT SOUP WITH CLAMS (1 cu~)
Clams 20 cups 2 cups

Bulgur 40 cups 4 cups
Rice washing 4 gallons 8 cups
Salt 1 cup 2 tbsp.
Dark leafy greens cut into strips 20 cups 2 cups
1. Clean, wash and drain the clams.
2. Cover with water and cook for five minutes. Remove from fire. Shell
the clams. Set aside.
3. Cover the bulgur with rice washing. Cook until tender.
4. Dissolve the milk in ten-cupsl1 cup water.
Ii. Add the leafy vegetables, clams, and milk five minutes before re-
moving from fire.
6. Serve hot.
34. BULGUR WHEAT WITH VEGETABLES AND SAUTED SNAILS
(1 cup) For 100 For 10
Snails 20 cups 2 cups
Dark leafy greens (cleaned) 20 cups 2 cups
Sweet potato, yellow 20 cups 2 cups
Salt 1 cup 2 tbsp.
Oil 1 btl. (300 cc.) 3 tbsp.
Garlic, minced 10 cloves 1 dove
Onion, sliced 10 pea 1 pc.
Ginger, sliced 10 pcs. 1 pc.
Rice washing. 2 gallons 4 cups
Bulgur 40· cups 4 cups
1. Wash snails and allow to drain.
2. Saute garlic, onion and ginger. Season with salt. Add the rice wash-
ing. Allow to boil.
3. Add the yellow sweet potato. Cook for five minutes.
4. Add the snails, cover and let boil for another five minutes or until
sweet potato is cooked.
For boiled b1tlg1tr
1. Soak the bulgur in one gallon/2 cups of water for two hours.
2. Add two gallons/4 cups of water and boil 5 minutes (with salt).
3. Remove from fire and serve warm, with sauted snails and vegetables.
35. BULGUR WHEAT AND RICE (with milk·) (! cup)
Ordinary rice 20 cups 2 cups
Bulgur 20 cups 2 'cups
Salt 1 cup 2 tbsp.
Milk powder· dissolved in 10 cups (1 pkt.) 1 cuP.
1. Clean the rice of any dirt, etc.
2. Put the rice and bulgur together in a kettle( saucepan). Add water
and salt.
9. Cover.
4. Cook until it is done. If the rice is still hard, steam the mixture till
the rice is tender.
5. Serve with one cup of milk>.
>If available
SAMPLE RECIPES 337
86. TOASTED WHEAT (with milk·) (I cup)

For 100 For 10
BulCUr 49 cupa 4 cupa
Sugar 10 cups 1 cup
1. Dissolve tbe milk in warm water.
2. Add 'he sugar and stir wel\ until dissolved. Set ..ide.
3. Toast the bulgur until tbere are signs of puffs.
4. Remove from cooking utenails and put in individual dishes.
6. Cover with milk and sugar mixture.
37. BULGUR WHEAT/MAIZE SOUP WITH TRIPE (witb milk·) (1 cup)

Tripe 1 kg. 1 cup
Water Ii gallons 10 cups
BulCUr wheat 20 cups 2 cups
Corn meal 20 cups 2 cups
Onion 10 pes. 1 pc.
Pepper (sweet, red) 10 pC8. 1 pc.
Salt I cup 2 tbllp.
Fisb sauce 1 cup 3 tbsp.
Cooking oil I btl. 3 tbsp.
Garlic, diced 10 pes. I pc.
Onion, leaves, cbopped 10 cups I cup
Milk powder dissolved in 10 cups I cup
Water 10 cups 1 cup
1. Clean tripe and cook until tender.
2. Add bulgur.com mixture to tbe liquid in whicb tripe was cooked.
3. Make sure that tbere is enough liquid to cook mixture rapidly to a
porridge consistency.
4. Add tripe cut into smal\ pieces, onion, pepper, salt and fish sauce.
5. Fry garlic until brown and before serving scatter on top of the soup
together with finely cut onion leaves, add milk and simmer.
-- --
• If available.
C. FOR LEAFY GREENS

I. Some sophisticated recipes
1. PICADILLO WITH DRUMSTICK LEAVES·
2 tbsp. cooking fat 4 cups rice washing
1 tap. minced garlic 2 tap. salt, dash of pepper
2 tbsp. sliced onion 3 cups drumstick leaves, washed
\oj, cup chopped tomatoes and sorted
1 cup ground beef or pork
Saute garlic, onion and tomatoes. Add ground meat. Cover and
cook 5 minutes over low heat. Add rice washing and bring to a boil.
Season with salt and pepper. Add drumstick leaves. Cook 5 minutes
longer. Six servings.
2. FISH FLAKES GHOULASH
cup pure coconut milk, diluted with 1 cup water
1
cup dried fish (boiled, flaked and fried in 1 tbsp. cooking fat).
1
2
segmenta garlic, minced
medium onion, sliced
1
% tap. salt
6 cups drumstick leaves, washed and sorted
4 pes. sweet pepper, crushed
Boil coconut milk, dried fish, garlic and onion for 10 minutes. SeaSOIl
with salt, stirring the mixture continuously. Add drumstick leaves and
crushed sweet pepper. Cook 5 minutes longer. Serve hot. Six servings
3. SHRIMP STEW
2 tbsp. cooking fat 1'A1 tap. salt
1 tap. minced garlic 5 cups rice washings
2 tbsp. sliced onion 12 pes. fresh shrimps, trimmed
1 tbsp. ginger, cut into strips 2 cups drumstick leaves, washed
1 tbsp. fish sauce and sorted
Saute the garlic, onion and ginger. Add fish sauce, salt and rice
washing. Bring to a boil and add shrimps. Cover and cook 10 minutes.
Add drumstick leaves and cook 5 minutes longer. Serve at once. Six
servings.
·Instead of drumstick leaves, you can use any of the following leaves
(chopped up; discard the stalks) :
Spinach - many local varieties e.g. Amaranthu8, Basella, etc.
Sweet potato leaves
Swamp cabbage (kangkong)
Chinese cabbage (dark green) Bitter melon leaves
Pepper leaves (any kind) Sayur Manis (Malaysia)
Bean tops (Sauropus androgynus)
Pumpkin (squash) tips Portulaca
SAMPLE RECIPES 339
4. THICK BEAN SOUP

