PART I. UNDERGRADUATE TEACHING Dr. D. B. Jelliffe
Professor of Paediatrics and Child Health, Makerere Medical School, Kampala, Uganda
SPECIAL
SECTION
EDIToR’s NOTE: The following Ls one of two symposia selected from the XI International Congress for publication in PEDIATRICS. The kind permission of Professor Tadao Takatsu, President of The Congress, is gratefully acknowledged.
XI
INTERNATIONAL
CONGRESS
OF
PEDIATRICS
TOKYO,
NOVEMBER
1965
TEACHING
NUTRITION
IN PEDIATRICS
IN DEVELOPING
COUNTRIES
FOREWORD
T
HE following Group Panel Discussion on “Teaching Nutrition in the Dc-veloping Countries” was presented at the XI International Congress of Pediatrics in Tokyo on tile afternoon of November 12,1965. This session, which was jointly
spon-sored by the International Pediatric Associ-ation (I.P.A.) and by the World Health
Or-ganization (WHO), deals with an extremely important aspect of pediatric responsibility
in all countries, but particularly in the
tecilnically developing” or “pre-industrial” countries, where protein-calorie malnutri-tion forms the basic background of much of the morbidity and mortality which is so
high in the pre-school age group. The ses-sion was well attended and provoked lively
discussion which must be omitted for lack of space. Because of its relevance to pediat-nc education and practice in those parts of
the world where most children are living
and because of the growing interest of the American Academy of Pediatrics in interna-tional child health activities, it seemed worthwhile to submit this Panel Discussion
Relation to Local Nutritional Scene
U
NIVERSAL aspects of nutritional science including biochemistry, physiology and the nutrient requirements of children,for publication ill PriIATmcs, which is read
extensively, not only by pediatricians in the Americas, but is also distributed to the
libraries of leading medical schools through-out the world. The resolution adopted at
the conclusion of the Group Panel Dis-cussion emphasizes the necessity for
con-centrating upon the basic causes of the relatively high mortality among pre-school children in the “developing” coun-tries and the need for relating child health programs to the special needs and
condi-tions of the region, rather than simply copying practices which may only be
rele-vant to child health needs in the technically advanced countries. Unfortunately, Dr. Federico Gomez of Mexico, who has con-tributed so greatly to our knowledge of malnutrition in childhood through his own observations and through the
encourage-ment and stimulation he has given his younger colleagues, was to have served as co-chairman, but was unable to attend tile Congress and was greatly missed.
DR. CHARLES A. JANEWAY, CHAIRMAN
obviously need to be taught. However, the teaching of nutrition to paediatric
under-graduates in medical schools in developing countries must particularly be geared, both
in scope and emphasis, to practical aspects
of the local nutritional scene, that is, to the types of malnutrition occurring, to the size
of the problem, to the always numerous, complex, and inter-locking causative factors,
and, above all, to realistic avenues for prac-tical prevention in the community itself.
Thus, the basic pattern of food produc-tion and consumption must be known, as related to the country as a whole, to its
var-ious regions, and to individual families. This will include some understanding of foods grown and imported, their distribu-tion, cost, seasonal availability, nutritional value, and correlation with rising
popula-tion pressure.
Major attention has to be given to the clinical picture, differential diagnosis,
ae-tiology, treatment, and prevention of local-ly important forms of malnutrition in chil-dren-most usually, therefore, to protein-calorie malnutrition (PCM) of early child-hood. Of especial importance will be local
methods of feeding young children, in-cluding cultural food classifications, breast-feeding practices, culinary methods, and evidence of change due to urbanisation.
The magnitude of PCM as a public
health problem, both as a direct killer and as a background to other disease, will
al-most always be a major theme.
The wide range of factors-many of
which are preventable-which can play a part in causation has to be emphasised. PCM in a community can be related to
ag-ricultural underproduction of protein foods, to poverty, to parental lack of knowledge, to heavy burdens of conditioning infec-tions, to disadvantageous local feeding practices, or to various combinations.
Logi-cal prevention depends on the identification of the most locally signfficant of these, most
likely to be amenable to practicable mea-sures.
Methods
Teaching should make maximal use of all
types of medical and non-medical staff, fa-cilities, and situations that are conveniently available.
MODIFIED CLASSICAL: Such classical meth-ods as lectures, demonstrations, ward
rounds, and guided reading are as impor-tant as techniques for supplying factual
knowledge as anywhere. However, if feasi-ble, others working in the nutritional field
(
including agriculturists, sociologists, and community development workers) shouldparticipate, particularly in group
discus-sions.
For more senior medical students, tutori-al presentations on broad-spectnim,
non-textbook topics requiring reflection and some personal research effort (even if only into the literature) are useful thought
stim-ulators, and often cross-culturally illumi-nating for expatriate teachers. Topics covered by such small-group seminars at Makerere Medical School have included: “Nutritional Ill-Health Education in Hos-pitals,” “Food Ideology among My People,” “Economics of Animal Protein for the
Vil-lage Mother,” “Effects of Advertising in Modern Uganda,” “Convincing Illiterate Parents that Kwashiorkor is Related to Diet,” etc.
SITUATIONAL EDUCATION: Nutrition can
be “taught” by many means, but the
likeli-hood of its being truly “learnt,” rather than merely memorised is enhanced by ensuring that situational education occurs wherever
possible and with direct student involve-ment.
Three situations may be particularly mentioned:
1. Students’ Hostel. In developing re-gions, college students very frequently themselves require practical guidance with regard to their diet. Often culturally condi-tioned to the limited range of foods
cus-tomary in the home village, an important step in teaching practical nutrition is the “auto-education” that can result in the vol-untary widening of the student’s own diet as a consequence of example and experi-mentation.
2. Hospital. Learning situations exist, or
673
foods on sale for mothers in the hospital
shop and the diets served to both children and parents are instances of the teaching of practical nutrition (or can be).
The presence of mothers in the wards
offers valuable opportunities for nutrition education, especially concerning breast-feeding and village-level protein foods, by group discussion and demonstration, in which active student participation must be ensured. Difficulties in making health
edu-cation effective can be shown by subse-quent home visiting and evaluation.
3. Community. Teaching nutrition in the
community context can be carried out in various ways. At Makerere Medical School,
students doing social paediatrics are allo-cated homes and families within the
defined area surrounding the teaching Health Centre. Part of their work is
con-cerned with the clinical and anthropometric nutritional evaluation of children in the
course of home visits and relating this to economic circumstances, kitchen facilities,
cultural attitudes, and the actual and po-tential availability of foods from the
culti-vation plot. Subsequently, students
them-selves plan and initiate a programme of nu-trition education aimed at improving the situation.
