What influences malnutrition?

WHAT INFLUENCES MALNUTRITION? Sally K. Livingston Influences pertaining to overnutrition, undernutrition and hunger and education must be considered in planning and/ or implementing nutrition education and other programs to improve the nutritional status of our citizens.

Many fact,ors must be assessed for a complete understanding of the causes of malnutrition and as a basis for future planning. It is difficult to discuss each cause separately because overlapping is great and interrelationships strong. It also is difficult to discuss malnutrition, especially undernutrition and hunger, without recognizing that there is a very strong social component involved. Food habits are formed by both objective and subjective factors (1). The objective factors include physical, biological, and technological influences. Physical availability of food is influenced by food production, food preservation, food preparation, and material influences. The subjective factors in forming food habits include cultural, social, and psychological influences. In this nation, we have two major problems: one caused by overnutrition (overeating), and one caused by undernutrition and hunger (lack of food). Both types of malnutrition affect all levels of our society. Each individual's nutritional status results from a combination of factors. This review discusses overnutrition, undernutrition and hunger, education, and influences pertinent to each.

Overnutrition During the last decade, various forms of overnutrition have been studied and analyzed in great detail. Obesity is one example. Important factors that contribute to a st,ate of obesity in an individual are: physiological influences, family influences, socioeconomic influences, physical activity influences, and psychological influences. These factors have been discussed in detail in many other articles and publications. Food is a physiologic necessity, but it is more than that. It has social, emotionTHE AUTHOR formerly was Nutritionist, National Dairy Council, 111 N. Canal St., Chicago, Ill. 60606, and now is Nutritionist, Special Pregnancy Program, Kaiser Permanente Clinic, 2200 O'Farrell St., San Francisco, Calif. 94115.

This article is prepared from a section of the paper Malnutrition in the United States-A Review written for the National Dairy Council, (September 1970) which supported publication of this article. 18

I JOURNAL OF NUTRITION EDUCATION

aI, and cultural significance. It has symbolic meanings. This is part of the complex human element in food practices. In a preventive program for weight control, it is as essential to examine learning, feeling, motivation, remembering, and thinking as it is to study nutrients, their functions, sources, and energy balance (2). To achieve this, one must look at the food practices of people throughout the life cycle but with emphasis on childhood and adolescence. The foundation for what the child knows, learns, feels, remembers, and thinks is laid very early. Therefore, comprehensive study of food and children can be helpful as a preliminary to understanding how people acquire their feelings and reactions toward food-a point extremely important in weight control.

just one manifestation of a more general problem: income inadequacy. I~ is compelling and dramatic to focus on hunger because its effects are visible and because the thought of hungry Americans is intolerable to the bulk of Americans in a society capable of producing food in quantity, quality, and variety greater than ever before seen on this earth. This social component has taken nutrition from the realm of the scientific and placed it with political and emotional issues. For this reason, many facts, opinions, and views conflict on the causes, influences, and solutions of hunger and undernutrition in our country. Some of these conflicting views are reflected in this discussion to present a broad scope of the problem.

Undernutrition and Hunger

Meaning of Food. The things we eat are, first, necessary and influential in survival and well-being (4). Second, food has many symbolic meanings to each individual. Within each cultural system, man is taught what foods are proper, and positive emotional feelings-particularly taste-become associated with them (5). The individual has negative feelings when exposed to what he considers "improper" foods and positive feelings for "proper" foods. The Maslow theory of human maturation classifies all human needs into physiological needs (survival needs) and

The very strong social component that has evolved around hunger since it has become a national concern sometimes makes it difficult to discuss unemotionally the causes and influences contributing to hunger and undernutrition. Nutrition involves food-its nutrient value and physiological function. It also involves people and human needs. At The Whit,e House Conference on Food, Nutrition and Health, one section of the panel on Food Delivery and Distribution as a System (3) stated: The problem of hunger and malnutrition is

Sociocultural Influences

FIGURE I

self-realization esteem or status belongingness security survival -

social need social need social need physiologic and social need physiologic need

See Lowenberg, M. et aI., FOOD AND MAN, p. 105. SUMMER, 1971

social needs, that is belongingness and love needs, esteem needs, and self-actualization needs (6). The idea behind this theory of human motivation is that a minimum satisfaction of a need is necessary before the person can move t,o seek satisfaction of the next need in the hierarchy (see Figure 1). At the survival level, food is on the "now" basis; interest in self is the most fundamental survival need of all. In applying this theory to the use of food, only when a person has the "proper" food, as he sees it, to satisfy hunger can he be interested in any other meaning for food. Only then can he be interested in storing of food so that future meals are assured. As the economic situation of the individual improves, he may move upward in the satisfaction of his food needs. The symbolic meanings of food are likely to be charged with emotions and, to a considerable extent, not amendable -even voluntarily-to the intellectual knowledge or goals of the person concerned (4). Eating, sleeping, and demonstrating love and affection are some of the areas of life where the professional meets head-on the irrationality and the complexity of symbolic elaborations on physiologic patterns. Moore (4) st,ates if we comprehend some of the symbolic meanings of food, we can make strides in devising ways of influencing food habits toward more beneficial nutrition. Cultural and Ethnic Influences. Culture enters the food experience shaping, emphasizing, even choosing the significant factors for defining that experience (7). The influences on food selection may be direct or indirect, representing a value that pervades all areas of living. Because food consumption patterns are one of the many aspects of culture, forces within the environment which produce cultural changes usually respond to changes in food practices. A cultural factor of great importance is expressed in the symbolic aspects of food and its value to the individual over and above satiation or nutrition (7). Food and eating are looked upon as symbolizing interpersonal acceptance, friendliness, sociability, or warmth (4). This symbolization begins after birth when eating is a matter between two peoplethe feeding adult (mother) and the eating infant. For the infant, eating means warmth, love, security, and affection as well as relief from hunger. Feeding is not only secure and warm in its emotional meaning to the one who accepts, but SUMMER, 1971

he IS most likely to see the giver as somehow glossed with the meaning of "mother." Bettelheim (8) points out that how one is being fed and how one eats have a larger impact on the personality than any other human experience. Eating and being fed are the most basic interactions between human beings on which rest all later evaluations of ourself, of t,he world, and of our relationship to it. Therefore, Bettelheim (8) concludes, anything that rubs it in that we are not given food in the right way and with the right emotions causes questions on the deepest level of our views of ourselves and of those who give us food. Lee (7) states that culture may present food mainly as a means of stilling of hunger or getting nutrition, or as a way to psychosomatic health. It may regard eating as a duty or a virtue, as a gustatory pleasure, or as a social or religious communion. Cultural and group influences determine not only what foods are eat,en, but they also determine the meal patterns, the number of meals in a day, the methods of preparation, and the utensils used. Changes in the way people live today are reflected in their eating habits. Many families eat few meals together. There is