4 tbsp. cooking fat '" cup shrimp juice
1 tsp. minced garlic '" cup pork broth
2 tbsp. sliced onion 3 cups water
'" cup sliced tomatoes 4 tap. salt
'" cup sliced boiled pork daab of pepper
'" cup sliced abrimp 3 cups of drumstick leaves,
1 cup dried mung beans, boiled washed aud sorted
Saute the garlic, onion and tomatoes. Add pork and shrimp. Covel'
and cook 3 minutes. Add mung beans, shrimp juice, pork broth and
water. Covel' and bring to a boil Season with salt and peppel'. Add
drumstick leaves and cook 6 minutes longer. Six servinp.
6. FISH STEW
'" cup dried pigeon peas, boiled in 2 large tomatoes, sliced
1 cup water 1 medium-size flab, cut into slices
8 cups rice waabing and broiled
2 cups green beans cut into 10 young lady's fingers (okra!)
2 inch lengths cut into 1 inch lengths
" cup fish paste 2 cups drumstick leaves washed
'" medium onion, sliced and sorted.
Add rice washing. to cooked pigeon peas. Boil and add green beans.
Cover and cook 3 minutes. Add fish paste, onion, tomatoes, fish and
lady's fingers. Cover and boil 2 minutes. Do not stir vegetables. Add
drumstick leaves, cover, and cook 6 minutes longer. Serve hot. Six
servings.
6. CRAB GHOULASH
1 big crab (boiled) 1 cup thick coconut milk
3 pea. sliced tomatoes 2 cups thin coconut milk
1 tbsp. sliced onion (more if desired)
1 tbsp. green onion leaves 1 cup drumstick leaves
1 tap. salt Ginger or red pepper to taste
Monosodium glutamate
(vetein, ajinomoto)
Boil crab; when cooked divide into parts. Set aaide. Put the thin
coconut milk, tomatoes and onion in a cooking pot, and bring to a boil.
Add the crab and let it boil for 3 minutes. Add the thick coconut milk,
followed by the drumstick leaves and onion leaves. Season with flsb
sauce and monosodium glutamate and cook for another 3 minutes. Serve
hot.
7. GADO-GADO
Salad
1 large potato or neet potato
1 cup bean sprouts
% eup green beans (eut in Ihort pieces)

% cup spinaeh (oooked - any kind)
pechay or other green leafy vegetable or banana flower (Blieed)
1 bard-boiled eu
BoU the potato and peel. Slice the potato and bard-boiled . . .
BoU or steam the green leafy vegetablee briefly.
BoU the bean sprouts and green beans briefly.
Arrange with oooked bean sprouts in the middle.
Mix the green leafy vegetablee and beans together and Ipread over the
bean sprouts.
Arrange the slieed potato and . . on top. Plaee in refrigerator.
Cover all with peanut eauee.
Pea_t ea_
'" eup peanut buttsr
1 eup grated eoeonut
1 garlic slieed
1 onion, sliced
1 or more pieeell of IImall red pepper
1 tbsp. fermented flah paats
juiee of tamarind
Fry the pepper, garlic and onion (lIlieed) lightly.
Grind the pepper and mix all together.
Mix together the peanut butter and grated eoeonut and about an equal
quantity of hot' water. Add the garlic, pepper, fish paste and tamarind.
Simmer for about 20 minutes until it becomes thick. Allow to 0001. Cover
the ealad with this sauce and keep in refrigerator.
(May add sliced cucumber or any other raw vegetable, e.g. sliced cabbage,
peehay. Also beaneurd - fried and slieed.)
8. POLYNESIAN PALUSAMI
Taro leaves, young (2 per adult, 1 per chiid)
Coconut cream - 1 cup
Salt to taste
O"tio1aal: Onion (small chopped)
ehillies
juice of citrus fruit
grated eoeonut
1. Prepare coconut cream (thick); add salt, onion, chillies and citruM
juice a8 desired.
2. Clean the taro leaves, pulling off thick fibrous parts at the base.
Fold about 6 leaves into a cup shape, pour in the liquid.
3. Place on a breadfruit leaf and tie the tops.
4. Bake in hot stone or other oven for % hour.
SAMPLE RECIPES 341
AIUntati1J~IV: Prepare eoconut cream, etc., as described. Roll the taro

leaves into a cylinder, cut this into slices. Place the liquid and the lellves
in a pan and simmer for 10 minutes.
Not~
(a) Do not use stems of taro.

(b) Some kinds of taro leaves cause itching in the throat.
Do not use leaves of the giant taro.
The leaves which have purple stems are usually good. Some varieties
of leaf should be partly sun-dried before cooking; local inhabitants
know these varieties.
II. Some simple recipes

1. TASTY SPINACH
1. Boll a little water and salt.
2. Then add leafy greens (chopped up just before cooking).
3. AlIlO a little chopped onion and! or garlic. (These are more tasty if
quickly deep-fried beforehand in oil.)
4. Boil or steam for 3-5 minutes. Keep excess water, if any, for IIOUp.
··6. Add a little vegetable oil (soya, or WesllOn - sunflower; or maize or
peanut) or pork fat. Heat gently while stirring.
6. Add Bome grated coeonut for extra flavour.
A serving of this should eover a good part of your day's needs of iron,
vitamins A and C, and IIOme B-vitamins.
··(a) Altematively, add 1 cup lIOur milk or eoeonut milk and simmer gently.
(b) In addition, IIOme previously cooked and chopped-up pork, shrimps,
anchovies or equid may be added at this point; it Increaaea the flavour
tremendously.
2. MIXED VEGETABLES WITH LEAFY GREENS

