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Nutritionand an

Active Life

From Knowledge to Action

Wilma B. Freire, Editor

Scientific and Technical Publication No. 612

Nutrition and an Active Life: From Knowledge to Action is ananthology by leading public health experts from the Pan AmericanHealth Organization and the international development community.The book’s selections focus on how research in nutrition and thepromotion of active lifestyles can provide vital input for the creationof public policy and planning and for the design, implementation,monitoring, and evaluation of programs.

You and I, in one way or another, stand to directly benefit fromthis science and its effective application. The knowledge gainedfrom the research presented here has the power to transform thelives of mothers and children, the economically active population,older adults, and all age groups whose sedentary lifestyle placesthem at greater risk of developing life-threatening chronic diseases.

Nutrition and an Active Life: From Knowledge to Action is animportant contribution that should be of particular interest to prac-titioners, researchers, and decision-makers in the fields of healthpromotion, community education, nutrition, maternal and childhealth, physical activity, policy development in public health andurban planning, social communications, and other related areas.

525 Twenty-third Street, N.W. Washington, D.C. 20037 U.S.A.www.paho.org

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Nutritionand an

Active LifeFrom Knowledge to Action


Also published in Spanish (2005) with the title:Nutrición y vida activa: del conocimiento a la acción

ISBN 92 75 31612 0

PAHO HQ Library Cataloguing-in-Publication

Pan American Health OrganizationNutrition and an active life: from knowledge to action.

Washington, D.C.: PAHO, © 2005.(Scientific and Technical Publication No. 612)

ISBN 92 75 11612 1

I. Title II. Series1. NUTRITION2. NUTRITION PROGRAMMES3. NUTRITION POLICY4. EXERCISE5. NUTRITIONAL REQUIREMENTS

NLM QU 145

The Pan American Health Organization welcomes requests for permission to repro-duce or translate its publications, in part or in full. Applications and inquiries shouldbe addressed to the Publications Area, Pan American Health Organization, Washington,D.C., U.S.A., which will be glad to provide the latest information on any changes madeto the text, plans for new editions, and reprints and translations already available.

© Pan American Health Organization, 2005

Publications of the Pan American Health Organization enjoy copyright protection inaccordance with the provisions of Protocol 2 of the Universal Copyright Convention.All rights are reserved.

The designations employed and the presentation of the material in this publication donot imply the expression of any opinion whatsoever on the part of the Secretariat of thePan American Health Organization concerning the status of any country, territory, cityor area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

The mention of specific companies or of certain manufacturers’ products does notimply that they are endorsed or recommended by the Pan American Health Organiza-tion in preference to others of a similar nature that are not mentioned. Errors and omis-sions excepted, the names of proprietary products are distinguished by initial capitalletters.

The authors alone are responsible for the views expressed in the publication.

Cover image © Digital Vision

CONTENTS

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

The Contribution of Science to Action

The Policy and Program Implications of Research on the Long-term Consequences of Early Childhood Nutrition: Lessons from the INCAPFollow-up Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Reynaldo Martorell

The Role of Research in the Formulation of Infant Feeding Policies in Latin America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Cesar Victora, Elaine Albernaz, and Chessa Lutter

Micronutrients: Successful Interventions for the Correction of Specific Deficiencies

Control of Iodine Deficiency Disorders: The Contribution of the Ecuadorian Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Wilma B. Freire, Koenraad Vanormelingen, and Joseph Vanderheyden

Sugar Fortification with Vitamin A in Guatemala: The Program’s Successes and Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Omar Dary, Carolina Martínez, and Mónica Guamuch

Virtual Control of Vitamin A Deficiency in Nicaragua . . . . . . . . . . . . . . . . . . . . . . . . . 61José O. Mora, Gloria E. Navas, Josefina Bonilla, and Ivette Sandino

Folic Acid Fortification of Wheat Flour and the Prevention of Neural Tube Defects in Chile: A Successful Experience . . . . . . . . . . . . . . . . . . . . . . . . . 93Eva Hertrampf

iii

Integrated Strategies at the Local Level

Implementation of Breast-feeding Practices in Brazil: From International Recommendations to Local Policy . . . . . . . . . . . . . . . . . . . . . . . . . 109Marina Ferreira Rea and Maria de Fátima Moura de Araújo