Socioeconomic conditions can be influences for good nutritional status, as for this child, or contribute to hunger and malnutrition.

an increasing number of meals eaten away from the home, either in a family unit or as individual members. These changes contribute to a de-emphasis on homemaking and food preparation. They also encourage an increasing number of family members to make their own food choices and at an early age. Food habits vary from one cultural group to another because each group, in its own evolution, sets up a complex pattern of standardized behaviors (6). Individuals within a culture respond to the approved behavioral pressures by selecting, consuming, and using those foods that are available. It is true, therefore, that the food habits of a group are the product of the group's present environment and past history. In attempting to change or improve the food habits of an individual or group, it is necessary for the nut.rition educator to understand the symbolic aspects of food to the individual over and above its nutritional value as well as the past and present food habits of his cultural or ethnic group.

Socioeconomic Influences Economic deprivation, social position, and health and nutritional status are interwoven. The vicious circle (see Figure 2) illustrat,es the close relationship between health, economics, and social progress and how poverty engenders disease which in turn engenders more poverty. Poverty is the lack of money for life's necessities as seen by society and the individual. Hunger is a symptom of poverty. It is part of the vicious circle. Hunger has its roots in poor education, poor employment, poor housing, racism, poor health, and unequal access to community services, legal services, and public information (9). Poverty exists in all regions of our country: on the farm, in the mountains and valleys of Appalachia, and in the urban ghettos. Hunger U.S.A. (10) estimated that 10 million or more Americans suffer from hunger and malnutrition. Kupchik (11) states almost 20% of all Americans-more than the entire population of Canada-live in abject. poverty and despair. There are many conflicting estimates of the number of malnourished; accurate figures are difficult to obtain. Poverty is not limited to a specific ethnic or cultural group. Although 40% of the black people in this country live in poverty as compared with 12% of the white population, Lowe (12) estimates that a total ef 21 million white people JOURNAL OF NUTRITION EDUCATION

I 19

and only 10 million black people live at or below the poverty level. Thus, he states, the problem is more a white problem than a black problem. Statistics on the number of American Indians, Mexican-Americans, and other cultural or ethnic groups that live in poverty are difficult to establish. In a discussion of the socioeconomic influences of hunger and malnutrition, Ireland (13) points out that it is important to examine the life styles of lowincome families to better understand their reactions; their life conditions limit their outlook on life. These conditions consist of four general limitations: comparative simplification of the experience world; powerlessness; deprivation; insecurity. These limitations are, of course, relative. The poor, of all strata in society, have the least opportunity to experience varieties of social and cultural settings (13). Their own setting is one of the least intricacy and flexibility. Throughout life they experience a very narrow range of situations and demands. The position of the poor in relation to society and its inst.itutions is important ( 13). The poor have practically no bargaining power in the working world. Unskilled and uneducated, they are the most easily replaced workers. The poor man is close t.o helpless even to acquire information and training to change his job situation. He has neither knowledge nor the means to get it.

It is reasonable to suspect that the general condition of deprivation, almost universally associated with poverty, is felt with particular intensity in American society (13). Deprivation is, after all, relative. When it is defined as the lack of resources relative to felt wants and needs, it. is evident that America has one of the greatest gaps between generally accepted goals and the extent to which the low-income group can realistically expect to attain them. As a nation, we stress, perhaps inordinately, the values and virtues of high attainment (13). The richness of life in the rest of society plus the awareness that some people have actually succeeded in the strenuous upward move, makes the condition of the unachieving poor one of the unremitting deprivation. Their relative deprivation is, perhaps, the condition which more than anything else affects the life-view of the poor. People with low-incomes are more at the mercy of life's unpredictability than are the more affluent (13). Sickness, injury, loss of work, and legal problems -a range of hazardous possibilitiesmay overwhelm anyone. To the poor man, they are especially fearful; his resources are more sparse. Constant, fruitless struggle with these conditions is likely to produce estrangement-from society, from other individuals, even from oneself (13). The wholeness of life which most of us experience-the conjunction of values,

FIGURE 2 Lack of Energy

('",IiO.

~

Low Earning Capacity

Frequent

\

THE Disease

\

VICIOUS CIRCLE

Poor Housing and Squalor

Ignorance or Lack of Education

See Lowenberg, M. et aI., FOOD AND MAN, p. 195. 20 I JOURNAL OF NUTRITION EDUCATION

Poverty

)

/

Inadequate Food and Poor Nutrition

knowledge, and behavior which gives life unity and meaning-is less often felt by the poor. They see life as unpatterned and unpredictable, a series of events in which they have no part and over which they have no control. Conceptualized as "alienation," this view of life is repeatedly found associated with lower social and economic status (13). It is multifaceted; despair can be generated and felt in many ways. Generally, however, it seems to have four forms of expression (13): Powerlessness. The objective condition of helplessness in relation to the larger social order leads naturally to the conviction that one cannot control it. The poor are widely convinced that individuals cannot influence the workings of society. Furthermore, they doubt the possibility of being able to influence their own lives. Meaninglessness. The alien conditions in which an individual may be caught up tend to be unintelligible. He does not grasp the structure of the world in which he lives, cannot understand his place in it, and never knows what to expect from it. Oriented, by need, to the present, he is relatively insensitive to sequences in time. Anomia. The term "anomie" was originally coined to describe situations in which social standards have been broken down, or have no influence upon behavior. It has subsequently been pointed out that this normless condition is a probable result of failure of prescribed behavior to lead one to expected goals. The life view of individuals caught in such a discrepant situation is likely to be cynical, perhaps fatalistic. The situation, moreover, induces people to believe in luck. The poor are in no position to comprehend the whole of society's structure and operation, or to understand its dysfunctions. Isolation. More than any other segment of society, the lowest economic stratum is socially isolated. The poor man not only fails to comprehend society or his community, he is out of touch with it. Experiencing separation from society and each other, it is natural for them to feel alone and detached. Feeling no identity, even with each other, they view the world as indifferent and distant: "No one is going to care much what happens to you when you get right down to it." It is impossible to consider poverty and health (and nutrition) without examining the whole of contemporary America because we cannot isolate pov. SUMMER, 1971