When feasible, paediatric students par-ticipate in child health surveys carried out
in different communities to demonstrate
methods of nutritional assessment for use in rural areas and the multiple factors usually
involved in malnutrition.
Lastly, students must be made aware of the range of workers engaged in “nutrition” and their activities, especially in the field of health education. In Kampala, relevant
“outside visits” are arranged, for example, to a Community Development women’s
club in a rural area, to a school feeding pro-gramme (with a garden project), to
experi-mental fishponds, etc.
Su
m maryThe teaching of nutrition of paediatric
relevance will extend throughout the medi-cal curriculum, including biochemistry, physiology, haematology, pathology, and so on. However, most “direct” teaching will be given by the Department of Paediatrics. At
the same time, with the particularly close link between the health of the mother and
child in developing regions, teaching of paediatric relevance, including antenatal or foetal nutrition and the significance of
breast-feeding for survival, will obviously fall in part to colleagues in obstetrics. Like-wise, consideration of the epidemiology of
malnutrition, the development of preven-tive programmes and national policies fall partly within the realm of social medicine. Plainly, liaison, coordination, and combined sessions by these three disciplines are
neces-sary.
The teaching of nutrition for
undergrad-uates in medical schools in developing re-gions must be down-to-earth, practical, and related to local reality, including finance, culture, and food availability. It must be
developed as a living, dynamic subject of great interest, complexity, and importance.
In particular, the immense potential for im-provement by simple-seeming, preventive means needs major stress, especially through effective health education.
The student must be trained not only to
diagnose and treat the individual malnour-ished child, but also to recognize and
ana-lyse community causes and to think in terms of practical preventive programmes carried
out in conjunction with a wide range of workers, many of whom will be from out-side the medical field.
2. Remarks Based on Personal Experience with Medical Students in Latin America
Dr. Joaquin Cravioto
Mexico 7, D.F., Mexico
UNDERGRADUATE TEACHING: DISCUSSION
1. Remarks Based on Personal Experiences with Medical Students in Ceylon
Dr. C. C. de Silva
Colombo, Ceylon
T
HOUCH medical students in Ceylon, because of free education, now come from many poor village homes, they are very ignorant of food habits, especially among infants and young children. They have, therefore, to be made aware primarilyof the pattern of infant and child feeding in this country. They must also be taught at
well-baby and vell-child clinics, through demonstrations and talks, how to change these habits, taking into consideration the
cultural habits and general beliefs and ta-boos prevalent among the people. They must be taught why food habits often
change, quite apart from how to change them.
Home visits are very important in order to teach students that, even at the very low socioeconomic levels, some improvement
T
EACHING of pediatrics in developing countries, or in preindustrial societies, as we prefer to call ourselves, must be based on the recognition of the fact that thebulk of the physician’s practice is made up of sick infants and children, while demands for the preventive aspects of pediatric care are minimal. Furthermore, the vast majority of patients attending the so-called
well-baby clinics are in reality sick children, means of communication are obsolete, time
devoted by medical teams to each child is at a premium, and concepts of health and disease are not more modern than those
that prevailed in villages and towns back in the fifteenth and sixteenth centuries.
Preindustrial countries in Latin America are by no means homogeneous. Two well differentiated groups coexist side by side. One group is constituted by a minority of
may be achieved if the parents know some-thing about the food values of different
items of diet.
in the ward and outpatient department
the students will see the many results of in-adequate and imbalanced feeding. How tise disease could have been avoided must be
stressed more than the cure of the diseases present.
Finally, in every patient in a developing country, whatever the condition he is suffering from, the student must be taught the importance of assessing clinically the
nutritional status of the child. It is only in
tilis way that the student gets oriented to
the fact that, in many of the ills from which our children suffer, malnutrition is a significant factor in deciding the ultimate
prognosis of the disease.
families who possess among themselves al-most all the available land, water,
knowl-edge, “know-how,” transportation, capital, etc. The other group, formed by the majori-ty of the inhabitants, has a structure and functioning which could be described as pre-Newtonian in regard to technology and pre-Pasteurian in regard to prevention and treatment of disease.
The majority of families in the larger group are unable to pay for good medical services either directly or indirectly through taxation. Because of this, the salaries paid
by the government agencies in charge of providing medical care for the underprivi-ledged group seldom amount to more than
PART II. POSTGRADUATE TEACHING
Problems in Postgraduate Teaching of Pediatric Nutrition
Dr. Paul Gy#{246}rgy
Professor of Pediatrics, University of Pennsylvania, Philadelphia General Hospital, Philadelphia, Pennsylvania
Therefore, the minority group, which sel-dom includes more than 25% of the popula-tion, is not only the class responsible for di-recting the country’s policy but is also the main source of the medical profession’s
in-come.
The nutrition curriculum, or more
exact-ly, the pediatric curriculum, must prepare the physician to cope with the needs of
both groups, whose pathology,
unfortunate-ly, is quite different. The wealthier group has a nutritional pathology that does not
differ from that of infants and children liv-ing in highly developed countries, i.e. obe-sity, high consumption of refined foods, congenital defects of absorption or diges-tion, etc. The underpriviledged children
show mainly the pathology which results from the interaction of a heavily
contami-nated environment, a decrease in available food, and a delayed diagnosis.
It is extremely important to familiarize the medical student not only with the fact that undernutrition increases the severity of the complications and sequelae of common disorders (such as, measles, whooping
cough, and diarrhea) but that he must also be aware that when severe malnutrition is present the diagnosis of other pathology is
made more difficult and expensive because the signs and symptoms of various diseases are distorted or absent, e.g., the acute
ab-domen without the classical signs of perito-neal reaction, advanced tuberculosis with-out positive skin tests, hypothermia in
sep-ticemic processes, extensive asymptomatic hronchopneumonia recognized as cause of death only at postmortem, hypo-osmolarity
I
DEVELOPING COUNT1IIES with small num-bers not only of qualified pediatric specialists but also of general physicians and of ancillary health personnel,postgrad-of plasma in dehydration due to diarrhea,
etc.
Physicians in charge of government din-ics are often asked to participate in the
education of the public. Teaching health education is part of their duties. The curric-ulum, therefore, not only should contain
factual information on preventive medicine but also should provide incentives for the development of a positive and “active” atti-tude toward the physicians’ role as educa-tors. Mixed training (both in the lecture hall and in the field) with other
profession-als, particularly agricultural extensionists, nonmedical nutritionists, and school teach-ers, is a very useful step in this direction.