The Best Buy Project in Peru: Nutrition Recommendations within the Context of Local Urban Market Realities . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Bruno M. Benavides

Agita São Paulo: Encouraging Physical Activity as a Way of Life in Brazil . . . . . . . . 141Sandra Mahecha Matsudo and Victor Rodrigues Matsudo

Promoting Active Lifestyles and Healthy Urban Spaces: The Cultural and Spatial Transformation of Bogotá, Colombia . . . . . . . . . . . . . . . . . . 161Ricardo Montezuma

Integrated Strategies at the National Level

Improving Nutrition in Mexico: The Use of Research for Decision-making in Nutrition Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . 183Juan A. Rivera

The Public Policy Response to Epidemiological and Nutritional Transition: The Case of Chile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205Fernando Vio and Ricardo Uauy

Transportation, Urban Development, and Public Safety in Latin America: Their Importance to Public Health and an Active Lifestyle . . . . . . . . . . . . . . . . . . . . . 221Enrique R. Jacoby, Ricardo Montezuma, Marilyn Rice, Miguel Malo, and Carlos Crespo

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

iv Contents

PREFACE

This book, written by leading international public health experts from the Pan Amer-ican Health Organization (PAHO) and its collaborating institutions, demonstrates howresearch in nutrition and the promotion of active lifestyles has informed action in thedevelopment of public policies and in the design, implementation, monitoring, andevaluation of programs.

All of us are the beneficiaries of this science and its applications. Different types ofinterventions are presented, targeting mothers and children, the economically activepopulation, older adults, and all age groups whose sedentary lifestyle favors the devel-opment of noncommunicable diseases such as cardiovascular disorders, diabetes, andvarious types of cancer.

The collected contributions discuss a broad range of issues. These include actions tar-geted to individuals, such as those stressing the importance of breast-feeding and theprevention of micronutrient deficiencies, poor nutrition, overweight, and obesity. At themore complex and intersectoral level, the discussion highlights the effect of rapid ur-banization on epidemiological profiles, the benefits and limitations of social communi-cation and marketing in encouraging better nutrition and a more active lifestyle, andthe role of urban planning and structure in creating healthier behaviors and achievingrecommended levels of physical activity. Finally, the book explores the synergistic im-pact on human health and the quality of urban life that can result from the creation ofclose partnerships between the public health and urban development sectors, who, to-gether, can increase road safety, reduce urban crime and violence, protect the environ-ment, and preserve public spaces.

From remote rural villages to the world’s largest metropolises, Nutrition and an Ac-tive Life: From Knowledge to Action embraces a diversity of Latin American settings andsuccessful, well-integrated strategies. In each case, the physical, social, cultural, andeconomic determinants of health, particularly as these relate to nutritional habits andphysical activity levels, are described, as well as how the creation of healthy public poli-cies and evidence-based interventions can improve both health status and quality of lifeat the individual and population levels.

The Millennium Development Goals (MDGs) adopted by the United Nations in 2000have brought the idea of investing in people’s health to the very center of the global de-velopment agenda. The health-related MDGs have been established as the critical un-derpinning for PAHO’s technical cooperation efforts over the next decade. The series ofresearch findings presented in Nutrition and an Active Life: From Knowledge to Action aimto provide support to the Organization’s Member States in the form of effective andpractical working tools as these countries strive to bring national health plans and pri-orities in line with the MDGs.

Five of the eight MDGs receive special attention in this book. They are: MDG-1, deal-ing with the eradication of extreme poverty and hunger; MDG-4, focusing on the reduc-tion of child mortality; MDG-5, improving maternal health; MDG-7, ensuring environ-

v

mental sustainability; and MDG-8, forging a global partnership to promote socioeco-nomic development.

The Millennium Development Goals are important milestones for progress in humandevelopment which incorporate relevant indicators of the effectiveness of health sys-tems in addressing key health problems amenable to intervention. By encouraging so-cial participation and increasing health literacy regarding relevant health issues, PAHOseeks to empower a global community to work together in achieving the MDGs. In thissense, Nutrition and an Active Life: From Knowledge to Action is an important contributionthat should be of particular interest to practitioners and researchers working in healthpromotion and community education, nutrition, maternal and child health, physical ac-tivity, public policy design and planning in health and urban development, and socialcommunications.

