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Promoting mother and child nutrition in the Arab Gulf
Promoting mother and child nutrition in the Arab Gulf A. 0. Musaiger
The recent rapid growth in the wealth of Arab Gulf states is well known. What is less well appreciated is that the nutritional well-being of their populations has not improved accordingly. Mothers and children are especially vulnerable to malnutrition; problems associated with nutritional deficiency and with obesity are both common. The author discusses some of the causes before outlining a battery of measures within and outside the health sector which he argues are urgently needed. Above all, he says, mothers should be the main focus of nutritional interventions. Dr Abdulrahman 0. Musaiger is Head of the Nutrition Unit, Public Health Directorate, Ministry of Health, PO Box 42, Manama, Bahrain.
‘A. 0. Musaiger, ‘The state of food and nutrition in the Arabian Gulf countries’, World Review of Nutrition and Dietetics, Vol 54, pp 105-l 73
‘/bid. 3N. Eid, S. Al-Hooti, N. Bourisly, M. Khalafawi, A. Elimam, and M. Al-Gayer, Nutritional Status in Kuwait. 7. Nutritional Assessment of School Children, Kuwait Institute of Scientific Research, Kuwait, 1984, p 19. 4A. 0. Musaiger, W. B. Gregory and J. D. Hass, ‘Growth patterns of school children in Bahrain’, Annals of Human Biology, Vol 16, 1989, pp 155-167. 5Musaiger, op tit, Ref 1.
8
The Arab Gulf states have experienced rapid social and economic changes during the past 30 years, resulting in great changes in lifestyle and nutritional status. Two kinds of nutritional problems have been observed: undernutrition such as growth retardation and iron deficiency anaemia, and overnutrition such as obesity and its complications. Mothers and children are the groups most vulnerable to malnutrition. Studies in the Gulf have shown that iron deficiency anaemia is highly prevalent among mothers, the prevalence ranging from 31% to 54%.’ On the other hand, obesity, heart disease and diabetes are also problems of concern among mothers. For example the prevalence of obesity among adult females was about 40% in both Bahrain and Kuwait.’ Teenage obesity was also noticed by Eid et al, who found that 44% of girls aged 14-17 years were obese (based on weight for height).” Breastfeeding has declined steeply in this region, and more mothers have started to introduce commercial baby foods at a very early stage in the infant’s life. It has been found that a high percentage of mothers (3&60%) in the region prepare baby feeds wrongly and unhygenicaily. This will of course affect the nutritional status of young children. Gastroenteritis is still the main health problem in preschool children in the Gulf.
Growth retardation and iron deficiency anaemia are major nutritional problems in children. Severe cases of growth retardation are very rare. It has been reported that growth rates of pre-school children in the Gulf are close to the international standards (NCHS) in the first 69 months of their life, but fall drastically thereafter. In general the height and weight of schoolchildren in the region fall between the 25th and 5th percentiles of the NCHS standard.” The prevalence of iron deficiency anaemia among pre-school children ranged from 29.9% to 67%, while among schoolchildren it ranged from 12.6% to 46.2% .’ Dental caries is now becoming a crucial problem in schoolchildren. The prevalence of dental caries exceed 50% in many Gulf states. Several initiatives have been undertaken to improve and promote the health and nutritional status of mothers and children in the Gulf, but such activities are scattered and not organized. Additionally the integration of these activities with the nonhealth sector is weak, leading to inadequate preventative measures. The aims of this Viewpoint are to highlight the main nutrition activities related to mothers and children in the Arab Gulf states, the obstacles being encountered and some measures that could be taken to promote nutrition among these vulnerable groups.