Sayote Lady's lingers (okra)
Squash (pumpkin) Eggplant
Yellow sweet potato Any green leaves (eIeaned;
Carrots chopped up)
Fresh green beans
1. Using just enough water, boll any or all of the above until tender
(carrots take a llttle loupr than the others); then cut into slices
(or slice first if desIncI).
2. Add an equal quantitiJ' of any of the I_vee mentioned above.
3. Simmer for 3 minutes, add a Utt1e vegetable oil and simmer 2 minutes.
4. U desired, add a few ImIIll dried shrimps, and/or some grated eoeonut,
pepper, ginger, etc.
ANNEX VIII
PACIFIC ISLAND DIETS
(Based on compilations of the Nutrition Section,
South Pacific Health Service, Suva)
Because the foods available in the South Pacific are often quite ditferent
from those commonly available elsewhere in the Region, this annex is a
compilation of recommendations for this area, supplementing those already
given elsewhere.
A._LOCAL GREEN VEGETABLES
The tropical types of green leafy vegetables are at their best during the
hot wet summer months. These plants require a good deal of rain to make
them grow quickly. The fresh young leaves should be soft and crisp. As a
general rule it may be said that the more mature leaves of tropical vegetables
tend to be tough and strong flavoured. When picking local greens like bele,
tubua (churailla), take the crisp tops and side shoots of the plant. In a
few days the plants will have put out new leaves.
1. B",. (Hibiscus Manihot)·
This green is an excellent family stand -by. It is a perennial and will
grow for several years, though it is a good idea to replant annually. Cut-
tings can be taken froru the bundles bought in the market. Plant pieces
about 6-8" long in good soil. Make sure that the garden is well drained but
at the same time moisture can be maintained. Be" does well along the sides
of a drain or on a contour.
How to us. b.,.
Pick the young leaves. tops and side shoots. Wash and place in boiling
salty water and boil with the lid on for about 5 minutes, turn over once
during the cooking. Do not cook longer or .tum the leaves more than once
because a sticky substance comes out of the leaves. giving an unattractive
texture. Drain the leaves and add a little melted butter or margarine and
a few drops of lemon juice.
Bs" may also be boiled for 3-5 minutes in coeonut cream.
For ehUd,..,.
Bs" is a good first green for bahi... The young shoots are almost fibre-
leas. Boil these for a few minutes and then push through a strainer or
mash well with a fork. Chopped be" leaves may be added to vegetable soups
for children.
2. Creepinll epiMCh (Buella rubra)
This spinach may be grown as a hush or a climber. If you do not have

much space in your garden it ia a good idea to put up a climbing fence about
··'Aiblu·· In Ne. GuIDes.
342
PACIFIC ISLAND DIETS 343
three feet high. Plante IDAY be grown from cuttiDgII or aeeda. Plant the
stalks from a bunch of spinach. In the wet weather thilI win take root in a
.. few weeks. This plant is best grown annually from cuttiDgII or aeeda.
Spinach seeds readily and once established in a garden it is there for a long
time.
HO'IQ to ,....
Pick oft the larger leaves and shoote. All the leaves of this. plant are
tender 80 there is no need to avoid the older on... Wash well and place in
boiling salted water. Boil for 8-6 minutes. Do not cook longer because the
leaves become stick)'. Drain wen and serve with melted butter or margarine
and lemon juice or with miti. Cold spinacb leaves make an excellent aa1ad.
Mix with a little oil and vinegar dreuing or thin mayonnaise.
Cooked spinach leaves may be sieved and uaed to make a good cream
soup.
This is one of the beat local greens for babies. The leaves contain no
hard fibre. Boil for five minutes and sieve or mash. This leaf hal a high
iron and vitamin content, and il 'particularly good for young babies and
expectant mothers, for any member of the family who haa been ill and needs
"building up".
3. FfW'fI tips - Ota (Athyrium esculentum)

This plant belongs to the fern family. The young shoots of ferns are
eaten In many countries. There are two types sold in the Fiji markets. The
smaller ota is sold in thick bundles. The shoots or fronds are about
! - 1" in thickness. The choice of ota depends on personal taste. The
lIoung green and brown shoots provide a crisp green which when cooked IDAY
be eaten hot with coconut cream sauce (miti) or butter and lemon sauce, or
cold, with salad dressings. The shoots should be young enough to snap off;
use the first 4-8 inches and discard the tough end of the stalk, aa with
asparagus. Wash ota shoots well and then place in a pot of boiling salted
water. Let the ota come to the boil - turn over once and bring to the boil
and then remove and drain. The green stalks should be quite crisp.
Ota may also be prepared by cutting the stems lengthwise into small
pieces - almost shredding, then cover with boiling salted water, leave for
five minutes and drain. Ota prepared this way is delicious served cold with
a dressing or mixed with fresh grated coconut chutney. The Fijian people
use koTa - which is a fermented fresh coconut, to flavour this dish. ata
prepared this way is called ota sllisBi.
Ota ca... a/ao b.. cooked like api1l4flk. The fern-like leaves should be
stri pped oft the tough ribs and then boiled in salted water or coconut cream
(1010) for about five minutes.
Anotk<IT tllpe 01 ata which has a larger frond and leaf is also sold in
the market. This has a stronger flavour than the first kind but is prepared
in the same way.
When cooking both types of Fiji fel'Dll be careful to avoid overcooking.