erty or health from their interlocking places in the fabric of our society (14). Hunger and poverty are aggravated by indifferent citizens and bureaucratic procedures, by prejudice against "poor" people and minority groups, by red tape, by unreasonable regulations and by discrimination, states Gilstrap (9). Opinions differ on the influences that create poverty and hunger. The life views of low-income people themselves may influence continuation of the vicious circle. Ireland (13) states that there are four distinctive themes peculiar to lower class behavior, all apparently the result of a deprived, alienated condition: fatalism, orientation to the present, authoritarianism, and concreteness. Attitudes toward the poor such as "Why can't they work for it as I did?" and the effect of middleclass values on society may also influence continuation of the poverty cycle (I5).

The demographic profile of poverty in the United States today is indicative of its heterogeniety. The poor among the Blacks, the American Indians, the Mexican-Americans, the aged, the disabled or the unskilled are not poor for the same reason. However, there may be some common factors in their conditions, such as low-income or dependence on assistance (14) . For instance, some aged are retired professional people who are poor because of fixed retirement income. The poor are no longer invisible (16). They constitute a revolutionary force in American society. Their condition is inextricably woven with other than economic issues such as civil rights, civil dissent, and the morality of the war. The poor are no longer isolated. They have allies among the affluent. The U.S. Riot Commission (11) reports that we are now moving toward two societies, one black, one whiteseparate and unequal. Segregation and poverty have created in the racial ghetto a destructive environment totally unknown to most Americans. It (11) continues: Black in-migration and white exodus have produced the massive and growing concentrations of impoverished Negroes in our major cities, creating a growing crisis of deteriorating facilities and services and unmet human needs. It is increasingly clear that Americans will either have to abolish the slums, or the slums will destroy the very fabric of our society. The effect of poverty and racism have combined to produce an appalling mortality and morbidity gap between white SUMMER, 1971

and nonwhite Americans (14) . Many surveys have shown that poor health care and unsanitary conditions in the ghetto result in higher mortality rates and higher incidence of major diseases but with lower availability and utilization of health services (II). Infant mortality for nonwhites is almost three times as high as for whites. Inadequate medical care is one facet of the victimization to which Negroes have been subjected ( 14) . Leo and Rosen (14) state that when linked with deteriorated and overcrowded housing, inferior nutrition, and low-income, there is no doubt that the health needs of poor black people are acute. Today, the number and scope of existing services is inadequate to meet the slum's massive problems and break the vicious circle of poverty and malnutrition. Education, health, employment and family services as presently deployed can scarcely play their part in halting the deterioration of the slums, much less in improving them, states Kupchik (II). In his report to the National Commission on Community Health Services, Conant (11) notes that apathy, ignorance, and threat of harmful economic and political consequences constitute serious obstacles to progressive health actions. Age Influence Within the poverty .profile, children and the aged comprise the largest single group. Lowe (12) cites data to the effect that 24 % of all children under 15 live

Age influences nutritional status. As one grows older, there are many adjustments to be made.

in poverty in the U.S. Preliminary data from the National Nutrition Survey (17) shows the age distribution of the groups particularly vulnerable to nutritional stress: Children 0 t ,o 6 years old constituted 19% of the group; children 10 to 16 years of age, 25% and adults 60 years and older accounted for 13% of the total group. The Senate Select Committee on Nutrition and Related Human Needs (18) was informed that there are 20 million people 65 and over-l0 % of the U.S. population. Thirty percent of the population who are 65 and over live below the poverty line established for purposes of the Social Security Administration Poverty Index, and another 10% have incomes only slightly above the poverty line, making a total of 40% of this age group who are in poverty or in near poverty (19). As one grows older, especially on retirement, there are many adjustments to be made. Gertman (20) points out that the nutritional problems of the senior citizen result from: economic changes resulting from retirement and reduced income; physiological changes such as loss of teeth, diminished sensitivity of taste and smell, and decreased physical activity and metabolism; social changes such as altered living patterns and family composition; and psychological changes resulting from loneliness and anxiety. The reasons for the nutritional problems of children are more complex and varied. The effects of nutrition on the intellectual development and education of the child will be discussed separately. The education, race, environment, and attitudes of the parents play an important role in the nutritional status of the child. The education of the parents plays an important role in the economic level of the family. The increasing mechanization of farming and industry calls for less and less unskilled labor, making employment increasingly difficult and competitive (21) . Although illegal, discrimination in housing, employment opportunities, and education affects the socioeconomic level of the family and child. With a limited family income, the nutritional status of the child is affected when the family cannot obtain or does not know the necessary food for a balanced and nutritious diet. School lunch programs, in themselves, are theoretically nutritionally adequate and can supplement the diet the child receives at home (22). However, many low-income families cannot afford to provide the JOURNAL OF NUTRITION EDUCATION I 2t