In summary, in our experience tile
curric-ulum of nutrition in pediatrics in Latin America should cover the following points: (1) diagnosis of nutritional status; (2) modifications produced by malnutrition in the pathology of prevalent disorders; (3)
treatment of common nutritional pathology -mainly, protein-calorie malnutrition,
nu-tritional anemia, goiter, and iron and vita-mm A deficiencies; (4) nutrition education, particularly feeding of infants during the first year of life; (5) interrelations between
social structure and function and the de-velopment of malnutrition in infants; (6) diagnosis and management of nutritional
disorders prevalent in highly industrialized societies.
The last point should never be
over-looked if the physician is to be prepared to take proper care of his private practice,
which will provide him with the majority of
ilis income.
676
The collditions in various countries may
1)C different in many aspects of the problem
in question and in consequence there is no ready formula applicable to all developing
countries of the world.
With permissible generalization the fol-lowing overall scheme appears to cover all
essentials.
1. The postgraduate teaching in pediat-nc nutrition for general physicians should be entrusted to well qualified, preferably academic, pediatric specialists of the
coun-try in question. Most countries have such experts, with good training, available for postgraduate training.
2. It appears to be better suited to the conditions of most developing countries, if
tile qualified teachers give their training in the outlying provinces, states, or larger dis-tricts and do not hold their training course
in a central location. Neither the sparse
health workers, M.C.H. physicians, nurses, nor practicing physicians in rural areas or
even in small cities can be easily spared for a 2 to 3 day course far from their local
ac-tivity. It is more satisfying and almost pre-dictably better if lectures are given by the visiting teachers as national consultants in
(
or near) the place where the “students” are working.3.
Such courses, given in various parts of the country by as many “teachers” as are available, should last in one given place for 2 to 3 days. In tile morning (or afternoon) the teachers should discuss the most impor-tant nutritional problems, with special em-phasis on their application in practice.These are: (A) infant nutrition-breast-feeding, supplementary feeding, vitamins, iron and iodine (trace elements), and
flu-tI’ItiOITl and infection; (B) dangers of the post-weaning period-protein-calorie mal-nutrition, diarrhea (and its dietary treat-ment), and hydration and treatment of
se-vere shock; (C) deficiency diseases and their prevention; (D) special attention to the pre-school child-source of protein in the post-weaning period and the pre-school
child age, according to availability in the country or even in the state, province, or
dis-trict; (E) sanitation, as part of good nutri-tion; (F) special infectious and hereditary
diseases with nutritional implications.
In addition to these lectures, 2 half days, and perhaps an additional full day, should
be reserved for “grand-rounds” in the health center and to visits in private homes
with patients having nutritional-dietary problems.
4. Who should teach the leading pediat-nc experts who in turn (as explained above) teach the general physicians, prac-ticing pediatricians, health workers, etc. in the rural areas and smaller towns?
An outside nutritional consultant is re-quired for this purpose. He should teach nutrition, especially recent developments in nutritional research, in the academic cen-ters of the country. One person of high
cal-ibre would suffice. After this high level con-ference, the temporary foreign consultant
should accompany the national expert on one of the regular field trips in order to
evaluate the scheme in use.
5. In countries where no, or only very few, national pediatric specialists who are well versed in modern scientific nutritional trends are active, it becomes necessary to send promising young pediatricians who
are interested in academic careers for in-tensive training in foreign countries. If one or more academic centers in a country lack specialists in pediatric nutrition, but an-other medical school in the same country has such an active expert, the training could take place in the candidate’s own
country at the medical school.
If a foreign institution is to be selected for postgraduate training, it is desirable to select one in a country where similar nutri-tional problems exist as in the country of
origin of the candidate, provided pediatric experts in nutrition are available for train-ing. A second alternative is to send the
trainee to a highly developed country and specifically to an academic pediatric center where pediatric nutrition receives high
priority and where experts with experience in the nutritional problems of developing
train-POSTGRADUATE TEACHING: DISCUSSION
1. Training in Nutrition of Health Workers From Developing Countries
(R#{233}sum#{233}) Dr. J. Senecal
Directeur, #{201}coleNationale de la Sante Publiquc, Rennes, France, Formerly Professor of Pediatrics, Dakar, Senegal
ing. Training in Public Health Nutrition in
Schools of Public Health is no substitute for
training in tIle combination of pediatrics and nutrition.
The training period may vary from six
fliOliths to three years, depending on the ex-perience of the trainee and on his desire to work toward an advanced degree.
One of tile prerequisites for such training
T
LIE curriculum of this training innutri-tiOIl should keep in account three char-acteristics of developing countries: (1) 80% of the population, mainly illiterate, live scattered in small communities; (2) the very high mortality rate among children is due to communicable deseases and malnutrition
(undernutrition and protein deficiency); (3) skilled workers are extremely rare as corn-pared to local needs.
Three types of technicians are required:
1. Physicians (1 for 40,000 inhabitants is the usual average), their role is niainly to organize, manage and supervise a
team-the size of this team is related to the eco-nomic resources of the country; to make re-searches to determine the most important local problems and to find solutions; in nu-trition, to determine the epidemiology of nutritional disorders, to list local products, to increase these resources or to find new products, to educate the population;
espe-cially the mothers. All these activities should be coordinated with those of the members of agricultural or educational ser-vices.
2. Nurses and midwives (1 for 30,000 in-habitants), besides physicians, play a similar
in highly developed countries must be the
assurance that the trainee, after his return to his O\VI1 cOuIltrv, vill receive a satisfacto-ry academic position.
In developing countries, problems of nit-trition will remain in the forefront of medi-cal activity for many years to come. Post-graduate teaching in pediatric nutrition
should be planned accordingly.
role of management and supervision, re-quiring a good public health training.
3. Engineers building new community facilities increase the health level of the population. In these countries, the agricul-tural engineers, in addition to their primary role to increase food production, must have some knowledge of public health problems.
The training of “ing#{233}nieurs des travaux ruraux et des techniques sanitaires” realised in France by both the “minist#{232}res de
l’Agri-culture et de Ia Sante Publique” answers to this purpose.
Such fully qualified personnel are very limited in number and this number cannot
increase so long as basic training (primary school) is poorly developed. The training of auxiliaries is necessary and has been ac-conlplished in several countries.