The flavour and texture can be spoiled by boiling for a long time.
Ota grows along the banks of streams in the bush. It is difficult to
find the right conditions in which to grow it in most gardens. "
4. Taro leaves - Rourou (Colocasia esculentum)'
There are several types of rourou Bold in the market. The leaves should
be young and fresh. Older leaves tend to be tough and may contain an
irritating substance which, if the leaves are not sufficiently cooked, will
sting the mouth and throat. Thia substance is not poisonous but it can cause
discomfort.
The presence of this irritating substance in leaves varies to some extent
according to the variety of plant, the place grown, and the ~limate. In dry
weather leaves tend to be tougher and stronger in flavour. As a general rule
try to choose the smaller-leafed bunches with pale green stalks. If you have
the red stalked variety be careful to remove the red veins in the leaf.
How to vrepare
Pull the leaf ott the stalk, place in a large pot of boiling salted water
and cook till the leaf is soft - 6-10 minutes. Drain ott the water, mash up
with a fork and reheat with coconut cream or with a little butter or marga-
rine, and a squeeze of lemon juice.
If you think the leaves are a little tough or old, it is a good idea to boil
for about 15-20 minutes in plenty of water. Drain ott the water and then
boil for a few more minutes in coconut cream.
DO NOT use the cooking water from older rourou or the red stalked
variety.
Rourou may be flavoured with chillies, onion, coconut cream or lemon
juice.
5. Amaranth... - Churaiya (Amaranthus viridis)
Two varieties grow in Fiji - one has small and the other large leaves.
The small-leafed churaiya is sold in bunches and is available throughout
the year. The reddish stems are about 6" long. To use, strip the leaves
ott the tougher part of the stem and snap ott the top shoots. Wash well and
boil in salty water for five minutes. Drain and flavour with a little butter,
margarine or coconut cream. A little grated nutmeg or lemon juice adds
to the flavour. The large leafed churaiya is sold in bunches 9-12" long.
Strip ott the leaves and throwaway the stalk. Both types of churaiya grow
easily from cuttings or seeds.
6. Swamp cabbage - Ota kare" or Wa kUm4ta (Ipomoea aquatica)
The leaves of this water plant are widely used in South East Asia.
Swamp cabbage grows well in Fiji. It is usually found growing in ponds
.Some Xanthoaoma luvea (aiant taro) are at.o 8uitable. etlpeeiaUy X. brasiliens. avail·
able from the Fiji Department 01 Aartc:ulture. It jp"Owa easil, In d~mp. aemi...hady conditio••
and i. resistant to pest..
or wet places. The leaves have a good fiavour and a high food value, they
are fairly low in fibre and are a good green for young children. Cook in
the same way as churaiya.
7. Water CTe •• - Karesi (Nasturtium sarmentosum)
This green grows in the same way as swamp cabbage. It can be success-
fully cultivated in a disused drain or any other permanently wet place in
a garden. The young leaves and stems may be eaten raw or cooked.
Water cress for use in raw salads must be gathered from a clean stream
or garden. It is very important to see that the plant is not growing in a
strev,m that is contaminated by drainage from houses, latrines or from cow
yards, etc. If in doubt about the place in which the cress has grown, use it
i~ soups or as a cooked green vegetable. To cook, place leaves and crisp
tops in boiling salted water and boil for about S-li minutes. Drain and
serve dressed with coconut cream, butter or margarine. Do not boil cress
for longer than five minutes because it will become tough and stringy.
Cooked water cress may be sieved to make a delicious cream soup.
8. Wild chiUie leav" (Capsicum fructescens) and Portulaca - Boro ni

rokete.
The young leaves of the small chillie that grows witd in Fiji makes a
good green vegetable. Strip the leaves ot\' the stems, wash and boil in
salted water for five minutes. Serve with a little coconut cream, butter or
margarine. Wild portulaca has fleshy leaves which are very soft and make
a delicious vegetable, prepared in the same way. Portulaca is available even
on dry atolls.
9. Pumpkin and .",•• t pOUlto .hoot.
Take the crisp shoot ot\' the plant and cook in same manner as water
cress. These greens are particularly good served with coconut cream. Pump-
kin tips make a good first green for habies. These should be sieved or very
well mashed. Pumpkin tips can be available even on dry atolls.
10. CaBSaVa leav.s
Cassava leaves like other greens are a very good source of minerals
and vitamins. Many people do not realize that they can be eaten. Certain
kinds are sweet, others are bitter. Local people usually know those which
are sweet and safe. If in doubt about safety, try them on pigs first!
Method of preparation
The young shoots are picked from the caBsava plants. These can be
chopped up and boiled or put whole into a pot of boiling water for 5-10
minutes. After this time the water should be drained off and if the leaves
were put in whole then they should be taken out and chopped finely with a
sharp knife.
A good thick coconut cream should be boiled and ready for the chopped
leaves. Boil this for 5-10 minutes again and then remove from the heat.
This can be served with any meat or fish as a green. A very good dish
can be obtained if sea shells or any tinned stuft' is cooked with the leaves.
This is often eaten amongst the Lauan people - \mown to them as Vaka-
sakere. , ,
11. Green beam (Phaseolus VUlgaris, etc.)

Long beam grow all the year round. The flavour depends on correct
cooking. Slice in diagonal alices, cook in boiling aalted water for 7-10
minutes and serve with French dressing, melted butter or margarine.
Frmeh beam grow throughout the year. Plain stringleas variety.
pare and cook as for long beans.
Pre- . ,
U Be these together with green leafy vegetables.
B. SUPPLEMENTARY WEAMNG FOODS FOR

PACIFIC ISLAND INFANTS
The word "weaning" means to teach the child who feeds from the breast
, ,
to eat foods in addition to mother's milk. The important word in this defini-
tion is "teach". Young infants are very conservative in their tastes. The
majority of babies are quite happy to consume milk in sufficient quantities
for the first 6-7 months of life. When foods with dift'erent tastes and textures
are given, the first reaction is to reject the new food. At this stage the
mother must realize that the teaching programme has started; the baby has
to be taught to accept the new fiavours and textures in food.
The best approach is to give the new food in strained and diluted form
in small quantities. For examples, one teaspoon of pawpaw juice may be
diluted in three teaspoons of water for about two days; after one or two
days the baby will cease spitting out the juice. When this mixture haa been
accepted the amount of water may be decreased till the baby is taking pure
pawpaw juice. The rule throughout the early months is to give a very little
of the new food in small quantities until the food is fully accepted. Let
the baby become used to one new food before beginning on another. 11
Sometimes it is a good idea to mix small amounts of a new food with
one that is already accepted. In this way the baby is hardly aware that
a new food has come into the daily meals - an example of this would be
to add egg yolk to mashed vegetable or strained banana to strained pawpaw.
The attitude of the mother is of the greatest importance in teaching
the baby to eat. The mother must be quiet and confident. She must not
get upset when food is spat out of the mouth. She should show pleasure
when the baby eats the new food. Even small babies are' alert to the
atmosphere in the home. When the mother is unhappy or worried, the baby
soon reacts by crying and refusing to eat. It is most important that feed-
ing takes place in il quiet and relaxed atmosphere.
The first si% months of life should be regarded as an important learning
period. During this time the main food is milk. In addition, babies are
eating small amounts of strained or maahed fruit, soft vegetsbles, soups
and milk puddings and egg yolk. Sometimes a mother will complain that it
is not worthwhile preparin~ sueh a small amount of food. It must be ex-