Mirta Roses PeriagoDirectorPan American Health Organization

vi Preface

ACKNOWLEDGMENTS

The goal of the Pan American Health Organization (PAHO) is to bring together inthis book the scientific output and successful experiences of recent years in the Ameri-cas in the areas of nutrition and the promotion of active lifestyles and to disseminate thelessons learned to countries in this Region and in other regions of the world. This un-dertaking was very well received from the outset, and we owe a tremendous debt ofgratitude to the authors who supported the project and enthusiastically contributedchapters to it. Together, these contributions offer a body of knowledge and experienceof enormous value that can help guide the design and execution of similar policies andprograms and reduce the high prevalence of nutritional and chronic disease disorders.

Secondly, we wish to offer special thanks to Dr. Gina Tambini, Manager of the Areaof Family and Community Health of PAHO, for backing this effort to share the experi-ences and work in nutrition and physical activity in Latin America through a bookgeared toward researchers, academicians, students, policymakers, and program direc-tors. We trust that this publication will be very useful in this group’s research and edu-cation activities, as well as in the execution of different policies and programs.

We also express our special thanks to Judith Navarro and her team in the PAHO Areaof Publications, who placed their competence and dedication at the service of this proj-ect, so that the book could be published in a timely manner.

Wilma B. Freire1

Editor

vii

1Dr. Freire is Co-director of the Institute of Research in Nutrition and Health, Universidad San Francisco deQuito, Ecuador. Until April 2005, she served as Chief of the PAHO Nutrition Unit in the Area of Family andCommunity Health in Washington, D.C.

INTRODUCTION

In recent years, the health situation in the Americas has improved considerablythanks not only to better living conditions and greater access to health services, but alsoto the implementation of far-reaching nutrition policies and programs. However, nutri-tional deficiency disorders persist, and are now, moreover, accompanied by overweightand obesity, problems resulting from poor eating habits and unhealthy lifestyles. Nutri-tional deficiency disorders and problems of excessive caloric intake are seen in virtuallyevery country. While children under 3 continue to suffer from malnutrition, withstunted growth and anemia, overweight and obesity are on the rise not only amongadults, but children as well.

Stunting rates range from 10.5% in Brazil to 46.4% in Guatemala, with the highestprevalence rates recorded in Bolivia, Ecuador, El Salvador, Haiti, Nicaragua, and Peru.Low weight-for-age is more prevalent in Ecuador, Guatemala, Haiti, and Nicaragua,with levels ranging from 11% to 24%. Both micronutrient deficiencies and problems ofoverweight and obesity are the product of improper diet and are found especially inyoung children and pregnant women. Anemia in children under 5, measured by lowhemoglobin levels, is present in all the countries, with levels of approximately 20%.Prevalence rates in pregnant women are above 30%, and are 25% among women ofchildbearing age. At the same time, prevalence rates for overweight and obesity inwomen of childbearing age exceed 30% and are found in the majority of the countries,with the exception of Haiti; school-age children are also among those affected.

Notwithstanding, in recent decades several nutritional disorders have been broughtunder sufficient control that they have ceased to be a public health problem. Theseachievements are the result of the application of effective strategies that have demon-strated the feasibility of fighting these problems and reducing their devastatingconsequences.

This book details programs and policies implemented in the Region that have helpedto improve the overall health of the population by reducing the high prevalence ratesof nutritional disorders and promoting healthy lifestyles. It is hoped that these experi-ences will serve as examples that may be replicated in other communities and nationsinside and outside the Region of the Americas.

Not all the experiences described in this book have been subjected to a rigorous eval-uation of their effectiveness. Nevertheless, after careful analysis of the programs con-sidered successful, we have decided to include them for the following reasons: theyoffer programming lessons because they were conceived with highly innovative vision;they have been implemented using viable processes and were able to elicit broad mul-tisectoral participation; and they have raised awareness among the target populationsof their right to good health and nutrition. Readers will be able to readily identify andappreciate these elements and will find in these programs a source of information,guidance, and reflection.

ix

The chapters in the book are divided into four sections: the first consists of a reviewof scientific evidence, and the second focuses on successful interventions in the area ofmicronutrients. The last two sections encompass strategies adopted at the local and na-tional levels to address issues related to nutrition and the adoption of healthier, moreactive lifestyles. The four sections are followed by a chapter summarizing the book’smost salient messages and offering conclusions based on these.