In the teaching of these personnel, nutri-tion always plays a great part. Very sophis-ticated teaching is valuable for the physi-cian (physiology, nutritional troubles, eco-nomical and psycho-sociological factors,
2.
Teaching of Nutrition to Future Pediatric Specialists in IndiaDr. S. T. Achar
Retired Professor of Pediatrics. Emeritus Medical Scientist, Women’s and Children’s Hospital, Madras 8, India
678
T
EACHINC. of nutrition to pediatric spe-cialist trainees in countries like India is even more important than in tile well de-veloped countries because of the preva-lence of malnutrition and undernutrition in the former. Not only the marasmic andkwashiorkor babies but also most children attending hospitals in India need attention with regard to nutrition, whatever the ill-ness that brings them there. Let me illus-trate. Quite often a child with Fallot’s tetralogy is unfit for surgery until its
nutri-tional status is improved by proper
coun-selling of the mother. Even the child who comes for scabies or ear discharge has to have his diet looked into. Undernutrition due to underfeeding is found in infants and small children among the vell-to-do classes,
though to a lesser extent, because of tradi-tional overdilution of milk formulas,
with-holding of solid food until well past 1 year of age, etc.
In tile training of pediatricians here,
teaching of nutrition will have to be a
con-tinuous process during their whole training in the outpatient departments, during ward rounds, and even during posting of the
trainees to the surgical and other clinics. Didactic lectures on the principles of
nutri-tion are no doubt useful and necessary, but the place of careful diet history taking, diet
surveys, careful clinical assessment of nutri-tional status, and counselling of m9thers
needs to be emphasized in everyday work.
If these aspects are not sufficiently im-pressed upon the trainees by the teachers themselves setting the example, then there is the ever present danger of the pediatric specialist trainees being absorbed in the ac-ademic pursuit of the so-called “interesting
cases” or interest in nutritional aspects being diverted to sophisticated laboratory investi-gations while neglecting other, above men-tioned, clinical and field aspects. Indians
working in India certainly cannot afford to do that.
I would like to outline how I and my staff have been trying to organise a
con-tinuous nutrition training to our trainees keeping the above mentioned objectives in mind.
The first step has been the training of the staff themselves-the professors down to the registrars themselves-to be aware of the nutrition problems in the region. These
vary from area to area in India, as does the investigative work and curative aspects
that have emerged out of these investiga-lions. The teaching staff must also he famil-iar with the infant feeding practices in the
region, including the types of feeding
uten-sils and the good and bad points about these. Such familiarity will come, not mere-ly by reading, but by field work in the broad sense of the term, including study of the family diet. Knowledge of the locally available cheap, protein foods and the cost
aspects of various foods suitable for infants must be studied by the staff if they are to have a realistic approach to this problem. The professor and his staff with the trainees
must and could make periodic visits to the local shops and markets to ascertain the prices of available articles of infant food,
e.g., cheap fish, roasted bengal grain avail-able in most Indian places and costing only
a fifth of animal protein, edible green leaves suitable for infants, etc. They should familiarise themselves with the availability of data on analyses of these foods which are
t’sually obtainable from the Nutrition Re-search Laboratories, India, so as to be able to give a realistic turn to their teaching.
work-3. Problems Facing Those Organising the Teaching of Child Health in a
Developed Environment
Dr. 0. H. Wolff
Professor of Child Health, Institute of Child Health, Great Orinond St., London, England
ing in a neighbouring place, even though the talks and demonstrations were on
mat-ters like latrines, flies, etc.
As regards the trainees, I feel they are what we teachers shape them to be. If
they are not at present taking sufficient in-terest in all the above mentioned aspects of
nutrition but seem to be more intrigued by paper electrophoresis or complex biochemi-cal studies, it is partly because their major attention is on passing the final examination wilich invariably hardly assesses or gives enough credit for the candidates’ familiarity with aspects of nutrition referred to above. \Ve teachers who are also examiners can
contribute to a change in this aspect of the existing system of examination by breaking away from old traditions. Even more, we teachers can organise counselling of
moth-ers of children admitted in the wards as is
I
T IS my assignment to talk about some of the problems that face those of us who work in a developed country and whosere-sponsibility it is to organise a teaching pro-gramme in child health for doctors coming from the developing countries and who
plan ultimately to return to their own coun-try. I hope you will agree that some of the questions I am asking are important; whether you agree with my partial answers is, I believe, less important.
The first problem is : do the developed
countries have anything of importance to
offer to these doctors? You will expect me to answer tiliS question in the affirmative
because as a professor of a postgraduate
institute of child health, many of whose stu-dents come from the developing countries, I might otherwise find myself without a livelihood! You must then forgive me for a
little special pleading.
All would agree that he who plans to
practice in a developing country should
re-being attempted in some places in India like Madras. The staff are encouraged to
talk to mothers individually and in groups on infant feeding (in relation to the particu-lar infant), disposal of excreta, etc.
How-ever, the interest shown by the trainees in such practical demonstrations depends on
the activity of the senior staff themselves in this regard. It is true that the latter, unfor-tunately, are overburdened with other
rou-tine duties, but a way must be found to allot time for this also.
Lastly, periodic visits and/or short re-fresher courses in the Nutrition Research Laboratories, Hyderabad, with an excellent
and practical nutrition teaching museum are well worthwhile and could form part of
the training programme of all pediatricians in India, or at least some of the staff could imbibe this and pass it on to others.
ceive much of his training in that country. But the teaching of child health and nutri-tion is not only the concern of the medical man; the educationist, the anthropologist,
the economist, the statistician, yes, and even the politician, have important con-tributions to make. Among doctors many
specialists are involved; to mention just a few, the clinician, the expert in growth and development, the expert in nutrition,
medi-cal administration, the workers in the field of public health and preventive medicine, the microbiologist, haematologist, biochem-ist, and so on. Only a few medical schools
and universities in the developing countries are at present in a financial position to
de-sign a teaching programme in child health and nutrition with the participation of all, or even the majority, of such experts. The more lavishly endowed and staffed medical
schools of the developed countries should have less difficulty, particularly if good
680
faculties in the university. It is of course es-sential for several members of the teaching
staff to have first hand knowledge of the developing countries.
The second question is: which doctors should spend a period of postgraduate
study in a developed country because finance will only be available for a small
minority? My answer would be: those who intend to return to their country as teachers of paediatrics and child health should be
given priority. It is essential for them to have a good command of the language spoken in the country where they plan to spend a period of postgraduate study.