money for school lunch for their chil- Study findings (26) have shown $e dren,and-until recently-many local prevalence of anemia or dietary evaluagovernments did not attempt to provide tions proving low-iron intake among free lunches for these children. Still an- these groups. In recent years, studies other factor affect,ing children is that, in such as the National Nutrition Survey some instances, parents reject their chil- have correlated evidence of high prevadren leaving them devoid of love, food, lence of anemia with low dietary iron and other basic essentials for health sur- intake among the lower income populavival (23). tion of t,he U.S. Although it is believed Poverty or low socioeconomic status to be prevalent among all segments of are not the only causes of poor nutrition, our population, few studies in other s~ates Leverton (24). It is possible for a socioeconomic groups show a relationchild to be well-fed but poorly nourished ship between dietary intake and nutribecause of unrecognized conditions that tional status. Summaries (27) of nutritional surinterfere with the body's use of the energy and nutrients from the food in- veys show t,hat adolescents received a gested. Infection and physiological and poorer diet as compared to younger chilpsychological stress are among the most dren. The diets of teen-age girls preusual of such conditions. It also is pos- sented the least favorable picture of all sible for a child to be poorly fed and groups studied. Hampton and co-workmalnourished because of poor food hab- ers (28) study of students in the 9th to its and lack of home supervision, even 12th grade showed t,hat the diets of though he comes from a middle-class or many, especially the girls were inadequate in iron and calcium and, to a lesser affluent home. Previous studies indicate that the prev- degree, vitamins A and C. Criteria for alence of undernutrition may be high this study were from the standpoint of among teen-agers and women of child- mean nutrient intake levels and the perbearing age. A preliminary USDA re- centages of subjects having int,akes beport (25) on food intake and nutritive low two-thirds of the 1964 Recomvalue of diet,S showed the groups with mended Dietary Allowances. Many of average diets low in more than one nu- the obese individuals were consuming trient were all age groups of females diets inadequate in these nutrients. The nine years and over, boys 12-17 and men students were generally dissatisfied with 75 years and over. In addition, iron in t,heir sizes and shapes, with girls generalthe diets of infants and children under ly wishing to lose weight and boys wish3 years averaged about 50% under the ing to gain weight (29). The feminine ideal of a figure thin to the point of ema1968 recommended 'allowances. Nutritional anemias are most likely to ciation may be a factor in the poor dietdevelop during periods of rapid growth ary practices of teen-age girls and the suc,h as infancy and adolescence and popularity of fad diets for girls of normal during the childbearing years in women. weight as well as obese girls.

·Physiological and Mental Influences

There has been an increased recognition of the interaction between diet during pregnacy, infancy nutrition, and intellectual development of the child. Lowe (20) stated: "It is our conviction that nutrition is the key to normal development of infants and children. In effect, the quality and quantity of nutrition given during the first 2 to 4 years of life may have the effect of programming the individual for the rest of his life." He also stated that the earlier malnutrition exists, the more devast~ting the impingement on growth and development. The same author (20) added: "Finally, the prevalence of intellectual compromise and even mental deficiency may be 3 to 5 times as frequent in children of families living in poverty. In effect, malnutrition, high infant mortality, and prematurity rates and high levels of mental deficiency coexist as a constellation of abnormalities tha~ are most frequent among our families living in poverty." Testifying before a Congressional Committee, Lowe (12) stated that the infant mortality among poverty families is from 2 to 3 times as high as i~ is in middle-class America. In our favored communities, the infant mortality rate is 16 deaths per 1000 live births. In our poor black communities, it may be as high as 50, and, in some predominantly black rural slums, rates may reach 100 deaths per 1000 live births. This means tha~ 10% of all children born die within the first year of life, he added (12). Prenatal care for mothers of disadvantaged children is almost non-existent, because of lack of money, medical facilities, education, and motivation to seek medical care. More stillborn and premature babies are born to t,hese mothers than to well-fed mothers (21). The prematurity rate in the poor communities is from 2 to 4 times as high as it is in middle-class communities (12). In suburban American counties, the premat,urity rate amounts to 5% while in the inner city of certain urban slums, it may amount to 25%. Lowe (12) feels this figure is of importance when we realize that up to 75% of all infant, mortality in the first month of life results from immaturity. The influence of the mother's prenatal diet on her infant has been well established by the studies of Burke and her co-workers, Dieckmann and co-workers and ot,hers (2). There is a growing realiThere has been an increased recognition of the interaction between diet during pregnancy, in- zation that undernutrition during the fancy nutrition, and intellectual development. Undernutrition during prenatal period and immediprenatal period and the period immediately after birth may affect brain development and functions as well as growth. 22 I JOURNAL OF NUTRITION EDUCATION

SUMMER, 197t

ately after birth may affect brain development and functions as well as physical growth (30). For a sizable portjon of the survivors of childhood deprivation, undernutrition may permanently retard physical and mental growth resulting in loss of learning ability during the most critical years of intellectual development. Depending upon the degree of prematurity or immaturity, up to 50% of low birth weight infants may, upon survival, have intelligence quotients (IQ's) below 70% (12). It has been estimated that 75 to 85% of alI mentally defective children are born in a poverty environment. Malnutrition is more complex than the mere stunting of the brain and body or the erupting of a single disease from inadequate diet (21). Social and psychological factors complicate a study of intellect.ual development and malnutrition. Unstimulating home environments, poor educational facilities, and lack of incentive because of repeated discouragement are examples of psychological and social deprivation that can affect intellectual performance. It is difficult to delineate between dietary deficiencies and environmental influences in evaluating the effects of malnutrition on int,ellectual development although there is a close relationship between the two. Food deprivation emanating from poverty and allied social problems can lead to a generation of retarded individuals so limited in their potential that they may be unable to break the vicious cycle. A lack of proper nutrients will decrease a person's productivity, resulting in apathy, lethargy, and lack of initiative.

By the time the child is three, the brain has reached 80% of its adul~ weight, compared with 20% for the rest of the body (21). Malnutrition serious enough to limit height and weight gains will also limit the growth of the brain. The effects of undernutrit.ion in early childhood on intellectual development may be more severe and longlasting than are the more readily observable effects of malnutrition on physical growth (31). Evidence implicating malnutrition in faulty mental development comes from two types of studies carried out in animals and humans (32). The first type, mostly in animals and to a lesser extent in humans, demonstrates chemical changes in the brain permanently induced by malnutrition early in life. These studies have shown a reduction in the number of brain cells in both rat and SUMMER, 1971