The first section consists of two chapters. In the first of them, Martorell examines thelong-term consequences of early malnutrition and how research findings may helpshape better policies and programs. The chapter is based on lessons learned from a se-ries of longitudinal and follow-up studies conducted by the Institute of Nutrition ofCentral America and Panama and Reynaldo Martorell. It analyzes research launched inthe 1960s and still under way. The studies are unique, in the sense that they begin withinterventions during early childhood whose effects are followed into adulthood and thenext generation. The second chapter, written by Victora, Albernaz, and Lutter, also re-viewed studies conducted in Latin America in the second half of the twentieth centuryand their contribution to the design of policies related to infant feeding. This review fo-cuses on the role of research findings by demonstrating the impact of breast-feeding onchild health and growth.

The second section presents effective strategies utilized by micronutrient programsand consists of four chapters. The first, by Freire, Vanormelingen, and Vanderheyden,describes the successful experience of a program to control iodine deficiency disordersin Ecuador. This program set a true milestone by clearly demonstrating that salt iodiza-tion is the most effective and least costly measure for combating iodine deficiency dis-orders in the Americas. The second chapter, by Dary, Martínez, and Guamuch, focuseson vitamin A sugar fortification in Guatemala, an initiative that not only managed to re-duce cases of blindness from vitamin A deficiency, but also decreased infant morbidityand mortality by improving immune response. This experience led other countries toadopt similar programs, as was the case in El Salvador, Honduras, Nicaragua, Nigeria,and Zambia. The chapter summarizes the evolution of sugar fortification in Guatemalafrom 1988 to 2005 and its vicissitudes, updating and complementing works previouslypublished on the subject. The third chapter, by Mora, Navas, Bonilla, and Sandino, de-scribes the experience of a program to control vitamin A deficiency in Nicaragua anddiscusses the lessons learned, so that others may take advantage of them. Nicaragua,like other countries facing this issue, recognized the important role played by vita-min A in the health and survival of children and decided to adopt a national controlplan to improve intake utilizing the most effective and least costly supplementation andfortification strategies that could be implemented at the national level. The fourth chap-ter, by Hertrampf, describes the successful Chilean experience of wheat flour fortifica-tion as a way of decreasing the incidence of neural tube defects, for it has been shownthat food fortification is effective in preventing these malformations. This strategy hashad particular impact in countries where a food staple suitable for fortification could bereadily identified. Hertrampf reviews the role of folates in the metabolic process andthen presents the epidemiological and clinical characteristics of neural tube defects andeffective strategies to prevent them. She concludes with an overview of the Chilean ex-perience, demonstrating the benefits of fortifying wheat flour with folic acid.

The third section analyzes integrated strategies adopted at the local level and in-cludes four chapters. The first one, by Rea and Araújo, describes the Brazilian experi-ence in effectively promoting the practice of exclusive breast-feeding during the first six

x Introduction

months of life and, following the introduction of complementary foods, continuedbreast-feeding until the child reaches 2 years of age or older. Among the most notewor-thy of the strategies employed are wide-reaching social mobilization and multimediacampaigns and the establishment of a national network of human-milk banks. The sec-ond chapter, by Benavides, describes the Best Buy Project developed by the PeruvianInstitute of National Research in partnership with grassroots organizations (communitykitchens), the mass media, the private sector, and the international community. Theproject periodically monitored food prices in Lima, the country’s capital, with a view toidentifying foodstuffs available in local markets containing the most cost-effective unitsof energy and protein. This information was used to design and develop nutritionallysound recipes in community kitchens at prices within the economic means of low in-come population groups. Messages promoting “best buy” foods and recipes incorporat-ing them were distributed through the mass media and in face-to-face educational ac-tivities. Evaluation of the program showed that it is possible to improve access to highlynutritious foods after only a five-month period. The third chapter is about a successfulmodel for promoting active lifestyles, the Agita São Paulo Program. This experiencedemonstrates the effectiveness of forging partnerships with national and internationalorganizations and of having political backing and a strong scientific foundation. Thechapter describes the history and key characteristics of the program, emphasizing itsmultisectoral essence. This section ends with a chapter by Montezuma on the link be-tween the urban environment and an increase in physical activity. The author describesthe transformation of Bogotá, Colombia, a process which helped to counteract a trendof growing dependence upon individual motorized transportation. The increase in ve-hicular use is related to the growth of sedentary lifestyles, a factor that contributes torising overweight and obesity among urban dwellers. The Bogotá experience showsthat the structural design of cities directly and indirectly influences many behaviors re-lated to physical activity and a sedentary lifestyle among the population and that pos-itive changes in the physical environment have a greater potential for increasing phys-ical activity than do policies targeting individual behavior alone. These changes includegreater access to means of mass transportation, and the creation of public spaces forpedestrians (such as plazas, sidewalks, and pedestrian-only streets), bicycle paths, andurban parks.