The third problem is: at what stage in their postgraduate career should this study period take place? I suggest that it should be delayed for at least 2 to 3 years after
qualification. so that the doctor will have become acquainted at close quarters with the local problems in his country and will
have gained sufficient niaturity and in-dependence of thought to enable him to
look critically at Western practices in the field of child health. He will then not be tempted to import into his country some of our less desirable Practices-to mention just one, tile tendency to keep the preventive and curative services separate-nor some of the practices which may be harmless in a
developed country but are disastrous in a developing country, such as the omission of
breast-feeding or its early termination. The fourth problem concerns the content of tile course. I suggest that, though in the main this must be of direct relevance to the developing countries, we should also give these students some insight into the activi-ties-clinical, teaching, and research-that are going OIl ill the teaching hospital. Otherwise they viil be disappointed and
will feel themselves excluded from inter-esting activities. It would be unfortunate if in our minds paediatrics were divided into the paediatrics of the developed countries
and that of the developing countries. The basic principles of child health are the same all over the world and can be exposed by
the gifted teacher in many different ways.
Whatever is decided the content of the cur-riculum should be, it is essential that before
leaving his country the student should know what to expect, so that he will not he
disappointed.
The fifth problem concerns the personal involvement of the student in the course. It
may be difficult to give much clinical re-sponsibility to him, but it might be possible to arrange for him to participate in a re-search project. Ideally the project should
have direct relevance to the problems of the developing countries, such as, a growth and development study. However, there are
certain prerequisites for any kind of re-search (such as, planning the project, ac-curate measurement, and recording of data) which can be learned equally well from a
)r0ject not quite so directly related. It is essential that he takes an active part in the teaching programme; to make such
partici-pation practical, small informal discussion groups are preferable to formal lectures. In such groups postgraduates from various
de-veloping countries can also discuss with each other the problems facing their
different communities.
The sixth and last of tile problems I want to mention concerns the conditions under which niany of these students have to live when they come to a so-called “developed” country. For many this will be their first experience of life in a developed country and understandably they may feel insecure
and lonely in a strange city. Often there is difficulty in finding pleasant accommoda-tion at a reasonable price near the medical
school. There is an urgent need for residen-tial accommodation close to the hospital
where not only the student but also his
family can live. In such a college or hostel attached to the school, friendships will quickly spring up not only between the stu-dents but also equally important between students and staff of the hospital. At the
same time, the students will see much more of the day-to-day work of the hospital.
Finally, I should like to acknowledge
681
4. Problems Facing Visiting Teachers from a Highly Developed Country
Dr. Bo Vahlquist
Professor of Pediatrics, University of Uppsala, Sweden
M
personal experience emanates en-tirely from Ethiopia and the Ethio-Swedish Children’s Nutrition Unit, a gov-ernmental project in the field of healthwilich started in 1962. More detailed infor-mation about this Unit is found in one of
the exhibits.
The Children’s Nutrition Unit cooperated in 1963 and 1965 in the “Advanced Graduate Courses in Maternal and Child Health”
sponsored by the Swedish Authority for In-ternational Development (SIDA). These
courses with 11 to 15 members have spent
4 to 5 weeks of their time in Africa, pre-dominantly Ethiopia, and the following 5 to
8 weeks in Sweden. Nutrition teaching has comprised 20 to 30 hours of lectures and
demonstrations.
I should like to comment on the prob-lems facing visiting teachers as follows:
1. Nutrition embraces a very wide field-from anthropology to clinical medicine.
More than many other disciplines it needs intimate cooperation between different professional groups and different
organiza-tions.
2. There is an urgent need for reliable background data from representative popu-lation groups. Too many reports and publi-cations on the nutritional situation in de-veloping countries are misleading because of unreliable analyses and/or errors in
sam-pling.
3. In many countries there is a lack of reliable data with respect to food
composi-tion. Only recently has more concerted work on African food tables been started.
4. In many areas of the world
protein-calorie malnutrition among pre-school chil-dren is extremely prevalent. Nevertheless, the doctors are much more concerned \Vitil
other types of diseases, e.g., the
comniuni-cable ones. This has to do with the fact that
undergraduate medical teaching up to re-cently has given comparatively little inter-est to nutrition.
5. The full importance of the interaction between nutrition and infection is only
slowly becoming realized.
6. It takes some time before doctors from highly developed countries manage to switch home-land nutrition interests,
usual-ly dealing with effects from overnutrition of one kind or another, to the interests of the developing country with malnutrition in
various forms as an almost regular feature in pre-school years.
7. A key problem is to work out pro-grams where an often very limited budget gives a maximum response with respect to health. Rarely will there be much place for sophisticated methods of approach.
8. It is not always easy to convince the ministries that malnutrition, although not contagious in the usual sense of the word,
can be as much a threat to the health of the nation as many communicable diseases.
9. The training of teachers on all levels is
of paramount importance. The right use of mass communication media for nutrition education needs much consideration.
10. It is urgent that an international or-ganization like WHO in tile future gives
continuously more emphasis to nutrition, especially the problems related to
5. The Role of WHO in Improving Education in Nutrition for Pediatricians Dr. W. Winnicka
Chief Medical Officer, Maternal and Child Health, World Health Organization,
Geneva, Switzerland
T
HE most serious and widespread nutri-tionai diseases in developing countries occur in children below the age of 4. The important role played by paediatricians,particularly during the last 20 years, in the identification of different forms of malnutri-tion in young children, as well as in their treatment and prevention, justifies WHO’s
continued support of training paediatricians in nutrition.
This is the more important as
undergrad-uate paediatric courses in many medical schools still give insufficient instruction in diseases of malnutrition and their social
and public health significance. Nor is nutri-tion given due consideration in the teaching of such basic disciplines as physiology and
biochemistry.
Past and present WHO post-graduate training activities for paediatricians in flu-trition fall into five categories: (1) ad hoc
training seminars, (2) annual training courses, (3) nutrition training centres for medical and health personnel, (4) fellow-ship programme, and (5) publications.
AD Hoc T&ic SEMINARS: At an early date, WHO recognized the need to train various categories of health workers in nu-trition and organized, usually in coopera-tion with FAO, a number of ad hoc training seminars in the different regions.