human infants who were malnourished at an early age. Winick (See Ref. 33) has data that strongly suggest that severe malnutrition in early infancy, and possibly during fetal growth, results in a reduction of brain size and that this is due to reduced brain cellularity rather than to smaller celIs. He has demonstrat,ed, using normal brains colIected in the U.S., that DNA content increases linearly until birth, more slowly until six months of age and very little thereafter. Winick compared the brains of two groups of children in Sant.iago, Chile: the control group consisted of 10 welI-nourished children who had died acutely of accidents or poisoning, and the study group consisted of nine children under one year of age who had died with severe malnutrition. The brains of the severely marasmic children alI showed reduced weight and reduced quantities of DNA, RNA, and protein. These findings are consistent with a reduct,ion in the number of brain celIs in the malnourished children, and it appears that the younger the child is when he develops malnutrition the more marked will be its effect on the brain. Although Winick's study produces important new evidence on t,he human being, there is still much that is unknown. The second group of investigations, more numerous in children than in animals, attempts to deal directly with the effects of malnut.rition on intellectual development (32). These studies present two major drawbacks: validity of the tests for intellectual development and the isolation of malnutrition as the only or a~ least the most significant variable. Within these limitations, using various types of control population in numerous countries, the data would suggest that undernutrition - especially during the first year of life~wi11 cause ret.ardation in physical, motor and intellectual development (32). One of the studies in Mexico suggests that these children show specific learning disabilities especially in the area of perceptual disorders. Studies are currently in progress in isolated villages in Guatemala in which every effort is being made to control the environment and allow food intake as the only variable. Early results indicate that the children who are undernourished are most likely to be retarded in development. An II-year follow-up study in South Africa suggests that psychologic changes induced by malnutrition in early life may persist. Other studies from Chile, Columbia, and areas of Africa and Asia tend to

confirm these observations. In an att;empt to analyze the effects of malnutrition upon mental capacity during preschool age, Monckeberg (34) studied 500 preschool children in Chile who belonged to three different social levels. The groups consisted of middleclass children who were not malnourished, low-income children receiving food supplementation and medical assistance, and low-income children with a high incidence of malnutrition. The middle-class children and low-income children wit.h food supplementation had only a 3% subnormality (I.Q. under 80) while the low-income children with a high incidence of malnutrition had a rate of 40% subnormality. The study (34) points out that it still cannot be concluded that malnutrition "per se" is the only cause; the supplementation feeding program and medical assistance acted no~ only upon the nutrition state but also upon the environment and material motivation.

Technologicat Influences Lack of fortification of foods may be a contributing factor in malnutrition at all levels of society. Nonfat dry milk which did not have added vitamins A and D was distributed under the food commodity distribution programs primarily to the poverty groups until the fall of 1968; this may have contributed to the vitamin A deficiency symptoms found. The increase in rickets may be due to a decrease of milk fortified with vitamin D in some parts of the country. There has been a decrease in the consumption of iodized saIt which probably accounts for some of the increase in prevalence of goiter. Schaefer (17) has charged that preliminary results of the National Nutrition Survey suggest that in America our food fortification programs are not what they should be. Most of these programs are voluntary. Anyone can sell bread tha~ is not enriched, milk that contains little or no vitamin D and from which the vitamin A has been removed, or salt that is not iodized at prices a penny or so below the cos~ of the fortified product, and the unsuspecting wiIl buy it. He (30) feels that food fortification standards need to be exam.ined and, if need be, updated. With the advances in food technology and increased transportation facilities, the homemaker finds more and more food choices when she selects food for her family within her budget. The increased development of prepared and convenience foods requires knowledge for a wise selection that often is not presJOURNAL OF NUTRITION EDUCATION

I 23

ent, especially among the disadvantaged. The food supply and marketing practices in poor neighborhoods is another aspect for consideration. Concern has recently developed as to whether the poor pay more for groceries of less quality than those of higher incomes. Before an adequate evaluation can be made of any food price study, there must be some knowledge of consumer behavior of the low-income individual (35). Based on the facts of limited available income, limited available chain stores, and lower automobile ownership, still a majority of low-income consumers purchase their groceries in larger supermarket - type stores. Some low-income consumers perceive the supermarket as providing lower prices and a better quality of groceries. The groceries purchased by the lowincome consumer reflect not only his limited income but also such variables as age and ethnic culture. Alexis, as quot.ed by Coltrin and Bradfield (35), found that older white persons and young Negro families with limited incomes bought less frozen vegetables and fresh fruit and more meat items as pork chops, chicken, Spam, and more starch commodities than the higher income families. These result.s indicate the effect of limited purchasing power for a mixed age and racial population.

Education In opening the White House Conference on Food, Nutrition and Health, President Nixon (3) stated: "We see, then, that the problem of hunger and malnutrition is, really, two separate problems. One is to ensure that everyone is able to obtain an adequate diet. The second is to ensure that people actually are properly fed, where they have the ability to obtain the adequate diet." He continued: "On the one hand, we are dealing with the problem of income distribution. On the other hand, with the problems of education, habit, taste, behavior, personal preferences-the whole complex of things that lead people t.o act the way they do, to make the choices they do." Nutrition education, as it is now practiced, is not necessarily motivating all individuals to improve their food habits. In outlining HEW's plan to combat malnutrition in the U.S., Finch (37) pointed out that a second basic line of attack on the nutrition problem is through educational channels and, specifically, nutrition education. One cause of malnutrition in this country is ignorance of what constitutes good nutrition and what foods will contribute to it. While it must 24 I JOURNAL OF NUTRITION EDUCATION

be emphasized that in general no specialized knowledge of nutrition principles is needed in the U.S. today to obtain a balanced food intake, knowledge of nutrition is necessary if consumers are to use their food dollars to best advantage. Finch stressed that we must, in addition, prevent malnutrition which results from simple lack of basic knowledge of food values. Frost and Payne (21) stated: "Hunger exists in America. No set of rationalizations can change this fact or justify it. Educators do not presently control sufficient power or resources to eradicate this blight from society, but it is clear that educational programs are essent.ial for equipping present and future generations to make intelligent decisions about nutrition and related health concerns." They (21) add that "other organizations have an equal responsibility to regenerate community, state and national action to cope with existing interrelated conditions of poverty, neglect, discrimination and malnutrition in this most affluent of nations." A survey (37) found that, generally, nutrition education has not had the desired impact on what people eat at. any income. Schaefer (38) has stated that one clear-cut point standing out in the National Nutrition Survey is the need for improved education in nutrition, health and family planning education for the current mother, the future mother now in school, and every other person concerned with planning or purchasing food. There are more persons in the U.S.