The fourth section deals with integrated strategies adopted at the national level andconsists of three chapters. The first one, by Rivera, shows that mission-based researchin public health makes it possible to improve the population’s health status by apply-ing scientific method to the study of different objects and levels of analysis. The authordemonstrates that this methodology facilitates an in-depth analysis of the population’shealth using a multidisciplinary approach to generate information and can improve theorganized social response, resulting in better designed policies and programs to pre-vent and control poor nutrition. The chapter also presents evidence of how the use ofscientific research findings has led to actions with high impact and promising indica-tions for the future of malnutrition prevention and control policies and programs inMexico. The second chapter, by Vio and Uauy, describes the history of nutritional prob-lems in Chile and how the adoption of policies targeting priority issues, the reallocationof resources, and changes in program execution have enabled the country to bring anumber of nutritional problems under control. The experience gained within thisnational institutional framework has led to the search for other interventions to counterthe emerging problem of overweight and obesity. Finally, Jacoby and colleagues

Freire xi

present a chapter on this same topic in which they analyze a situation common acrossurban landscapes in the Americas: lack of personal safety, violence, gang activity, stress,physical inactivity, and social disintegration. These factors are recognized as a high riskto the population’s health and are responsible for the epidemics of cardiovascular dis-eases, mental health problems, and obesity that together account for nearly 60% of alldeaths in the Region. Jacoby and colleagues observe that unlike the public health ap-proach, which focuses on the individual, the urban planning mindset seeks to addressproblems from a collective perspective, setting as its priorities the improvement ofurban quality of life, securing a healthy environment, and providing efficient public in-frastructure, such as transportation systems and appropriate urban land use. The au-thors highlight the potential value for human health of creating a more active synergybetween the public health and urban development sectors.

We are proud to present this book to our readers in the certainty that they will dis-cover strategies, tools, and perspectives useful in addressing the health and nutritionchallenges in their communities. As its pages show, there is no magic bullet. Yet signif-icant progress can be achieved through selection from a highly diverse set of actions,depending on the problem’s nature and the environment in which change needs tooccur. While there exists no single prescription, starting with scientific evidence and re-viewing experiences that have been successful elsewhere can provide reliable clues fora given intervention’s viability and adaptability to local circumstances in your owncommunity or region.

Wilma B. Freire

xii Introduction

The Contribution of Science to Action

INTRODUCTION

Child malnutrition is a major publichealth problem in Latin America and theCaribbean, according to the United NationsSystem Standing Committee on Nutrition’s5th Report on the World Nutrition Situation (1).For example, 11.8% of preschool children inthis region are projected to be stunted by theend of 2005. Anemia rates in young childrenare reported to be alarmingly high; half tothree-quarters of preschool children werefound to be anemic (< 11 g/dL) in Bolivia,Haiti, and Peru according to estimates fromrecent national surveys (1).