The first seminar was held in Cairo (UAR) in 1950; two others were held in Marseilles in 1952 and 1955. The most
re-cent seminar was held in Bangkok in 1964. These seminars followed a similar pattern, dealing with some basic aspects of the phys-iology and biochemistry of nutrition while
concentrating mainly on those aspects of applied nutrition in developing countries relating to food production; dietary,
clini-cal, and anthropometric surveys; deficiency diseases; organization of health, agricultur-al, and educational services; training professional and auxiliary personnel; and
health and nutrition education of the pub-lic. Appropriate emphasis was given to the
paediatric aspects of malnutrition. These seminars lasted 6 to 12 weeks and were usually attended by physicians, including
paediatricians, and, in a few cases, nurses. Home economists, agricultural extensionists
and community development workers with university training were also admitted.
In view of the great importance of mal-nutrition due to protein-calorie deficiency in young children, two seminars were
devot-ed specifically to this subject: the
South-East Asian Inter-country Symposium on Protein Malnutrition in Children was held at the Nutrition Research Laboratories in Hyderabad, India, January 29 to 31, 1963; the Seminar on Protein-Calorie Malnutrition of Early Childhood was held at Makerere Medical School in Kampala, Uganda, Sep-tember 7 to 18, 1964, and was attended by representatives of more than 15 African states.
The participants in these training semi-nars were mostly paediatricians and
teach-ers of paediatrics at high technical and ad-ministrative levels, working in their
coun-tries on the problem of malnutrition in early childhood. In general the topics dis-cussed during such seminars are: physiolog-ical considerations, including nutritional requirements; nutrition during pregnancy and lactation; clinical aspects of malnutri-tion in young children; epidemiology; and treatment and prevention.
It is expected that additional seminars following the same pattern will be
orga-nized in other parts of the world.
These regional seminars, in addition to teaching and exchange of experience, have
as a main purpose stimulating interest in the countries of the region. They should be
683
health personnel in general, will gain a
practical approach to childhood nutrition problems.
Following the regional seminar in Kam-pala, Uganda, in 1964, a national seminar was held in Tanzania in 1965 with WHO
assistance.
The ad hoc training seminars performed
an important service when there were prac-tically no permanent training facilities available.
ANNUAL TRAINING CouiisEs: In 1963 this situation began to change. In cooperation with FAO and with the help of UNICEF,
the first annual training course was estab-lished jointly with the School of Hygiene and Tropical Medicine in London and the
University of Ibadan College of Medicine, Nigeria. With 4 months of basic training in London and another 4 months of applied nutrition in Ibadan, the student receives
broad training in nutrition as applied to conditions in developing countries. This should enable the student returning to his
country to participate in national food and nutrition programmes and activities. About
25 participants, of whom 50% or more are physicians, attend this course each year.
Five months of additional training were
recently added to this programme, award-ing the candidate a Diploma in Nutrition
on the successful completion of the London
University examination.
A similar annual training course for doc-tors, including paediatricians and medical
MCII workers from French speaking coun-tries, was organized in 1964 jointly by the Government of France, FAO, WHO, and UNICEF in cooperation with the
Univer-sity of Paris and the University of Dakar, Senegal. This course in applied nutrition lasts 11 months and includes training in Paris and Dakar and an additional 3 months of personal, supervised, field work
with a WHO or FAO nutrition project. All candidates completing this course
success-fully are awarded a diploma. A maximum of 20 participants, half of them physicians,
are admitted to the programme each year. The WHO/UNICEF assisted 12-month,
advanced training course at the Institute of
Child Health in London is directed to pro-spective university teachers and potential leaders in paediatrics and child health from developing countries where instruction is in English. Six fellows are trained each year.
The part of the course devoted to nutrition includes the study of the scientific basis of adequate nutrition, planning nutrition
sur-veys, practical application of nutrition to local and national feeding programmes, etc.
Nutrition is also one of the postgraduate subjects taught at the International Chil-dren’s Centre in Paris, which works in close
association with WHO and UNICEF. Special courses on nutritional problems have been organized by the ICC in several countries. Nutritional problems are part of the curriculum of international and regional courses of social paediatrics and public health applied to childhood. They are also
discussed in national meetings of health workers. This programme is directed
main-ly towards trained paediatricians or public health officers responsible for MCH ser-vices and for the training of personnel.
One of the problems which concerns
WHO is the situation of nutrition training in schools of public health.
As there are very few schools of public health in the developing countries, a con-siderable percentage of physicians must go abroad to study public health. However, in some schools of public health in the
techni-cally advanced countries, nutrition is not a compulsory subject. It is taught either casu-ally in other disciplines or only to those
stu-dents who have a special interest in nutri-tion. In view of the importance of nutrition
in public health work, WHO considers that nutrition ought to become part of the regu-lar curriculum everywhere.
NUTRITIONAL TRAINING CENTRES FOR
MEDICAL AND PUBLIC HEALTH GRADUATES:
In addition to the training carried out pen-odically in different pants of the world,
Ill
gwn
.lfrica The_4inericas
Eastern
Med iter- Europe
South East
ranean
1’2() 26 67 33
- 45 46 48
12() 71 113 81
Total
337
2O7
‘544
‘l’ABLE I
NuSIBF:tt OF F;ii,ovsitips A\VARDEI) ic NuTIuTIoN BY REGR)NS 1947 TO 1963
Fellowships for training 7 F’ellowsliips for attell(hILg
setuiiiars
I’otiils 98
JJesterrL
Pacific
19
42
61
health graduates extensive field experience with conditions that prevail throughout the
developing countries.
The Institute of Nutrition of Central
America and Panama (INCAP) was the first institution in a developing country to onga-nize a permanent training course lasting 12
weeks with emphasis on the public health and paediatric aspects of malnutrition.
During the past 10 years INCAP has trained over 300 medical MCH workers,
paediatnicians, and public health adminis-tnators who came from all the Latin Amen-can countries, as well as from Africa and Asia.
An Annual Training Course in Nutrition, organized under the auspices of WHO, has been held twice at the Nutrition Research Labonatories in Hyderabad, India. Sixteen
students were enrolled in the 1963-64
course and 15 students attended the
1964-65 course. The course lasts 3 months. The objective is to train medical officers
engaged either in: (1) clinical work and training, i.e., teaching preventive and so-cial medicine, paediatrics, obstetrics, and
general medicine in medical colleges, or (2) public health work, associated particularly
with the administration of public health, nutrition, and maternal and child health programmes.
The participants in the Hyderabad
nutri-tion course are drawn from different South-East Asian countries and from various In-dian states. During the last 2 years the countries represented were: Afghanistan,
Burma, Ceylon, India, and Thailand. In addition, mention must be made of
the course organized in Brazil. It is held in the Department of Physiology and Nutni-tion, Faculty of Medicine, of the University of Recife. Emphasizing child nutrition, it is
directed to physicians and paediatricians working in the North-East of Brazil.