malnourished because of nutritional ignorance and misinformation than because of poverty, according to Mann (39), who feels that no one has been interested in enumerating the persons too badly informed to select an adequate diet even with an adequate income. It is an obvious fact that many malnourished persons make bad food choices. Briggs (40) wrote that. "many people insist that all that is needed to solve hunger and malnutrition in this country is a minimum guaranteed income for all families and free or low-cost food for all needy persons. Such people have no faith in nutrition educat.ion and other proven means of preventing hunger on a long-term basis .... Unless people know what foods provide good nutrition and how to spend their money wisely and economically, we cannot expect malnutrition to be erased regardless of the availability of food . . . it (nutrition education) is vital in any successful program of combating hunger and malnutrition .. . people must have proper motivat.ion to eat well . . . the nutrition educator must not only be able to inform others how to choose and use food properly, but he must also have an understanding of all factors affecting the food intake of people." Many of the panels at The White House Conference on Food, Nutrition and Health (3) reinforced the need for improved education, especially in nutrition. Comments included: "Among the affluent it is clear that we have developed a society that is characterized by: 1) Overconsumption of cal-

The missing ingredient ... is the education of children about a well-informed choice of nutritionally sound foods. SUMMER, 1971

ories with food choices that are not necessarily the wisest on the basis of available nutritional information." Panel 11-3: Adults in an Affluent Society. "This report recognizes both the urgency for immediate action to eliminate hunger and the need for a long-range program in nutrition education. . . . Sound nutrition education should enable each individual, throughout his life, to make wise decisions about his food choices. Every person should have sufficient economic resources so that these choices can be made without compromising social values, family traditions or cultural preferences." Panel IV-I: Nutrition Education in Elementary and Secondary Schools. "Every American should have access to knowledge of nutrition and its relation to health as well as to the purchasing power to secure food to meet his nutritional requirements . . . . Although the first requirement is an adequate income to insure the resources necessary to procure food, lack of information and ethnic and cultural practices prevent many from achieving good nutrition. "Many Americans are not interest.ed in nutrition and do not know of the benefits good nutrition can bring." Panel IV3: Community Nutrition Teaching. "The panelists feel that one basic right of individuals in our society is the right to proper food. But in order to exercise this right effectively, every citizen must know enough about foods and nutrition to choose for himself those foods which will supply his nutritional needs. "It is clear that a great many of our citizens lack this necessary knowledgeboth rich and poor, educated and uneducated-despite the great range and influences of our educational system and our communications media. In fact, the gaps in our public knowledge about nutrition, along with actual misinformation carried by some media, are contributing seriously to the problem of hunger and malnutrition in the United States. We feel that the Nation does not have the coordinated stimulating program of nutrition education we need in order to see to it that our citizens are well fed. It's time we had one." Panel IV-4: Popular Education and How To Reach Disadvantaged Groups. Recognition that the educational system is failing to meet the changes within our society and the demands of a changing society has been growing throughout the last decade. Danger signals are flashing in school systems throughout the country. The signals say that in too many SUMMER, 1971

schools students are being prepared for a world that no longer exists. The signals are coming from different sources-educators, students, the affluent, the poor, blacks, whites-and in different ways: discussion, peaceful protest, confrontation and violence. However, there are dedicated, thoughtful leaders committed to the task of looking for answers, or retaining the best in human expression and personal creations through the processes of teaching and learning, and of going about it with freedom or thought unshackled by rigid perpetration of what is or has been rather than what may be. Taylor (41) has said the present unrest in our community here and everywhere in the world is the inevitable consequence of the breaking up of an old order and the transitional stage into a new order in which the poor, the ignorant, the uneducated, and the deprived are demanding that their rights be fulfilled in reality. He feels trouble comes from two sources: the absence of a philosophy which can give a sense of direction to educational action and the failure to recognize and to welcome the fact that a whole new sector of American society has begun to assert legitimate demands which have until now been ignored or frustrated. Rogers (42) made this point: Teaching focuses on the wrong emphasis: coverage of subject matter and what shall be taught. It doesn't make sense today because our environment changes constantly. What does make sense is facilitation of learning. This is exciting because it makes it possible for people to live in balance with constant change. Rogers feels that learning can be facilitated by three attitudinal qualities on the part of the learner and the teacher and their relationship: Realness or genuineness-the learner or the teacher is what he is and can be what he is. Prizing or caring-this is caring for the learner, accepting but not possessing him. The teacher has a basic trust, recognizes the learner is a many-faceted person. Emphatic understanding - this is being able to stand in the other person's shoes, not evaluating or judging but understanding. There are contributing factors relating to the educational structure that may have helped develop the dilemma of malnutrition amidst plenty existing in the U.S., according to Mann (40). Nutrition education has traditionally been con-

ducted in the home through the motherdaughter transfer of food choices and cooking skills and in the family meal conclave which transmitted customs of food selection and meal pattern. He points out this tradition has been widely disrupted by a number of new factors, largely developed in the last 25 years: The development of prepared and convenience foods has been aggressive and effective. These products make home preparation of food either unnecessary or rudiment,ary. Convenience foods tend to diminish both the role of the mother as preparer and guide and the function of the family meals as a demonstration unit for food usage. The de-emphasis on homemaking and food preparation has moved the mother out of the home to a job, abandoning children to their own selections, helped only by a small cash income. The missing ingredient here is the education of children about a wellinformed choice of nutritionally sound foods. Home economics is ineffectual in reaching the majority of students in schools and home economists do not reach a large segment of the general public with much nutrition education. The fundamental problem for nutrition education is reaching the preschool children who have not, learned to read. But they can be reached by television. The advertising industry recognized this fact long before nutritionists. Advertising uses television to sell its product and it starts early. But it is sales-oriented, not health-oriented. The physician has two important limitations as a source of nutrition education. In the present, mode of medical care he talks to the sick rather than the well. And the physician is inadequately trained in nutrition science. Panel IV-4 of the White House Conference (3) stated: "Education is not a substitute for food ... educational programs directed to the disadvantaged will have a negative effect unless the disadvantaged have the food they need in order to live a proper life. Indeed, educat,ion programs without food would be insulting. Food is the first priority. "But to feed themselves properly our citizens need not only food, but also enough knowledge to make the right food choices. This is the task of education we face." JOURNAL OF NUTRITION EDUCATION

