Public Health Nutrition

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This article provides information from the Lao People's Democratic Republic on household food security, current nutrition problems, their magnitudes and trends, food and nutrition policy and activities, and strategies for the development of short- and long-term approaches to dealing with the problems. The data were collected through published and unpublished documents, observations of Lao PDR medical and health facilities, rural schools, and villages, and interviews with Laotian nutrition and health specialists. The findings show that house-hold food security rests unstably on a risk-diffusion strategy and women's participation. A number of nutrition disorders are also prevalent. Control strategies require both long- and short-term actions focusing on assessment, advocacy, planning, training, appropriate model development, and communication for food and nutrition.

Introduction

As the nations of Indochina open their doors to peace and political stability, the national and international health and medical forces are challenged to strengthen basic health services for their populations. In the case of the Lao People's Democratic Republic (Lao PDR), one major problem area addressed through cooperative efforts between international development agencies, the Lao government, and foreign universities is food and nutrition. Information about the Lao PDR's nutrition situation is scattered and/or dated, hindering efforts to develop effective intervention strategies and programmes. Consequently, in 1990 UNICEF sponsored a team from the Institute of Nutrition, Mahidol University. in Thailand, to collaborate with UNICEF. WHO. and FAO in reviewing the available information on young child nutrition and household food security. This review was a prerequisite to developing appropriate community-based primary health care interventions and proposals to improve the nation's health information base and monitoring systems.

Household food security

Food security has many different definitions, yet at a basic level it is primarily concerned with household microeconomics. Special attention here is paid to household food security issues - namely food availability, acquisition or entitlement, food consumption, and the role of gender for each.

Household food availability

The Lao PDR household economy is largely dependent on agriculture for food production, especially livestock and rice. Buffalo and cattle are primarily used as draft animals rather than as a common food source. They are considered depositories of family wealth which can be readily liquidated to purchase needed domestic items and additional food. While swine and poultry are present in all villages, they are raised using non-labour-intensive methods which often include allowing the animals to forage.

Rice production is the fundamental component of the farming system, and all other production activities constitute secondary hut crucial elements. The estimated annual paddy (unmilled rice) requirement is 350 kg per person. which includes 10%, for postharvest losses and seed (60 kg per hectare). The proven production of rice is approximately 1.3 to 1.4 million tons of paddy [5] Using a 60%, milled-rice conversion factor, this amount is normally sufficient to meet consumption needs based on a per capita annual rate of 180 kg of milled rice. Erratic climatic conditions commonly cause production shortfalls. An inefficient distribution and market system also causes local deficits due to poor transportation and management.

Semi-migratory swidden farmers, particularly among the Lao Soung and Lao Theung, usually do not produce enough rice for their own needs. Consequently, they cultivate crops with short maturation periods to provide food before the rice harvest and in times of need. In many cases, home gardening operates as a supplementary food production system which can, in times of surplus, provide an additional source of income. In all three major ethnic categories, women assume major household economic roles, including vegetable growing, small-scale production. and marketing.

Household food acquisition or entitlement

Carbohydrate requirements in Lao households are met by rice and other supplementary staples. Maize and root crops are used mainly for animal feed. Requirements for protein, especially animal protein, usually cannot be met through farming alone. Therefore, almost every household member is involved in gathering and/or hunting so as to provide additional calories, protein, and other nutrients. Natural foods such as fish, snails, small game (e.g., frogs, birds), and forest fruits, shoots, mushrooms, and vegetables are common household food items. Men also hunt regularly during the post-harvest period for household consumption and to provide a substantial source of income among poor families. Currently, pressures on game animals and forest encroachment are strong and widespread.

Food sharing among households is more common in Lao Loum society than among the Lao Soung and Lao Theung. Internal trade in locally obtained food products (via cash or barter systems) is also more frequent in many lowland Lao Loum villages, but very little intra-village trade is conducted among the other ethnic groups [6]. In rural areas, markets are the means for obtaining small necessities (e.g.. salt. monosodium glutamate, occasionally meat). The use of markets as a major source of food supplies is constrained by poor transportation, limited food industries, the time required to travel to the nearest market, and restricted purchasing power. In urban areas Lao people spend a high proportion of their disposable income (up to 70%-75%) on food.

Food consumption

Presently, systematic data on household food consumption patterns are rare and largely confined to people living in Vientiane Prefecture [X]. Daily dietary intake is approximately 1,745-1,976 kcal, or about 70%-80% of the recommended requirement. The estimated 45.2-46.8 g of daily protein consumed is about 75% of the recommended 60 g per day. Rice constitutes more than 80% of total calorie and 50% of protein intake. Since the Lao eat a large variety of foods, their chance of consuming an adequately balanced diet is high, especially among adults. Unfortunately no nutrition survey exists providing quantitative and qualitative information on the dietary intakes of household members in different seasons and among different ethnic groups.

Breast-feeding is universally practiced in the Lao PDR, with more than 90% of mothers breast-feeding for more than 12 months. However. colostrum is usually discarded and breast-feeding is often delayed for one to three days after birth. Prepared supplementary weaning foods are unavailable. The practice of introducing semi-solid foods (e.g., premasticated glutinous rice) early can cause acute problems (e.g., peptic perforation) and long-term complications (e.g., bladder stone disease). Food taboos, such as withholding food during certain periods (e.g., postpartum and during illness), are also present and are potential causes of macro- and micro nutrient deficiency.

While gender differences appear to be insignificant, surveys have shown that girls tended to be marginally better off nutritionally than boys. It may be that girls have better access to food since they often help their mothers with cooking. Thus, children's food security issues may not be food availability or household acquisition, but food habits, family distribution, and the multiple roles of women in the family.

Food and nutrition situation

The effects of household food security issues are most clearly reflected in the nation's food and nutrition status. As with any quantitative assessment for the Lao PDR, however, the food and nutrition situation presented here must be considered very carefully, since information systems are only rudimentarily developed and there are no institutionalized nutrition surveys. Even where nutrition status data are available, explicit statements of definitions, criteria, cut-off points, and the like are frequently varied and sometimes even missing. Nonetheless, data from a few prior nutrition surveys. current hospital records, site visits, and interviews highlight the Lao PDR's present nutrition problems and their extent.

Food and nutrition policy, activities, and needs

The Lao PDR still does not have an explicit nutrition policy or a national food and nutrition plan. While a newly created National Committee on Food and Nutrition exists, it lacks a clear mandate to carry out the necessary steps for solving the nation's food and nutrition problems. Generally, the government views nutrition as a family responsibility, and consequently central level authorities have allocated a limited health budget for nutrition activities. The target population for government policy is preschool children,. representing a very small percentage of the total child population.

Growth monitoring

Growth monitoring activities in the maternal and child health programme at all levels currently use a weight-for-age growth card adapted from the 1979 WHO recommendations, which has been printed with support from UNICEF. The layout of the card could be improved. Also, since the parents keep the cards and clinics do not possess duplicates, the recording and reporting systems in clinics and higher levels are very poor. Consequently, it is extremely difficult to aggregate the growth-card information.