Child malnutrition is an even greaterproblem in Africa and Asia, where 34.5% and25.7% of preschool children, respectively, areprojected to be stunted by the end of 2005.However, there are pockets in the LatinAmerican and Caribbean subregions wherethe problem of child malnutrition is as exten-sive as in Africa and Asia. Estimated levels ofstunting for the year 2005 in preschool chil-dren are 7.4% for the Caribbean, 9.6% forSouth America, and 18% for Central Amer-ica. Countries with low levels of stunting inpreschool children include Chile, Cuba, andCosta Rica, with 1.5%, 4.6%, and 6.1%, re-spectively. At the other extreme, the coun-tries with the highest levels of stunting in

preschool children are Guatemala, Hon-duras, and Bolivia with 46.4%, 29.2%, and26.8%, respectively; levels similar to thosefound in many sub-Saharan African coun-tries. The 1998–1999 national nutrition sur-vey of Mexico found that 17.8% of preschoolchildren at the national level were stunted;however, there was considerable variation atthe subnational level, and this was associ-ated with variations in regional economic de-velopment (2). The regions of the north, cen-ter, and Mexico City had levels of stunting of7.1%, 14.5%, and 13.2%, respectively; lowerthan levels for the poorer and more indige-nous south, where 29.2% of preschool chil-dren were found to be stunted. In southernMexico, levels were 17.8% in urban areas but42.4% in rural areas.

Economic development, like stunting,varies across regions and countries. LatinAmerica had a gross national income (GNI)per capita of US$ 3,610 in 2001, compared toUS$ 519 and US$ 449 for the regions of sub-Saharan Africa and South Asia (which in-cludes India), respectively (3). The least de-

THE POLICY AND PROGRAM IMPLICATIONSOF RESEARCH ON THE LONG-TERM

CONSEQUENCES OF EARLY CHILDHOODNUTRITION: LESSONS FROM THE INCAP

FOLLOW-UP STUDY

Reynaldo Martorell1

3

1Chair, Department of Global Health, Rollins Schoolof Public Health, Emory University, Atlanta, Georgia,U.S.A. Research supported by the Fogarty InternationalCenter, National Institutes of Health, Bethesda, Mary-land, U.S.A.

veloped countries, a group made up of theworld’s poorest countries that includes onlyone American country, Haiti, had a GNI percapita of US$ 295. The country with the high-est prevalence of stunting in the Region ofthe Americas, Guatemala, had a GNI percapita of US$ 1,670.

Several observations may be made aboutchild malnutrition and national incomesbased on these data. The levels of child mal-nutrition in the Americas are incongruouswith the level of national economic develop-ment the Region has achieved. Most coun-tries, Guatemala and Mexico, for example,possess the resources to significantly lowertheir high rates of child malnutrition, butfirst they must make this goal a national pri-ority. Second, countries need to implementcost-effective policies and programs to ad-dress child malnutrition. To achieve this,policies and programs must be guided by thebest available scientific evidence, and pro-grams must be monitored and evaluated toimprove their functioning and maximizetheir impact on child nutrition.

The objective of this chapter is to reviewthe contributions to policies and programs ofa collection of studies unique in the historyof child nutrition research in the world, theINCAP Longitudinal and Follow-up Studies(4). These studies, conducted by the Instituteof Nutrition of Central America and Panama,a scientific and technical center of the PanAmerican Health Organization based inGuatemala City, began in the 1960s and con-tinue to this date. They are unique becausethey began with a nutrition intervention inearly childhood whose effects are beingtraced to adulthood and the next generation.Results from this body of INCAP studiesshow convincingly that there are short- andlong-term positive consequences of improv-ing nutrition in early childhood (5), whichthus provide fuel for advocacy for those in-terested in convincing policymakers to in-vest in maternal and child nutrition and alsoinform program managers about how best todesign nutrition interventions.

Three sections follow: a description of theoriginal longitudinal study and its key find-ings, a review of the characteristics and keyfindings from the 1988–1989 follow-up andother subsequent studies, and a discussion ofthe contribution of the INCAP studies topolicies and programs.

THE INCAP LONGITUDINAL STUDY AND KEY FINDINGS

The INCAP studies began in four villagesof the department of El Progreso in easternGuatemala. This is an area of the countryrarely visited by tourists; the environment isdry and dusty, and the population is ladino(i.e., Spanish-speaking mestizo). The villageswere selected after a long and careful processfrom which two pairs of similar villages wereidentified; then, one village from each pairwas chosen randomly to receive a nutritioussupplement and the remaining two villages acontrol drink.