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Many factors influencing the prevalence of hunger and poverty have been discussed. Education is another factor that affects the lives of the poor. Various educators, civic leaders and members of the poor have charged that the educational system is failing t.o meet the needs of the poor to help defeat the vicious cycle of poverty. The education of the wage earner in the family is a major factor in determining the socioeconomic level of the family. In turn, this affects t.he education and nutritional status of the child and, thus, the vicious cycle is often repeated. Nutrition education as to what foods are necessary for a balanced and nutritious diet, meal planning, and budgeting is even more essential to the low-income family. They mus~ spend their limited food dollars more wisely than the "rich" man. Middle-class families can afford to make mistakes in food buying that would be disastrous for the disadvantaged. In our affluent, literate, science-andhealth oriented society, nutrition educat.ion lags far behind its needs and possibilities. The approach of the behavorial sciences is to view any particular food habit as an inseparable part of the total pattern of human behavior. Food habits are interwoven with the entire way of life of people. The culture mus~ be understood in order to effect changes in food habits with a minimum of disruption. In other words, to improve dietary levels it is as essential to examine such relevant factors as learning, motivation, at.titudes and values as it is to study nutrients, their functions and sources. Wenkam (1) suggests that the role of nutrition education is to guide and strengthen forces leading to dietary improvements. She suggests the following guidelines: 1) Identify and understand the cultural factors of a people which will ultimately influence food decisions; 2) acquire detailed knowledge of the environment; 3) acquire skills in educational techniques and competence in subject matter; and 4) de-emphasize one's own cult.ural and professional values. Ullrich (43) has suggested that nutrition education needs to use techniques of evaluation which are effective. These must be developed along with program planning. When ways have been developed to show the effectiveness of changing food habits over a period of time, nut.rition education will gain more recognition, and fewer people will be poorly fed, she states. 26 I JOURNAL OF NUTRITION EDUCATION

What Now? Malnutrition exists because of many combinations of factors. Some say it is a matter of poverty and lack of money to buy food. Others that it is a failure of nutrition educators to effectively educate enough people. Still others point a finger at the food industry and its advertising and promotion schemes. The schools are blamed because of what. is described as weak nutrition education programs in the elementary and secondary schools. Governmental agencies are criticized because the food programs under their direction don't reach all the people for whom they are int.ended. Physicians, educators, nutritionists, and allied professional groups are labeled as living too much in an ivory tower, oblivious to the needs of all people and clinging to traditional methods that are not relevant. We are now emerging into a new era; the t.ime for the expose of hunger and malnutrition is past. We must now face the even more difficult, challenging problems of programming and directing the interests, the concern, and indignation of our people toward getting our problems solved (10). Malnutrition, with special focus on hunger, has become interwoven with political issues such as civil rights, civil dissent, and the morality of the Viet Nam war as well as economic issues. The political tactics and decisions may create frustration and reaction in many emotional and social issues from all segments of our society. Growing determination among the disadvantaged, concerned citizens and today's youth that bett.e r answers must be found constitutes a revolutionary force in American society. Masses of poor people are looking for answers that will give them a sense of personal involvement and dignity they and others feel they've never had. Levine's comments (44) about ·the racial crisis several years ago may also apply to the national concern about malnutrition: Denial of the crisis, or belief that it will be losl in the shifting winds of history may constitute comforting guiding fictions for many. But for those who hear the battle cries coming from small towns and suburbs, the crisis is real and the t.ime for planning is nowfor the forces march to their own drummers and the cadence quickens and the course is head-on collision. The existence of malnutrition in our country demands a program of action, not only to relieve human suffering but to secure justice and to affirm human dignity. Can each of us as individuals

and as professionals afford not to meet the challenge to help eliminate malnutrition in our country? The planners of the White House Conference on Food, Nutrition and Health recognized that there is some truth in the accusations of why malnutrition and hunger exist in the U.S. They realized that to eliminate malnutrition it is necessary to deal as comprehensively as possible with all aspects of food. The organization of the Conference illustrated this comprehensive viewpoint and, therefore, can serve as a blueprint for action programs. Action needs to be taken on many fronts. There is no single or simple solution. The recommendations of the White House Conference recognized two main types of action in order to effectively eliminate malnutrition. First, the urgency for immediate action revolving around money or other means t.o obtain food for an adequate diet. Second, the need for long-range programs in nutrition education. REFERENCES 1. Wenkam, N. S., "Cultural determinants of nutritional behavior," Nutrition Program News, U.S. Department of Agriculture, Washington, D.C., July-Aug. 1969. 2. A Source Book on Food Practices, National Dairy Council, Chicago, 1968. 3. White House Conference on Food, Nutrition and Health, Final Report, U.S.

Government Printing Office, Washington, D.C., 1970. 4. Moore, H. B., "The meaning of food," Amer. I. CUn. Nutr. 5:77,1957. 5. Neihoff, A., "Changing food habits," I. Nutr. Educ., 1: 1:10, Summer 1969. 6. Lowenberg, M. E., et a1. Food and Man, John Wiley & Sons, Inc., New York, 1968. 7. Lee, D., "Cultural factors in dietary choice." Amer. I. CUn, Nutr., 5: 166, 1957. 8. Bettelheim, B., Food to Nurture the Mind, The Children's Foundation, Washington, D.C., 1970. 9. Gilstrap, M., Hunger - An Action Guide, National Board of the YWCA of the U.S.A., New York, 1969. 10. The Citizen's Board ofInquiry into Hunger and Malnutrition, "Hunger U.S.A." Nutrition and Intellectual Growth in Children, Bulletin 25-A., Association

for Childhood Education International, Washington, D.C., 1968 pp. 19-24. 11. Kupchik, G. J., "Environmental health in the ghetto," Amer. I. Pub. Health, 59:220, 1969. 12. Lowe, C. U., "Statement by Charles Upton Lowe, M.D. Chairman, Committee of Nutrition, American Academy of Pediatrics Before the Committee on Agriculture, House of Representatives." April 1969. 13. Ireland, L. M., Low-Income Life Styles, U.S. Department of Health, Education, and Welfare, Washington, D.C., 1967. SUMMER, 1971