An-other nutrition course, mainly for public health administrators and MCH workers, is held at the School of Public Health in S#{227}o
Paulo.
FELLOWSHIP PROGRAMME: WHO has
given a high priority to the fellowship pro-gramme. This programme includes travel grants, training grants, bursanies, or
schol-arships. The length of the programme var-ics; sometimes a fellowship is granted for attendance at a specific short seminar orga-nized by WHO, and frequently it is given
for more extensive postgraduate training. In the field of nutrition, 544 fellowships were provided by WHO between 1947 and
1963. Of this total, 337 were fellowships for short-term and long-term training, and 207 were to attend short seminars. Table I gives the figures by regions.
Not all the regions have the same facili-ties for postgraduate training in nutrition. Until recently, few centres were available for specific postgraduate training. The re-cent development of additional training centres in the United States, Guatemala
(INCAP), England (London), France (Paris), India (Hyderabad), among others, have increased these facilities considerably.
PUBLICATIONS : There are few books about nutrition in infants and young chil-dren adapted to tropical conditions, yet
both undergraduate and postgraduate
train-ing programmes.
In 1955 WHO published a monograph called Infant Nutrition in the Tropics and Subtropics by Dr. Jelliffe. This book has been widely used and a completely revised edition will be published in 1966.
In a cooperative venture, WHO, FAO, and UNICEF are sponsoring the
publica-tion of a series of books on nutrition for
Af-rica. One of these books, written by Dr. La-tham for health workers, stresses the prob-lem of malnutrition in young children. It will be available in 1966 for distribution in
Africa.
Another book of a similar nature is being prepared by Dr. Wadsworth, with
assis-tance from WHO and UNICEF, in tile Western Pacific Region.
SUMMARY: The discussion may be sum-niarized as follows:
1. The WHO postgraduate training pro-gramme in nutrition has expanded
consid-erably in the last 4 or 5 years with the es-tablishment of permanent training centres.
2. WHO believes that postgraduate train-ing programiries in nutrition for
paediatri-cians and medical MCH workers are an
essential feature in the preparation of these workers for one of their main tasks, the
control of malnutrition in young children. This training should be given in existing training centres, organized at the regional level. Such training centres already exist in
the Americas, Europe, and Asia. Additional efforts should be made to organize similar
training centres in other regions of the world.
3. Ad hoc regional training seminars
de-voted to tile main nutritional problems in young children have proved to be of great value for paediatricians and medical MCH workers. More seminars should be
orga-nized along the same lines.
4. As nutrition is not regularly taught to undergraduate medical students, this gap in their knowledge must be filled at the ad-vanced level. WTHO considers that the
study of nutrition should be compulsory for all public health students.
5. In order to satisfy the increasing
de-nland for vorkers trained in nutrition, \VHO intends to expand its fellowship pro-gramme and lend more support to
postgrad-uate training, particularly in nutrition and
paediatrics.
6. WHO recommends that national semi-nars be organized in the developing coun-tries to follow up the regional seminars as-sisted by WHO and FAO.
6. Role of a Field Station in Nutrition Education
Dr. Mois#{233}sB#{233}har
Director, Instituto de Nutricion de Centro America y Panama (INCAP), Guatamala
T
HE importance of nutrition in healthand disease has been recognized since the beginning of medicine, but the science
of nutrition is relatively new and is not yet properly incorporated into medical train-ing. For obvious reasons, pediatrics has been the area of medicine where nutrition has received greater attention, and, indeed,
some of the important contributions in human nutrition have been made by pedia-tricians. Also, many of the specialists in
nu-trition have had their original training as pediatricians.
Even in pediatrics, however, nutrition
has been clinically oriented and directed to the individual either for the purpose of maintenance of good health and the
assur-ance of adequate growth and development, or else, for the treatment of diseases
direct-ly or indirectly related to nutrition. There is no question, however, that at the present time nutritional disorders are recognized among the most, if not the most, important problems in public health, with impact at
se but we are also considering the serious public health problems related to overnutri-tion or imbalanced diets. This should be
kept in mind, and, although we are going to limit this discussion to conditions in
de-veloping areas where the problems are mainly of undernutrition, most of what will be said could well apply to the training of
pediatricians for work in the more de-veloped areas where nutritional problems,
mainly related to overnutrition, are also of great public health significance.
The first point that I would like to em-phasize in relation to the teaching of nutri-tion in postgraduate training in pediatrics is that nutritional disorders are much more important as public health problems than
they are as clinical problems. The teaching approach, therefore, should be an epidemi-ological approach. This implies that in this sense it is not possible to provide adequate training in nutrition to pediatricians when the training takes place in large part, or
ex-elusively, in hospital wards. The study of children in hospitals, even in outpatient de-partments, does not provide enough
infor-mation and experience to understand the etiology of the disease, and such knowledge is fundamental for adequate treatment and
complete rehabilitation. This type of train-ing, of course, provides even less experi-ence for understanding the epidemiology of nutritional defects and what should be done for their prevention.
The second need that I would like to em-phasize in the teaching of nutrition in post-graduate training in pediatrics in the de-veloping countries relates to the recognition that basic knowledge in nutrition must be adapted to the conditions in these areas,
which differ in characteristics of fundamen-tal importance to the application of basic
principles from those encountered in tile more advanced countries. A few examples should illustrate the point. Let us first con-sider the problems related to the availabili-ty of foods. The nutritional requirements of children can often be satisfied by making the best possible use of foods which are
available in the tropical regions. Frequently
such foods are not readily available in the temperate zones, and, hence, are not con-sidered in the usual dietary practices rec-ommended in pediatric training in the
de-veioped areas. As a result, we often see
pediatricians trained in well qualified cen-ters trying to follow the recommendations
they have learned in regard to the diet of children living in temperate zones, without considering the availability of foods in the tropical environment in which they are working. The use of fresh papaya, pineap-pie, guava, or other tropical fruit juices
in-stead of the classical orange juice as an early source of vitamin C can be mentioned
as one practical example illustrating this situation.
The conditions of the physical environ-ment in which the pediatrician is working
also may he different from those in which he was trained, and he often fails, or is slow, in adapting the basic principles he
has learned to this new environment. A classical example of this situation is
illus-trated by the routine use of vitamin D sup-plement in infants and young children
liv-ing in areas where the amount of sunshine available the year round does not justify
this measure.