Nutrition and Medical Interventions

Detailed descriptions of the INCAP stud-ies are found elsewhere (4). The longitudinalstudy began in 1969 and lasted until 1977. Itsmain purpose was to assess the effect of im-proving protein intakes on the mental devel-opment of preschool children. At the time,protein deficiency was believed to be themajor cause of much of the child malnutri-tion in the world. The “treatment” drink wasformulated as an atole, or a type of hot gruelconsumed in Guatemala, and was madefrom Incaparina, a vegetable protein mixturedeveloped by INCAP, with dry skim milk,sugar, and flavoring. The atole delivered 11.5 g of high-quality protein per cup (180ml). It also contained energy (163 kcal/cup)as well as vitamins and minerals, but was nota good source of zinc. The intent of the studywas to provide this nutritionally potentdrink to women and children and then tomeasure its impact on mental development

4 Lessons from the INCAP Follow-up Study

by comparing test results in the treatmentand control villages.

The atole was provided in a supplementa-tion center twice a day, in mid-morning andmid-afternoon in order to minimize possibleinfluences on meal patterns at home. Atten-dance was open to all villagers, but was re-corded only for pregnant and breast-feedingwomen and for children 7 years or younger. Acup was given to each subject, but more wasgiven if desired. Intakes were recorded care-fully, after subtracting leftovers from theamounts given.

The control drink was devoid of proteinand had only a small amount of sugar andflavoring; it was called fresco and was similarto local drinks served at room temperature.The fresco provided 59 kcal/cup. Fear of“empty calories” and a desire to further iso-late the contrast in protein between the twodrinks led to vitamins and minerals beingadded to the fresco to achieve similar concen-trations as those found in the atole.

The psychologists in the project were con-cerned that the social interaction resultingfrom attending the supplementation centercould, by itself, influence child development.For this reason, procedures in atole and frescovillages were similar, including the layout ofthe supplementation centers and the mea-surement of attendance and intake.

Another important change was the estab-lishment of medical clinics offering preven-tive and curative services run by auxiliarynurses under the supervision of a physician.These services were free and not tied to par-ticipation in the study.

Dietary Impact

Home diets of mothers and children weremeasured using 24-hour recall surveys and,by analyzing dietary and supplement intakedata, it was possible to estimate the net im-pact of the supplements on total nutrientintakes.

The supplementation program was de-signed to create a large difference in net pro-

tein intakes between subjects in atole andfresco villages, and this was achieved inwomen and children. However, unexpecteddifferences were produced in other nutrientsbecause patterns of consumption of the sup-plements in women and children differed be-tween atole and fresco villages. Women dranklarger volumes of fresco than atole, such thatthe energy contribution of the fresco and atolewas similar despite the drinks’ different en-ergy densities. This also meant that intakesof vitamins and minerals among womenwere greater in fresco than in atole villages be-cause they were present in equal concentra-tions in the supplements.

On the other hand, in children less than 3years of age, supplement intakes were muchlower in fresco compared to atole villages,such that intakes of protein, but also energyand other nutrients, were greater in atole vil-lages. The home diets of young childrenwere measured every three months until 36months, beginning at 15 months and everythree months thereafter, for a total of eighttimes over this interval. Using these data andinformation about daily supplement intakes,average daily total protein intakes (homediet plus supplement) were 9 g greater inatole compared to fresco villages (Table 1) (6).Average daily total energy intake was 90 to100 kcal greater in atole villages. Childrenconsuming the atole may have decreasedtheir home dietary intakes slightly as evidentby the greater home dietary intakes in frescovillages. Also, intakes of vitamins and miner-als were greater in young children from atolevillages (not shown in Table 1). Finally, inchildren 3 to 7 years of age, as in women, agreater volume of fresco was consumed thanatole.

These patterns of consumption probablyreflect the nature and appeal of the drinks.Mothers and older children could drinklarger amounts of the fresco, a light drink,than of the hot and denser atole. Mothers, onthe other hand, may have viewed the atole asa food and the fresco as a refreshing drink,and they may have been more motivated to

Martorell 5

offer the atole to young children. Thus, the“protein” design was complicated by percep-tions and behaviors of the subjects. Inwomen, both supplements contributednearly similar amounts of energy, but onlyone had protein. In young children, the con-tributions to diets were along a broad frontand were not limited to protein.