FOOD POLICY
February
1990
Nutrition programmes In general there are few specific programmes for promoting the nutrition of mothers and children in the Gulf. Nutrition services are mostly linked with other health services that are provided in health centres and hospitals. These services can be summarized as follows: Growth monitoring. Increasing interest has been focused on use of the growth chart to measure the nutritional status of children. Growth charts are used in almost all health centres in the region, but no evaluation of the effectiveness of using such charts has been carried out. It would be hard to say that growth monitoring in the region’s health centres has helped in identifying the nutritional status of children, for various reasons. Firstly, the purpose of growth monitoring is not clear to many health workers. Secondly, the reliability and accuracy of the weight and height measures are in many cases questionable, due either to poor training of health workers or to the insensitive instruments used. Thirdly, health workers find it difficult to assess the nutritional status of children from growth charts, mostly because they have not been trained in how to use and interpret them. Fourthly, whether mothers visit mother-and-child health (MCH) clinics depend mainly on the health of their children, so many mothers may not come for several months, making assessment of the nutritional status of their children very difficult. Fifthly, there is a lack of awareness among both mothers and staff of the importance of using growth charts. Finally, the separation of growth monitoring from other health services leads to difficulties in promoting child health. Promotion of breastfeeding. Efforts to promote breastfeeding have been in progress since 1981, when the Gulf countries were shocked by the findings of international agencies such as Unicef and the World Health Organization (WHO) that breastfeeding had steeply declined and that the nutritional status of the region’s children had not matched its economic progress. Several steps were taken thereafter to promote breastfeeding in the
FOOD POLICY
February
1990
region, including banning advertising of infant formula on television and in the press, introducing an entitlement to maternity leave with full pay for not less than 45 days, allotting one hour each day for lactating mothers to breastfeed their children at home, issuing regulations concerning the distribution of free infant formula in health centres, the adoption by some countries of the WHO Code on the Marketing of Human Milk Substitutes, and putting emphasis on the advantages of breastfeeding in health edcuation programmes. Vitamin and iron supplements. General check-ups, weight and haemoglobin measurement are usually carried out on pregnant mothers visiting health centres or MCH clinics. If the Hb level of a mother is low or her health poor, she is given vitamin and iron tablets, especially in the second and third trimesters. One of the main obstacles to this service is the widespread belief that taking these tablets will increase the size of the baby and thus lead to a difficult delivery. Increasing the awareness of mothers about the importance of vitamin and iron supplements would be highly desirable. Nutrition education. All the Gulf countries are conducting educational programmes on nutrition for pregnant and lactating mothers, promoting breastfeeding and explaining weaning foods. The main tools used are booklets, posters and radio broadcasts. Television programmes are rarely used due to lack of people specialized in TV communication. Each year these countries spend hundreds of thousands of dollars on the preparation and production of nutrition and health educational materials to improve the health awareness of the public. However, such materials often fail to convey the intended message or achieve the desired change in beliefs and attitudes. This is because little attention has been given to sound pretesting of these materials at community level. The absence of a clear policy governing nutrition and health education programmes could be a major reason for this failure. For example, great emphasis had been
9
placed on the production of booklets and posters, but how many mothers can read these materials? Given that illiteracy rates among adult females range from 30% to 60% in these countries and an additional 30% of mothers are poorly educated, it is easy to conclude that very few will read the educational materials and these women will generally not be in the main target group (poor and illiterate mothers).