14. Leo, P. A. and G. Rosen, "A bookshelf on poverty and health," Amer. I. Pub. Health, 59:591,1969. 15. Roberts, E. A. and T. B. Roberts, "Middle-class values-opinions differ," Today's Education, NEA Journal, 59:20. 1970. 16. Sources, Blue Cross Association, Chicago, 1968. 17. Schaefer, A. E. and O. C. Johnson, "Are we well fed? . . . the search for the answer," Nutrition Today, 4:2, Spring 1969. 18. Wilmot, J., "Testimony of Miss Jennie Wilmot, member, Legislative Council, American Association of Retired Persons, National Retired Teachers Association Before United States Senate Select Committee on Nutrition and Related Human Needs on Nutritional Problems of the Elderly," September 1969. 19. Martin, J. B., "Statement of John B. Martin, Commissioner, Administration on Aging, U.S. Department of Health, Education, and Welfare Before the Senate Select Committee on Nutrition and Related Human Needs," September 1969. 20. "Hunger is a problem," Agricultural Marketing, U.S.D.A. Consumer and Marketing Service, Washington, D.C., 14: 3, June 1969. 21. Frost, J. L. and B. L. Payne, "Hunger in America: scope and consequences," Nutrition and Intellectual Growth in Children, Bulletin 25-A. Association for Childhood Education International, Washington, D.C., 1968, pp. 5-18. 22. Loyd, F. G., "Finally, facts on malnutrition in the United States," Today's Health, 47:32, Sept. 1969. 23. Egan, M. C., "Combating malnutrition through maternal and child health program," Children, 16:67, March-April 1969. 24. Leverton, R. M., "Facts and fallacies about nutrition and learning," I. Nutr. Educ., 1: 2:7, Fall 1969. 25. Fincher, L. J. and M. E. Rauschert, "Diets of men, women and children in the United States," Nutrition Program News, U. S. Department of Agriculture, Washington, D.C., Sept.-Oct. 1969. 26. Kelsay, J. L. et aI., "A compendium of nutritional status studies and dietary evaluations studies conducted in the United States, 1957-1967," I. Nutr., Supplement I, Part II. Vol. 99, 1969. 27. Davis, T. R. A. et aI., "Review of studies of vitamin and mineral nutrition in the United States (1950-1968)," I. Nutr. Educ. 1: 2:41, Supp. 1, Fall 1969. 28. Hampton, M. C. et aI., "Caloric and nutrient intakes of teen-agers," I. Amer. Diet. Assoc., 50:385, 1967. 29. Huenemann, R. L. et al. "A longitudinal study of gross body composition and body conformation and their associations with food and activity in a teenage population," Amer. I. Clin. Nutr., 18:325, 1966. 30. Loyd, F. G., "Thought for food: making U. S. hunger a has-been," Today's Health, 47:38, Nov. 1969. 31. "Nutrition and Mental Development," Dairy Council Digest, National Dairy Council, 37:25, Sept.-Oct. 1966. 32. Winick, M., "Nutrition and intellectual SUMMER, 1971

development of children," Nutrition and Intellectual Growth in Children, Bulletin 25-A, Association for Childhood Education International, Washington, D.C., 1968. pp. 25-28. 33. Anon, "The infant brain following severe malnutrition," Nutr. Rev., 27:251, 1969. 34. Monckeberg, F. B., "Malnutrition and mental behaviour," Nutr. Rev., 27:191, 1969. 35. Coltrin, D. M. and R. B. Bradfield, "Food buying practices of urban lowincome consumers-a review," I. Nutr. Educ., 1: 3: 16, Winter 1970. 36. Finch, R. H., "Toward a comprehensive food and nutrition program," Pub. Health Rep., 84:667, 1969. 37. Cronan, M. L., "The role of the school in providing for nutrition," Nutrition and Intellectual Growth in Children, Bulletin 25-A, Association for Childhood Education International, Washington, D.C., 1968. p. 51. 38. Schaefer, A. E., "Malnutrition in the

USA?" Nutrition News, National Dairy Council, Chicago, 32: 13, Dec. 1969. 39. Mann, G. V., "Nutrition educationU.S.A.," Food and Nutrition News, National Livestock and Meat Board, Chicago, Vol. 41, Nov. 1969. 40. Briggs, G. M., "Hunger and malnutrition," I. Nutr. Educ., 1: 3:4, Winter 1970. 41. Taylor, H., Talk given at 1967 Association for Childhood Education International Meeting as reported in NDC Re· porter, National Dairy Council, Chicago, 1967. 42. Rogers, C. R., Talk given at 1967 Association for Supervision and Curriculum Development Meeting as reported in NDC Reporter, National Dairy Council, Chicago, 1967. 43. Ullrich, H. D. "Hunger in America and nutrition education," I. Nutr. Educ., 1: 1 :5, Summer 1969. 44. Levine, L. S., "The racial crisis: two suggestions for a national program," Amer. I. Orthopsychiatric Soc., March, 1967.

FDA and APHA Action Responsibilities Under recommendations of panels at the N alional Conference on Food Protection, held April 4-8, 1971, both the Food and Drug Administration and American Public Health Association would be responsible for major portions of the nation's food protection program. The specific charges to these agencies are outlined below. FDA should: Improve inspection codes, standardize inspections and testing, and eliminate duplicate tests. Establish a committee to develop an industry self-inspection program, identify needed research areas, classify potentially hazardous foods according to risk, and evaluate resources for technical assistance to states and local communities. Establish a clearinghouse for information on possibly hazardous foods being shipped in interstate commerce. Advise on the implementation of plans for consumer education and be represented on a standing committee to coordinate consumer education plans.

Init,iate, with departments of education on Federal and state levels, a plan to include food safety in the curricula of all primary and secondary schools. This plan is to be completed within one year and must also include plans to work with youth groups on informal education programs. APHA should: Advise on implementing plans for consumer education. Develop courses and teaching aids for educational programs to be run by FDA. Take responsibility for forming a National Council for Food Protection, through the National Academy of Sciences/National Research Council, to be operable by January, 1973. Take the lead in fostering program evaluations for food protection programs, forming a task force to define elements of program evaluation and analysis. From: The Nation's Health, APHA Newsletter, May, 1971.

ACKNOWLEDGEMENT The Society for Nutrition Education has been aided in development of the Journal of NUTRITION EDUCATION by contributions received before and during regular publica. tion. A grant from the Nutrition Foundation, Inc., funded original development. Research Grant LM00734·03 from National Library of Medicine, National Institutes of Health, DHEW, to the Dept. of Nutritional Sciences, University of California-Berkeley, supports present development. In addition, contributions for development of the JNE have been received this year from Gerber Products Company; Griffith Laboratories, Inc., Hoffman. La Roche, Inc.; Kraftco Corporation, Mead Johnson Research Center: and The Quaker Oats Company.

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