Of even greater importance is the lack of recognition of fundamental differences in the cultural patterns of different popula-tions. This can lead a pediatrician to con-sider the beliefs and practices of a given population as plain ignorance simply be-cause they are different from the practices and beliefs to which he was exposed in his own culture and during his training. As a
result, he will find it extremely difficult, if not impossible, to “educate” the mothers because of the lack of proper communica-tion. For instance, recommending the intro-duction of a food in the baby’s diet on the basis of beneficial effects will be useless in a population of Mayan culture where foods are classified in a negativistic way into those which are considered harmful (always or under certain circumstances) and those which are not harmful. In this culture, the
SPECIAL SECTION
will render beneficial effects, does not exist,
and, therefore, the basis for recommending the food is not accepted. Dietary practices and beliefs, as most other cultural
charac-teristics, are usually based on sound reasons within the culture. Therefore, efforts to in-troduce modifications will have a better
chance of success when this is taken into consideration, and cultural peculiarities are not simply discarded as being the result of
“taboos,” “prejudices,” or “ignorance.” Similar considerations, in terms of cultural
differences, also apply to the concepts of health and disease and are, of course, perti-nent for the study of the etiology of disease and may be crucial for the establishment of proper treatment and preventive measures. The understanding and knowledge of perti-nent cultural concepts can be of great help
to a pediatrician, or any other physician for that matter, trying to apply the principles
of modern medicine in the developing areas of the world.
Both the cultural pattern and the
condi-tions of the environment in the developing areas may also make less adaptable, or even inapplicable, practices which are common in highly developed areas. The use of bottle
feeding, for instance, is very dangerous in populations with poor sanitary conditions, among whom the concepts of asepsis, con-tamination, and infection do yet not exist.
Finally, it is extremely important that pediatricians going to work in developing areas receive adequate orientation to the
economic aspects of child nutrition. Too often, recommendations learned in training with regard to the feeding of children are
economically impractical in the developing areas. Therefore, pediatricians practicing in
these areas may not emphasize their recom-mendations, knowing that they cannot be followed. Again, the basic problem is one of
failure in adapting basic knowledge to local conditions, applying instead procedures
which were developed for a completely different environment.
Thus far, I have mentioned examples of
the experiences which cannot be properly given to pediatricians when the training is
given in hospitals, even when located in
de-veloping areas. To be of value in training, a field unit must provide opportunities for
direct contact of the trainee with local con-ditions, affording him first hand experience with at least some of the important epide-miological factors of malnutrition. Field ex-perience should present a different set of
circumstances to which basic nutrition prin-ciples are to be adapted to emphasize in the process that such adaptations may be
necessary in any environment or cultural group; the experience should also provide the fundamental knowledge essential for
the adaptation process. This experience should be of great value not only to pedia-tricians who are going to work in public health programs or in teaching but also to
those who will work in hospitals or will es-tablish a private practice.
In our experience, the field unit should not be an isolated one devoted exclusively to nutrition programs but a complete health
unit in which the nutrition activities are in-corporated as a regular part of the overall health program of the center. It should be
properly staffed for this training, not only with medical and paramedical personnel
trained in public health but also with expe-rienced professionals in the social sciences. Although the latter professionals usually
cannot be part of a health agency team, they should be available for orientation of the trainees and for supervision and discus-sion of their experiences. The coordination
of the work of the health agency, serving as a training field unit, with the programs of other agencies working with the human
resources in the community for the general well-being of the population is another valuable experience for the trainees. This is
true particularly, as so often happens in nu-trition, when the work of other agencies in
the agricultural, educational, economical, and other related fields is of fundamental importance to complement the mission of the health agency. The pediatrician can then better understand his responsibilities
Resolution Presented by Dr. Gy#{246}rgyand Adopted by Panel and Audience
at Conclusion of the Session
which he is an integral part, who are vitally interested in improving the general condi-tions of the community.
The field unit should be very closely con-nected with a center, institute, or university
department where specialists, equipment, and other facilities are available for more profound studies in the clinical, metabolic, biochemical, pathological, epidemiological, and social aspects of the problems prevail-ing in the area.
This is important, not only to provide a better training and to complement, when needed, the experiences and knowledge
ac-quired directly at the field unit, but also to demonstrate that nutrition is a highly scien-tific and interesting discipline which can be challenging to the best minds. This should attract into the field the most brilliant, am-bitious students, who at present are tempted by specialization which may have greater prestige with the profession and the
general public.
Another opportunity provided by a field
unit to its trainees, and difficult to obtain
otherwise, is the study of children consid-ered “normal” in the community, that is, those who are not obviously ill. Knowledge of the characteristics of these children, their behaviour, their pattern of growth and de-velopment, and their general physical con-dition is indispensable for better
under-standing and interpretation of pathological conditions, and, in particular, for
recom-mending adequate measures for the
pre-Whereas it is generally accepted that the pre-school child represents the most vulnerable age class in the world, especially in the technically developing countries of the tropicai belt;
Whereas it is well established that the mortality
of the pre-school age class in some countries is many times higher than in well developed coun-tries;
Whereas there is general agreement that
malnu-trition and undernutrition are one of the
de-termining causes of this high mortality, and past
vention of disease or for rehabilitation. To clarify this last statement, I would like to
mention just one more example. In areas where the growth of children is markedly retarded during late infancy and early
childhood because of malnutrition, the size of school children is usually below that which is considered normal, although at
this age they may not have any serious nu-tritional deficiencies and may, in fact, be growing at adequate rates. Under such
con-ditions, supplementary feeding programs for school children may produce results
which are going to be deceptive and, cer-tainly, difficult to understand.
To summarize, I would like to quote the definition of nutrition given by the Council of Food and Nutrition of the American Medical Association : “Nutrition is the science of food, the nutrients, and other substances therein, their action, interaction,
and balance in relation to health and dis-ease, and the processes by which the
orga-IIi5ITI ingests, digests, absorbs, transports,
utilizes and excretes food substances. In
ad-dition, nutrition must be concerned with certain social, economic, cultural and psychological implications of food and eat-ing.” In closing, and in accord with the
con-cepts and philosophy of the definition just quoted, I would like to emphasize that it is precisely for providing experiences related to the second part of the definition of nutri-tion science that a field unit can be of great
value in pediatric training.
efforts have produced few significant results to
date;
Be it resolved that:
1. All promising approaches be made to the protection of the pre-school child on a world wide basis.
2. National and international agencies (WHO, FAO, UNICEF, UNESCO, World Food Program,
etc.) be strongly requested to put special