(4)
Obstacles Nutritional activities in the Gulf countries face many obstacles:
(1)
The absence of a nutrition department in some Gulf countries: Oman, Qatar and the UAE have no nutrition unit in the preventative health sector, and this can directly affect the planning and implementing of nutrition programmes. (2) The low priority accorded to nutrition activities: In none of the Arab Gulf countries is nutrition a real priority. Maternal and child nutrition are neglected in most health programmes. Even within maternal and child health services few efforts are devoted to improving the nutritional status of the mother and child. This is due to a misunderstanding of the role of nutrition in promoting the mother’s and child’s health. Health and related sectors pay greater attention to food quality control. Building sophisticated food laboratories and focusing on expanding and training manpower in the food control section account for the bulk of the effort dedicated to food and nutritional activities. (3) The lack of training in nutrition: Most health staff, especially community health workers, lack appropriate training in nutrition. This can be attributed to a deficiency in the curriculum of the region’s health and medical schools. Nutrition is rarely offered as an idependent subject in health colleges, and even then it is mostly basic. There is no information on nutritional prob-
10
(5)
(6)
lems in the local community and measures to solve them. The curriculum depends mainly on information from other developing countries which in many cases is not relevant to the situation in the Gulf. Poor support from international organizations: Although nutrition is one of the main concepts in primary health care, international organizations have rarely given support to nutritional activities in the Gulf, especially during the period 1981-88 when there was an urgent need for nutrition intervention programmes. Training in various fields of health has been conducted over the past 20 years through the international organizations, but nutrition training has been neglected. The idea that the Gulf countries are rich and therefore do not need nutrition programmes is commonly held among local and international authorities, and this may be the main reason for the insufficiency of nutrition activities in the past. The isolation of nutrition activities: There is a lack of understanding of the vital link between nutrition and other health services such as immunization, control of diarrhoeal and infectious diseases and MCH facilities. This has isolated nutrition activities from health intervention programmes. Nutrition-related activities in the region have concentrated on education and research, but there has been no real work on a community basis. The lack of manpower: Of all the areas of health in the region, the nutrition services have suffered from the most acute shortage of manpower. Nutritionists in the Gulf, whether nationals or nonnationals, are very few and far between.
Promotional measures Mothers should be the main focus of any nutritional intervention since without improving the nutritional and health status of mothers, efforts to promote the nutrition of infants and
FOOD POLICY
February
1990
young children will be less effective. The following measures should be taken into consideration in connection with any food and nutrition programme. Measures in the health sector
0
0
0
0
0
0
FOOD POLICY
February 1990
Integration of nutrition with other health promotion programmes such as MCH, diarrhoeal disease control and expanding immunization. Initiating a nutrition department in the health sector of countries lacking such a department, notably Oman, Qatar and the UAE. Identifying teenage girls who need special nutrition care, for which purpose routine screening of all girls aged between 10 and 16 should be conducted. Anthropometric measures such as height and weight can be used to detect nutritional deficiency in these girls. Since female school enrolment in the Gulf is very high, primary and intermediate schools are the most appropriate places to conduct this screening. Nutrition and health education programmes should contain more information on the nutrition of adolescent girls, pregnant and lactating mothers. Lessons on how to manage breastfeeding and on preparing balanced weaning foods are equally important in educational programmes. Stress should be placed on traditional food beliefs and how to correct them. A suitable selection of educational tools is vital in order to ensure that the message is effective and reaches the target groups. In these terms television is the best medium for nutrition education in the Gulf. Expanding MCH services to include more nutrition activities such as stool examination for detecting parasites among children, weight, height and haemoglobin screening for young mothers and monitoring the weight gain of pregnant mothers. Expanding the promotion of breastfeeding by ceasing to distri-
bute infant formula in health centres and hospitals, stopping the separation of the infant from its mother after delivery and giving it formula, applying the Code on the Marketing of Human Milk Substitutes to those countries which have not yet applied it, extending the allocated hour for breastfeeding to 6 months instead of 4 months, and controlling infant formula promotion in private clinics. Monitoring haemoglobin levels during pregnancy to control the iron deficiency anaemia. If the haemoglobin falls below l&11 g/dl, iron tablets should be given in addition to advice on eating more food which is rich in iron and enhances iron absorption. Encouraging the spacing of pregnancies in order to prevent the depletion of maternal nutrient stores. This can be done by encouraging breastfeeding for as long as possible. The recommendation in the Koran that a mother should breastfeed her child for the first two years of life should be used in health education to encourage the spacing of pregnancies, as well as advice on the appropriate use of contraceptives. Providing mothers in health centres and hospitals with more information on the sound preparation of weaning foods as well as infant formula (if it is necessary). Adequately training health workers in the nutritional management of children and pregnant and lactating mothers. Health workers have been found to be one of the major sources of nutrition information for mothers, especially illiterate mothers. However, these workers are in general ill prepared to advise mothers on sound nutrition. In-service training courses should be provided continuously, with more emphasis on the training of community workers (nurses and social workers). Giving high priority in health promotion programmes to the
11
0
0
control of obesity and other related diseases such as hypertension and diabetes. The prevalence of these diseases is alarming, and urgent preventative measures should be taken as early as possible. Emphasizing oral hygiene programmes in schools and health centres. Establishing a preventative and curate programme for schoolchildren should be given more attention. Legislation to introduce fluoridation of tap and bottled water should be considered in conjunction with any oral health programme. Carrying out epidemiological surveys to assess the magnitude and factors associated with nutritional problems. The lack of reliable data relating to the nutritional status of mothers and children may be one of the main reasons for not giving nutrition priority in health programmes.