plained to her that before six months of age the baby only needs very small
amounts of the new foods. He could manage on milk alone, but during this
time he should be learning to eat the foods that he will need to ensure good
growth and health after six months of age. The baby who has been taught
to eat the new foods during the first half year of life is happy to aceept
the egg yolk, mashed vegetables and other foods which are needed in the
second six months. .
Throughout the Pacific Islands it is usual to find babies growing very
rapidly during the first six months. At this period in life they often lur-
paSl the Australian or New Zealand infants in speed of erowth and gain
in weight.
At six months a change takes place. The healthy happy Pacific Islander
starts to lose weight, the gain in growth slows down. The child becomes
irritable. He seems to pick up infections easily, and these reduce his
strength.
The realIGn for this change in health and rate of growth, is lack of the
food he needs. Up to six months a baby can be adequately nourished on an
ample diet of breast milk; one of the reasons is that a baby bom from a
well-nourished mother has a store of iron in his liver which supplies his
need for haemoglobin during the first six months of life. After this age
milk alone is not an adequate food to provide for the growth of flesh and
haemoglobin. The baby must have additional protein foods - like egg, ftsb,
soft meats and soup .. soups made out of pulses (dhal) and peanuts.
After this age the infant's output of energy increases. Rolling over,
sitting up, erawling and attempting to walk greatly increase the need for
energy-'giving starehy foods. These should be soft mashed starchy roots or
fruits, breadfruit, yams, sweet potato, potato, rice and other suitable foods
of this kind. Well mashed banana is another excellent food. Puddings made
out of grated cassava or rice, etc., cooked with milk or diluted coconut cream
and water and flavoured with pawpaw or banana - (Lou of Fiji or Vaisalo
of Samoa) provide useful foods. At this age the infant also needs vitamina,
particularly vitamin A and vitamin C which are provided by cooked green
vegetables and soft ripe fruit. The much needed mineral iron is- obtained
from green leaves and from meat or shellfish soup and egg yolk.
TM preparation of foods for lloung infanta
One of the problems in preparing foods for babies under village condi-
tions, is to see that the food is hygienic and of a smooth texture. The tllree
months old baby is used to the smooth bland flavour of milk. The intro-
duction of foods of different textures that have a rough feeling on the
tongue will cause him concem until be gets used to the new food.
In the PacUl.e Islands the traditional way of preparing first foods for
infants was to strain fruit juices through masi or tapa cloth, and for the
mother and grandmother to chew the food till it was of the right consistency.
The mixture was then fed on a finger or plUllled from the mother'. mouth
into her infant's mouth.
A main problem of introducing foods Into the young infant'. diet i. to
find practieal ways of preparing the food in a IlUitable form. The equipment
needed to prepare food properly consists of two small enamel bowls or cupa,
a metal spoon, a fork, a wire strainer, a bottle for boiled water. It i.
possible to replace enamel bowls with smooth coconut cups, likewise a clean
stone may be used to pound food, in place of "fork. The infant may be fed
with a clean-cut coconut leaf or a shell in place of spoons.
Straining of fruit juice and soups is best done with a metal strainer.
These days many families own a tea strainer. If this is kept clean it may
be used for the baby's food. In place of a metal strainer the coconut fibre
which grows round the tops of young palms may be used. This should be
scraped, then washed and boiled. The fibre is cut into squares and kept in
a box or balr. It is not advisable to use cloth for straining juice because
of the difficulty in ensuring the cleanliness of this. Coconut fibre is dis-
carded after use, whilst small pieces of cloth have many uses in the home.
The need for clean preparation of food cannot be over emphasized. It
is important that this be fully discussed with mothers. The medical worker
must demonstrate the preparation of foods and show how equipment is cleaned
and stored away from flies and dust. Useful education programmes may
also be arranged by the Women's Club..
Mothers throughout the world tend to complain about the preparation of
the small amounts of food needed by the baby. In the Pacific Islands, many
family foods are suitable for the baby. For example a little soft taro, yam
"
or rice may be taken out of the pot, mashed with the cooking water or milk
and given to the infant. Fish, meat soups, dhal (pulse) and green vegetable
soups are suitable foods. In most cases there is no need to make special
foods. The daily family food just has to be strained or mashed up till it is
of the right consistency. The use of family food in the baby's diet should
be discussed with mothers. In modem times the preparation of infant foods
has received a great deal of attention and this has been encouraged by the
manufacturers of special baby foods. The medical worker should discuss
the family meals with the mothers and explain how the foods which are used
in the daily meals may be prepared for the baby.
Agf! at wh.ich. to introduce foods
There is no absolute rule about the age at which dift'eJ;ent foods should
be given to the baby. This depends on several factors, such as the tradi-
tional weaning practices, the efficiency of the mother, the hygiene of the home
and the rate of growth of the baby. In many traditional societies, between
the fourth and sixth months the mother begins to introduce supplementary
foods in the baby's diet. It is always necessary to take into account the
existing traditional customs and if possible to rely on them in order to
promote smooth weaning habits.
In addition the age at which foods are Introduced will depend on the
ability of the mother to understand the importance of cleanliness.. For exam-
ple it would be unwise to suggest the use of uncooked fruit juice at the ...
of one month to women living in primitive fly-infested villages. In this ease,
the addition of foods should be delayed till 4-6 months of age. It milrbt be
better to start the infant on cooked vegetable soups taken out of the famUy
cooking pot rather than raw fruits.
The rate of crowth of the baby is also important. Die babies need
more food than mnaller Oneil. It is usual to start the former on strained
banana, fruita and other starchy foods about 2-8 montha. A smaller child
may start later.
However, all infants should. be eating some soups and maahed veptables
by six months of age.
The bottlefed baby must be treated di1ferentIy. Boiled and dried milks
contain no vitamin C. The baby must have fruit juice daily to prevent the
development of scurvy.
Suitable foods for ..... durinfl tTl" fird • _eM
Pawpaw provides the baby with vitamin A and vitamin C. It is one
of the most important foods for infants in the tropiCL Pawpaw juice may
be given at a few weeks of age mixed. with boiled water.
To prepare the- juice, place pieces of ripe fruit in a piece of boiled cloth
or coconut fibre (wlo in Fij I) and press out the juice with the fingers. This
method should not be recommended unless the mother can be relied upon
to boil the cloth or vulo. A more satisfactory method is to press the flesh
through a wire strainer.
At 2-8 months of age the Infant should be having finely maahed or
sieved pawpaw of thick consistency. Fruita such as mango, tomato, cooked
guava and other fruita of mild flavour may be prepared In the same way.
Rip. ba1l4114. This is one of the best fOods for young infants. ItIs
important to use fruit that has some black on the skin. This means that
the atarch baa been turned into sugar and the fruit is easy to d:igeet. The
fruit must be quite soft. Ripe banana makes a good food for the three
months old baby. It should be mashed to form a soup. Lumps can be re-
moved by putting through a wire strainer.
V'g"tabl88. Soft yellow or red vegetables like pumpkin, carrot and
tomato and the leaves of edible green leaves which contain littls fibre may
be given about 4-6 months.
Green leaves from the following plants are particularly suitable for in-
fants - creeping spinach (Basella alba), bele or pele (Hibiscus manihot),
ferns like the ota dina of Fiji (Athyrium esculentum), churaiya or tubua of
Fiji ~Amaranthus viridis) and the portulaca commonly known as a garden
weed in Fiji, and which is called te boi in the Gilbert & Ellice Islands. Most
of these plants can be easily grown in a garden or found in the bush or
amongst cultivated crops.
The starchy roots and fruita are usually started about 3-4· months.
Small pieces of cooked taro, yam or breadfruit, sweet potato or rice are
mashed up with the soup from green leaves. When these foods are accepted,
fish soup and meat soup may be mixed with the vegetable IOUp.
Foods made from green coeonut and the embryo of the germinating
coconut may be given in the 4-6 months period.
Cooked egg yolk, m.,at and flah soups are gradually introduced between
4-6 months of age.
Foods aft.... • m01.ths
Between six montha and one year of age the baby· should learn to take
food three times a day. The milk feed i. given first and this is followed by
suitably prepared food. Drinks of fruit juice and boiled water, green coconut
water or cool boiled water are given mid-morning and afternoon. The follow-
ing is a suggested routine for feeding after six months of age.
Early a.m. Milk
Mashed root vegetable or ripe banana or cooked
breadfruit mixed with fish or milk and water; or rice
and fish or milk; or a cooked "porridge" made from
oatmeal or sharps or sorghum, fish or milk, and
water.
10 a.m. Fruit drink or water and mashed raw ripe fruit.
Milk.
Midday Meat soup or fish soup or soft cooked egg or soup
made from dried peIUI or beans (dhal) or green
vegetables mixed with root vegetable or rice.
Milk.
Night Same al morning or midday meal.
When the baby starts to get a few teeth, food need not be so carefully
mashed. However, up till 16-18 month. it is Important to see that food is
soft and I!QY to chew.
I'M k6JI 11./"" ",.. llear 0/ 11.,,_
The moat di1Bcult period arises when the infant ceases to be fed from
the mother'. breast. In many cases the protein content of his daily food is
SUddenly reduced. Unless protein is supplied from other foods the child will
su1l'er.
Unfortunately a belief has developed in the Pacific Islands that infants
should be weaned at nine months of age - an age recommended in temperate
climates where cheap and plentiful supplies of cows milk are available.
Many .Pacific Island women are quite happy to extend the breast feed-
ing period to eighteen months and sometimes longer. This should be en-
couraged as long as the child ia receiving a mixed diet in addition to the
mother's milk.
Mothers must be taught to provide substitute protein foods for breast
milk once feeding ceases. Suitable soups and stews can be made out of many
local foods if these are prepared by the right method.
At the Fiji School of Medicine Department of Nutrition a number of
useful recipes, which provide protein for the child after one year of age,
have been prepared. These recipes should be explained, and demonstrated
to women's clubs and at infant welfare clinics.
Mothers should also be made aware of the value of skim milk powder
for feeding infants after the weaning period. Dried pulses should also be
used to a much greater extent.
Infants raised on the regime discuaaed in these pages do extremely
well. The deterioration in growth and standard of health does not occur
at the weaning age, as long as suitable foods are given.
The improvement of infant nutrition in the Pacific depends to a very
great extent on educating the mother in the principles of basic nutrition,
and teaching her how to prepare suitable protein foods for her child.
C. ADDITIONAL RECIPES FOR PACIFIC ISLANDS