Measures 0
12
in the non-health
sectors
Improving school feeding programmes. Canteens in schools do not usually provide nutritious foods for the children. Carbonated beverages, chocolates, sweets, potato crisps and corn puffs are the main foods sold in schools. Action to improve the nutritional quality of the food offered to children is urgently needed, especially in primary and intermediate schools.
l
l
l
Introducing nutrition as a subject in the curriculum of health and medical colleges. as well as in schools. The information introduced should be related to nutritional problems in the local community, and should take into account the social and cultural factors affecting food intake. Promoting female literacy. It is well documented that educated mothers are more likely to consume nutritious foods and provide better nutritional care for their children. Therefore measures to reduce the illiteracy rate among adult females should be supported and encouraged. Introducing iron fortification of food. Fortification of food with iron is one of the most effective and cheapest ways of reducing the incidence of iron deficiency anaemia in the Gulf. Fortified food should be consumed by the vast majority of the community. Wheat flour is the best foodstuff for iron fortification in the region. Wheat is usually imported (except in Saudi Arabia), but milling processes are carried out locally. Additionally the majority of bakeries purchase their flour from the same sources, as wheat flour is subsidized and distributed by governmental bodies in all the Gulf countries. There is thus a good opportunity to introduce the fortification process into the mills.
FOOD POLICY
February
1990
The recent rapid growth in the wealth of Arab Gulf states is well known. What is less well appreciated is that the nutritional well-being of their populations has not improved accordingly. Mothers and children are especially vulnerable to malnutrition; problems associated with nutritional deficiency and with obesity are both common. The author discusses some of the causes before outlining a battery of measures within and outside the health sector which he argues are urgently needed. Above all, he says, mothers should be the main focus of nutritional interventions. Dr Abdulrahman 0. Musaiger is Head of the Nutrition Unit, Public Health Directorate, Ministry of Health, PO Box 42, Manama, Bahrain.
‘A. 0. Musaiger, ‘The state of food and nutrition in the Arabian Gulf countries’, World Review of Nutrition and Dietetics, Vol 54, pp 105-l 73
‘/bid. 3N. Eid, S. Al-Hooti, N. Bourisly, M. Khalafawi, A. Elimam, and M. Al-Gayer, Nutritional Status in Kuwait. 7. Nutritional Assessment of School Children, Kuwait Institute of Scientific Research, Kuwait, 1984, p 19. 4A. 0. Musaiger, W. B. Gregory and J. D. Hass, ‘Growth patterns of school children in Bahrain’, Annals of Human Biology, Vol 16, 1989, pp 155-167. 5Musaiger, op tit, Ref 1.
8
The Arab Gulf states have experienced rapid social and economic changes during the past 30 years, resulting in great changes in lifestyle and nutritional status. Two kinds of nutritional problems have been observed: undernutrition such as growth retardation and iron deficiency anaemia, and overnutrition such as obesity and its complications. Mothers and children are the groups most vulnerable to malnutrition. Studies in the Gulf have shown that iron deficiency anaemia is highly prevalent among mothers, the prevalence ranging from 31% to 54%.’ On the other hand, obesity, heart disease and diabetes are also problems of concern among mothers. For example the prevalence of obesity among adult females was about 40% in both Bahrain and Kuwait.’ Teenage obesity was also noticed by Eid et al, who found that 44% of girls aged 14-17 years were obese (based on weight for height).” Breastfeeding has declined steeply in this region, and more mothers have started to introduce commercial baby foods at a very early stage in the infant’s life. It has been found that a high percentage of mothers (3&60%) in the region prepare baby feeds wrongly and unhygenicaily. This will of course affect the nutritional status of young children. Gastroenteritis is still the main health problem in preschool children in the Gulf.
Growth retardation and iron deficiency anaemia are major nutritional problems in children. Severe cases of growth retardation are very rare. It has been reported that growth rates of pre-school children in the Gulf are close to the international standards (NCHS) in the first 69 months of their life, but fall drastically thereafter. In general the height and weight of schoolchildren in the region fall between the 25th and 5th percentiles of the NCHS standard.” The prevalence of iron deficiency anaemia among pre-school children ranged from 29.9% to 67%, while among schoolchildren it ranged from 12.6% to 46.2% .’ Dental caries is now becoming a crucial problem in schoolchildren. The prevalence of dental caries exceed 50% in many Gulf states. Several initiatives have been undertaken to improve and promote the health and nutritional status of mothers and children in the Gulf, but such activities are scattered and not organized. Additionally the integration of these activities with the nonhealth sector is weak, leading to inadequate preventative measures. The aims of this Viewpoint are to highlight the main nutrition activities related to mothers and children in the Arab Gulf states, the obstacles being encountered and some measures that could be taken to promote nutrition among these vulnerable groups.
FOOD POLICY
February
1990
Nutrition programmes In general there are few specific programmes for promoting the nutrition of mothers and children in the Gulf. Nutrition services are mostly linked with other health services that are provided in health centres and hospitals. These services can be summarized as follows: Growth monitoring. Increasing interest has been focused on use of the growth chart to measure the nutritional status of children. Growth charts are used in almost all health centres in the region, but no evaluation of the effectiveness of using such charts has been carried out. It would be hard to say that growth monitoring in the region’s health centres has helped in identifying the nutritional status of children, for various reasons. Firstly, the purpose of growth monitoring is not clear to many health workers. Secondly, the reliability and accuracy of the weight and height measures are in many cases questionable, due either to poor training of health workers or to the insensitive instruments used. Thirdly, health workers find it difficult to assess the nutritional status of children from growth charts, mostly because they have not been trained in how to use and interpret them. Fourthly, whether mothers visit mother-and-child health (MCH) clinics depend mainly on the health of their children, so many mothers may not come for several months, making assessment of the nutritional status of their children very difficult. Fifthly, there is a lack of awareness among both mothers and staff of the importance of using growth charts. Finally, the separation of growth monitoring from other health services leads to difficulties in promoting child health. Promotion of breastfeeding. Efforts to promote breastfeeding have been in progress since 1981, when the Gulf countries were shocked by the findings of international agencies such as Unicef and the World Health Organization (WHO) that breastfeeding had steeply declined and that the nutritional status of the region’s children had not matched its economic progress. Several steps were taken thereafter to promote breastfeeding in the
FOOD POLICY
February
1990
region, including banning advertising of infant formula on television and in the press, introducing an entitlement to maternity leave with full pay for not less than 45 days, allotting one hour each day for lactating mothers to breastfeed their children at home, issuing regulations concerning the distribution of free infant formula in health centres, the adoption by some countries of the WHO Code on the Marketing of Human Milk Substitutes, and putting emphasis on the advantages of breastfeeding in health edcuation programmes. Vitamin and iron supplements. General check-ups, weight and haemoglobin measurement are usually carried out on pregnant mothers visiting health centres or MCH clinics. If the Hb level of a mother is low or her health poor, she is given vitamin and iron tablets, especially in the second and third trimesters. One of the main obstacles to this service is the widespread belief that taking these tablets will increase the size of the baby and thus lead to a difficult delivery. Increasing the awareness of mothers about the importance of vitamin and iron supplements would be highly desirable. Nutrition education. All the Gulf countries are conducting educational programmes on nutrition for pregnant and lactating mothers, promoting breastfeeding and explaining weaning foods. The main tools used are booklets, posters and radio broadcasts. Television programmes are rarely used due to lack of people specialized in TV communication. Each year these countries spend hundreds of thousands of dollars on the preparation and production of nutrition and health educational materials to improve the health awareness of the public. However, such materials often fail to convey the intended message or achieve the desired change in beliefs and attitudes. This is because little attention has been given to sound pretesting of these materials at community level. The absence of a clear policy governing nutrition and health education programmes could be a major reason for this failure. For example, great emphasis had been
9
placed on the production of booklets and posters, but how many mothers can read these materials? Given that illiteracy rates among adult females range from 30% to 60% in these countries and an additional 30% of mothers are poorly educated, it is easy to conclude that very few will read the educational materials and these women will generally not be in the main target group (poor and illiterate mothers).