1. MILK
These recipes are suitable for all the family, eepecially you~ ehildren
and invalids. Use 3 level tablespoons of skim milk powder per eup water,
or 4 level tablespoons of whole milk powder per cup water.
(a) B4114114 milk dri1lk
1 ripe banaua
1 eup milk, either fresh or thick powdered milk (for thick milk use
1 cup water to 4 tablespoons milk powder).
Method
1. Prepare milk.
2. Mash banana thoroughly.
S. Pour _hed banana into milk and stir well.
4. Serve in glau.
This is a good banana drink for bahi.. and sick people.
The drink is very refreshing.
(b) Skim milk .trixk witl z.m- jIa"owr
2 cUJIB water
4 level tahleapooll8 IIdm milk powder
Lemon leaves or lemon gra&II
M.tllod
1. Wash leaves and boll in water 6 minutes.
2. Strain.
3. Mix 2 eUJIB of liquid with 4 level tablespoons of milk powder.
4. Add a little Bugar to flavour.
(e) Riee pudding (made in two ways for habies 4-6 months)
1M, cup riee
It cups milk
2 teaspoons Bugar
M.tMd
1. Wash rice and cook alowly in milk. Do not boil fast becaUlle
the mixture will burn. U the pudding is too dry add some water.
Add aupr when cooked.
OR
2. Wash rice and cook in water.
Add sugar when cooked and serVed with milk.
(d) CcqR1IG f'/Uldi",
2. level tableapooll8 grated raw cuaava