(4)
Obstacles Nutritional activities in the Gulf countries face many obstacles:
(1)
The absence of a nutrition department in some Gulf countries: Oman, Qatar and the UAE have no nutrition unit in the preventative health sector, and this can directly affect the planning and implementing of nutrition programmes. (2) The low priority accorded to nutrition activities: In none of the Arab Gulf countries is nutrition a real priority. Maternal and child nutrition are neglected in most health programmes. Even within maternal and child health services few efforts are devoted to improving the nutritional status of the mother and child. This is due to a misunderstanding of the role of nutrition in promoting the mother’s and child’s health. Health and related sectors pay greater attention to food quality control. Building sophisticated food laboratories and focusing on expanding and training manpower in the food control section account for the bulk of the effort dedicated to food and nutritional activities. (3) The lack of training in nutrition: Most health staff, especially community health workers, lack appropriate training in nutrition. This can be attributed to a deficiency in the curriculum of the region’s health and medical schools. Nutrition is rarely offered as an idependent subject in health colleges, and even then it is mostly basic. There is no information on nutritional prob-
10
(5)
(6)
lems in the local community and measures to solve them. The curriculum depends mainly on information from other developing countries which in many cases is not relevant to the situation in the Gulf. Poor support from international organizations: Although nutrition is one of the main concepts in primary health care, international organizations have rarely given support to nutritional activities in the Gulf, especially during the period 1981-88 when there was an urgent need for nutrition intervention programmes. Training in various fields of health has been conducted over the past 20 years through the international organizations, but nutrition training has been neglected. The idea that the Gulf countries are rich and therefore do not need nutrition programmes is commonly held among local and international authorities, and this may be the main reason for the insufficiency of nutrition activities in the past. The isolation of nutrition activities: There is a lack of understanding of the vital link between nutrition and other health services such as immunization, control of diarrhoeal and infectious diseases and MCH facilities. This has isolated nutrition activities from health intervention programmes. Nutrition-related activities in the region have concentrated on education and research, but there has been no real work on a community basis. The lack of manpower: Of all the areas of health in the region, the nutrition services have suffered from the most acute shortage of manpower. Nutritionists in the Gulf, whether nationals or nonnationals, are very few and far between.
Promotional measures Mothers should be the main focus of any nutritional intervention since without improving the nutritional and health status of mothers, efforts to promote the nutrition of infants and
FOOD POLICY
February
1990
young children will be less effective. The following measures should be taken into consideration in connection with any food and nutrition programme. Measures in the health sector
0
0
0
0
0
0
FOOD POLICY
February 1990
Integration of nutrition with other health promotion programmes such as MCH, diarrhoeal disease control and expanding immunization. Initiating a nutrition department in the health sector of countries lacking such a department, notably Oman, Qatar and the UAE. Identifying teenage girls who need special nutrition care, for which purpose routine screening of all girls aged between 10 and 16 should be conducted. Anthropometric measures such as height and weight can be used to detect nutritional deficiency in these girls. Since female school enrolment in the Gulf is very high, primary and intermediate schools are the most appropriate places to conduct this screening. Nutrition and health education programmes should contain more information on the nutrition of adolescent girls, pregnant and lactating mothers. Lessons on how to manage breastfeeding and on preparing balanced weaning foods are equally important in educational programmes. Stress should be placed on traditional food beliefs and how to correct them. A suitable selection of educational tools is vital in order to ensure that the message is effective and reaches the target groups. In these terms television is the best medium for nutrition education in the Gulf. Expanding MCH services to include more nutrition activities such as stool examination for detecting parasites among children, weight, height and haemoglobin screening for young mothers and monitoring the weight gain of pregnant mothers. Expanding the promotion of breastfeeding by ceasing to distri-
bute infant formula in health centres and hospitals, stopping the separation of the infant from its mother after delivery and giving it formula, applying the Code on the Marketing of Human Milk Substitutes to those countries which have not yet applied it, extending the allocated hour for breastfeeding to 6 months instead of 4 months, and controlling infant formula promotion in private clinics. Monitoring haemoglobin levels during pregnancy to control the iron deficiency anaemia. If the haemoglobin falls below l&11 g/dl, iron tablets should be given in addition to advice on eating more food which is rich in iron and enhances iron absorption. Encouraging the spacing of pregnancies in order to prevent the depletion of maternal nutrient stores. This can be done by encouraging breastfeeding for as long as possible. The recommendation in the Koran that a mother should breastfeed her child for the first two years of life should be used in health education to encourage the spacing of pregnancies, as well as advice on the appropriate use of contraceptives. Providing mothers in health centres and hospitals with more information on the sound preparation of weaning foods as well as infant formula (if it is necessary). Adequately training health workers in the nutritional management of children and pregnant and lactating mothers. Health workers have been found to be one of the major sources of nutrition information for mothers, especially illiterate mothers. However, these workers are in general ill prepared to advise mothers on sound nutrition. In-service training courses should be provided continuously, with more emphasis on the training of community workers (nurses and social workers). Giving high priority in health promotion programmes to the
11
0
0
control of obesity and other related diseases such as hypertension and diabetes. The prevalence of these diseases is alarming, and urgent preventative measures should be taken as early as possible. Emphasizing oral hygiene programmes in schools and health centres. Establishing a preventative and curate programme for schoolchildren should be given more attention. Legislation to introduce fluoridation of tap and bottled water should be considered in conjunction with any oral health programme. Carrying out epidemiological surveys to assess the magnitude and factors associated with nutritional problems. The lack of reliable data relating to the nutritional status of mothers and children may be one of the main reasons for not giving nutrition priority in health programmes.
Measures 0
12
in the non-health
sectors
Improving school feeding programmes. Canteens in schools do not usually provide nutritious foods for the children. Carbonated beverages, chocolates, sweets, potato crisps and corn puffs are the main foods sold in schools. Action to improve the nutritional quality of the food offered to children is urgently needed, especially in primary and intermediate schools.
l
l
l
Introducing nutrition as a subject in the curriculum of health and medical colleges. as well as in schools. The information introduced should be related to nutritional problems in the local community, and should take into account the social and cultural factors affecting food intake. Promoting female literacy. It is well documented that educated mothers are more likely to consume nutritious foods and provide better nutritional care for their children. Therefore measures to reduce the illiteracy rate among adult females should be supported and encouraged. Introducing iron fortification of food. Fortification of food with iron is one of the most effective and cheapest ways of reducing the incidence of iron deficiency anaemia in the Gulf. Fortified food should be consumed by the vast majority of the community. Wheat flour is the best foodstuff for iron fortification in the region. Wheat is usually imported (except in Saudi Arabia), but milling processes are carried out locally. Additionally the majority of bakeries purchase their flour from the same sources, as wheat flour is subsidized and distributed by governmental bodies in all the Gulf countries. There is thus a good opportunity to introduce the fortification process into the mills.
FOOD POLICY
February
1990