1 teaspoon aupr
1 cup milk
M.tAod
1. Mix all ingredients together.
2. Cook over slow heat till boiling. Simmer ten minutes. Stir well
to prevent burning.
Thil pudding could al80 be steamed in banana leaf (/Ii ko_, Fiji).
(e) Milk 8/1ue" lor gre61/. 16/11168 - use instead of coconut cream
1 cup milk, either fresh, or thick powdered milk (1 cup water to
4 tablespoons milk powder)
3 teaspoons lemon juice
Little finely chopped onion
Salt
M.tAod
1. Prepare milk. DUring the beating proceu add 'ir teaspoon of
lemon juice and beat, then add the rest slowly.
2. Add finely chopped onion and enough salt to taste.
3. Serve in jug or bowl, with cooked green leaves, ftsh or shellftsh.
At times coconut cream is hard to get, especially in town, 80 this
method of making coconut sauce with milk i8 useful to know. The
taste ie slightly di1ferent. from the coconut cream recipe.
(f) T/ITO letIlIA (Rourou) in milk for children

2 cupe milk, either fresh or thick - (2 cupe water to 6 level
tablespoons milk powder)
Taro leaves, 1 bunch, about 1 lb.
Little onion and salt.
MetAod
1. Prepare milk and put In a pot to heat.
2. Prepare rourou - clean under the tap.
8. When milk ie boDing take the leaves and put into pot and leave
lid on.
4. Boll for 6 minutes, then turn the leavel over.
Boll for another 6 minutes then serve.
Watch carefully to _ that pot does not boil over.
Taro leaves In milk is a very good body-building food for all the
family. This Ie a partlc:ularly good dish for little children and eick
people. Other kinde of green leaves may be cooked In the same
way.
Note: Dried milk mixtures burn very easily, always stir the pot
well. . Do not put on very hot fire or primUs.
(C) MfHMd 11/1_ _ 0'1' oooked root 1I.getllllz.. /1M dfUd milk
Thoroughly JDalh a very ripe banana or 80ft taro, etc., with
1 tablHpOOn milk powder.
(h) Ve/1l1to6_ i1I ..,,\ite 811Mee made from ftour or crated cauava
1 % cupa veptable water
8 level tablespoons skim milk powder
2 level tableepoons ftour or 2 tablespoons grated raw cauava
% teupoon salt
1 cup chopped veptablea, e.ll. carrot, pumpkin, sweet potato, wreen
leaves
Metlaod
1. Prepare veptables and boil till 110ft. Save cookinlr water.
2. Combine ftour and skim milk powder and mix to a smooth paste
with a llttle c:old water.
8. Graduall7 stir in 1 % cups veptable water - mix till DO lumps.
Stir over heat and boil 6 minuteL Then mix with cooked veae-
tablea.
2. EGGS
(a) Soft-boiUd e/1/1.
Place an ellil on top of a pot of boiling root veptable.. Remove
after four minuteL Alternatively, place 8Ir1f in pot of cold water
and take out when water boilL
Mash the 1-2 teaspoons of yolk with BOft taro, yam or .west potato.
(b) Stell1Md e/1/1 cutllrd
1 en
1 tablespoon sieved or mashed cooked veptable
% cup milk
Pineh of ..It
Met1aod
Mix altogether and beat well. Put in enamel bowl and place over
a pot boiling water. Cook at low heat till en il ftrm.
8. COCONUT
.(a) Green cOOOt&vt
Serape the fieah out of a creen nut and mash up very finely. Mix
with % cup eoc:onut water beaten with 2-8 level teaspoon. milk
powder. The milk ean be replaeed with 2-8 teupoons of finely
mashed fish ftellb. Give about 8-4 montbL
(b) Germiftllti7&/1 COOO7&vt
Take out the eoc:onut embryo (1I11t'11 of Fiji). Cook tillBOft in coconut
powder. .ash
water or water; when cool sprinkle with 2-3 level teupoona of milk
up till very 110ft.
Not.: The you... coconut and IproUting contain very little protein.
Milk powder is added to iDCreUe the protein. If milk II not
available DIe cooked and ftneIy IIIlIIIhed flab fieab.
4. SOUPS
The following are suitable for infants 4-6 m.ontlla (or. older) .
(a) Dried p ..../"eoM
'AI cup dried peas Dr beans (dbal)

2 cups water
'AI onion (can be left out)
2 teaspoons oil or fat
M.t1wId
1. Wash the dried peas or beans with cold water and leave to soak
several hours - if poaaible for one day or night,
2. Add water and boil until the dried peas or beans are cooked.
3. When cooked strain (save the water for IOUp). Rub through a
sieve, or mash well.
4. Chop onion, and fr;v till brown in fat. Add aome of the water
to make a soup. J Ult before serving add the 80ft peu or beau
witb a little salt. Serve with rice or cooked root vegetables. A
good lunch or tea dish for young children.
Not.: Dried peas and beau take a long time to cook. The cooki...
time can be reduced if peas are aoaked in water for half to
one day before boiling.
(b) Fuh
4 011 /lab or about one lmall /Ish (3 tablespoou when chopped

up)
l'A1 tablespoons coconut cream (can be left out)
l'A1 cups water
'AI teaspoon saIt
Metlt.od
1. Clean flab. Remove Besh from boDeB.
2. Cut /lnely with lmife.
3. Cook In water until tender.
'" Strain ftah with Bsh water; if no strainer beat tiJl the mixture
is thiclt and smooth.
5. Add l'A1 tablespoons of coconut cream if available, and a little
saIt.
(c) Peo_t
6 tableepGolUl peanuts
1 tablespoon saIt
3 cup. water
Ifetluxl
1. Remove sheila and then crind nut. by pounding with a stone,
or put through a mlncer.
Z. Boil· ground peanut. in water for ten minutes, add salt.
S. Strain.
(d) MM.t In' U_

'% cup liver or meat
1'% cups water
'% teaspoon salt
"" cup chopped vegetablee
Metluxl
1. Cut up meat very finely.
2. Ad~ salt and water; let stand live minutes.
I. Add vegetab1e8 and simmer ftfteen minutes. Do tlDt boil
(e) SI&eUjWli
6large ahellftsh, or 12 small onel

1 pint water
"" onion (for older children only)
'% teaspoon salt
2-8 tablespoona grated cassava or sweet potato to thicken.
(This can be left out.)
Method
1. Prepare in the usual way and then cook 1111 soft.
Z. Chop up till like minced, using a heavy chopping knife, e.g. cane
knife.
Put back in water, add very finely chopped onions and boil
a few minutes.
The soup may be thickened with grated caasava or sweet potato
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140. Malcom, S.H., S.P.C. techno papers, Noumea:
... ... . .
a. No. 18
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b. No. 23
(1952) New Hebrides
c. No. 60
(1953) New Caledonia
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(1955) American Samoa
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141. Marshall, E.L. (1939) A review of American reaearchon seasonal
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142. Marquez-Sumabat, L.R. Nutrition and dietetics
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148. Merrill, A.L. &: Energy value of foods
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REFERENCES 869
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J. Nutr., 74.413
l45. Millis, J.
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J. PMi4t., 45, 692
c. (1955) The effect of economic background. on body
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J. trop. PMi4t., 1, 156
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in infants in the ftrst year
J. Pedi4t., 48, 770
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pore
M.d. J. Ma14l1a, 12, 416
f. (1958) Growth of preschool Chinese and Southern

Indian children in Singapore
Med. J. Ma14l1a, 18, 531
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1'6. Millie, J. &: Tye, C.Y. The relatioll between birth weight alld weight
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Tra1lB. roy. Soc. trop. M.d. HIIf/., 62, 200
148b. Morley, D.E. Woodland. Controlled trial of pyrimethamine in pregnant

M. &: Cuthbertson, women in an African village
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149. Murai, M.• Pen, F. &: Some tropical South Paciftc Island foods
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150. Murry, S.T. (1957) Home curing of ftsh
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C. No. 370 (1967) Pesticide residuea in food
D. No. 378 (1N'l) SpeeUleationa for the identity and purity of food
additl".. and their toxicological evaluatlon;
lOme emalaifien and stabiliaerB and certain
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283. WHO, Geneva
L (1968) .alnutrition and d i _
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378 THE HEALTH ASPECTS Of FOOD AND NUTRITION
237. WHO. New Delhi

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THE HEALTH ASPECTS

OF FOOD AND NUTRITION

Printed and distributed by the

Second edition, Taiwan. 1972

World Health organization 1972

This Manual enjoys copyright protection in accordance with the

The designations employed and the presentation of the material in this

The mention of specific companies or of certain manufacturers' products

The Western Pacific Regional Office is grateful to the East

Burroughs Wellcome Museum of Medical Science, London l4B

Geographical and agricultural factors .......... 4

II. THE PRINCIP AL FOODS USED IN THE

III. THE PRINCIPAL NUTRITIONAL

V. NUTRITION SURVEYS 128

VII. FOOD HYGIENE AND STANDARDS........... 179

IX. APPLIED NUTRITION AND

I. FOOD COMPOSITION TABLES ................ 206

Introduction .................................. 206

II. NUTRITIONAL REQUIREMENTS ............. 221

General comment. 221

III. SAMPLE SURVEY FORMS .................... 249

General infant feeding and weaning practices .... " 249

IV. SOME ANTHROPOMETRIC INDICATORS

V. MORTALITY DATA IN THE COMPARATIVE

VI. FOOD FOR INFANTS - a sample pamphlet .. , .. , 301

VII. RECIPES .. , .... , ....................... ,.". 309

A. for infants and toddlers . . . . . . . . . . . . . . . . . . . . . 309

VIII. SOUTH PACIFIC ISLAND DIETS.............. 342

3.1 Principal features of protein-calorie deficiency 42

A.2.1 Prediction of N Dp Cal % ................ 232

Plate 1. A malnourished family .................. 43

1. SCOPE OF THE MANUAL

Nutrition is the science of food and the nutrients as related to

nion documents on nutrition in maternal and child health and

2. PLANNING FOR BETl'ER NUTRI'nON

This manual deals mainly with those aspects of nutritional

3. GENERAL FACTORS AFFECTING HUMAN NUTRITION

3.1 Geographical and agricultural factors

Geographical and agricultural factors have an important

3.2 Socio-eeonomic factors

often have to go to school without breakfast, and family meals

foods just mentioned. 1ao•140 Urban people with adequate income

THE PRINCIPAL FOODS USED

important as energy sources. They are particularly rich in B

1. FOODS WlUCH ARE PRIMARILY SOURCES OF ENERGY

low in calcium. Certain high-yielding and high-protein varie-

fant feeding; but because of its fat content. it cannot be stored

PROPORTION OF NUTRIENTS IN LIGHTLY MILLED RICE

~ Un4.r.llled, hom. po.nded or parboiled ric ••

When rice is soaked or steamed before pounding or milling,

Rice is usually washed in the kitchen before it is cooked. This

Maize may be cooked fresh on the cob and eaten as whole

vitamin content. Enriched white flour is however quite widely

This is the staple food in substantial parts of New Guinea and

the very low consumption of protein-rich foods. Daily protein

Probably Colocasia species were the original staple foods in

Yams probably originated in India, and include various spe-

tubers are grown in subcoastal parts of New Guinea and some

In the tropical parts of the Region, this is grown at high alti-

spread nutriti.onal deficiencies - often referred to as beriberi but