Key Findings

One of the major findings from the studywas that food supplementation improvedbirthweight (7). However, this analysis couldnot be done using the randomized design.Comparison of mean birthweight for new-borns of women consuming atole duringpregnancy to those corresponding to womenconsuming fresco showed a small but in-significant difference in favor of atole vil-lages. However, other analyses were carriedout that showed that consumption of theatole, and unexpectedly, of the fresco as well,improved birthweight. The analyses alsoshowed that energy, rather than protein orother nutrients in the supplement, best ex-plained the relationship between supple-ment intake during pregnancy and improve-ments in birthweight. The analyses to

support this claim were made possible by theoverlapping ranges in supplement energy in-takes during pregnancy in atole and fresco vil-lages. Since the energy contributions fromthe supplements were similar in both typesof villages, by virtue of women consumingmore of the less energy-dense fresco than theatole, intent to treat analyses could not showa difference between atole and fresco villages.However, comparisons of high- and low-consumption groups suggested improve-ments in birthweight. Specifically, womenwho consumed more than 20,000 kcal fromthe supplements during pregnancy (about111 kcal/day if ingested during the last sixmonths of pregnancy), whether in atole orfresco villages, had half the risk of deliveringa low-birthweight baby (< 2,500 g), com-pared to those who ingested less than 20,000kcal. Care was taken to control for poten-tially confounding factors, much needed be-cause these analyses no longer used the ex-perimental design.

The key outcome of the study was mentaldevelopment. Physical growth was an im-portant outcome for the study, but largelybecause confirmation was needed that theatole was biologically efficacious in order toproperly interpret effects on mental develop-


TABLE 1. Contribution of the supplements to total energy and protein intakes in children 15–36 monthsof age.a

Males Females

Atole Fresco Atole Fresco(n = 128) (n = 135) Diff (n = 118) (n = 104) Diff Pooled s

Energy, kcal/dHome diet 785 814 –29 718 756 –37 213Supplement 156 26 130 150 2.3b 127 79Total intake 941 840 101 868 779c 89 226

Protein, g/dHome diet 20.1 22.5b –2.4 19.3 21.0 –1.7 5.9Supplement 11.0 0.0 11.0 10.5 0.0b 10.5 5.4Total intake 31.1 22.5b 8.6 29.8 21.0b 8.8 7.5

aHome diet values are averages of as many as eight recall surveys conducted at 15 mo and every 3 mo thereafter until 36 mo.bp < 0.001.cp < 0.01.Source: Martorell R, Habicht JP, Klein RE. Anthropometric indicators of changes in nutritional status in malnourished populations. In:

Underwood B, ed. Proceedings, Methodologies for Human Population Studies in Nutrition Related to Health. Washington, DC: US Depart-ment of Health and Human Services, National Institutes of Health; 1982:96–110. (NIH Publication No. 82-2462).

ment. For example, lack of an effect ongrowth might indicate that the nutrition ex-periment was ineffective and cast doubt onany possible conclusion about effects onmental development. As it turned out, theatole had a substantial effect on growth, butonly in the first 3 years of age (8). The rea-sons for an effect during the first 3 years, butnot from 3 to 7 years of age, include greatergrowth rates, greater relative nutritional re-quirements, and more frequent and severediarrheal diseases in younger children. Pat-terns of growth failure in study subjects sup-port the greater vulnerability of young chil-dren; growth failure was particularly acutein children younger than 18 months. Byabout 24 months, children grew in length atrates not unlike those of children in devel-oped countries (9). Thus, although growthfailure occurred before 2 years of age, chil-dren in Guatemala retained some capacity togrow better up to their third year of life in re-sponse to improved nutrition.

A simple analysis true to the randomizeddesign was used by Habicht, Martorell, andRivera (10) to examine the effect of the nutri-tion intervention on child growth. This analy-sis used village as the unit of analysis andcompared atole and fresco villages in terms oflength at 3 years of age before and after sup-plementation (Table 2) (6). The baseline infor-mation came from a cross-sectional survey ofchildren carried out in 1968, one year before

the beginning of the study. The similarities ofthe four villages at baseline are evident andreflect the care with which the villages werematched; the differences between the largeatole and fresco villages were 0.15 cm (atolelarger), and the corresponding differences forsmall villages were 0.75 cm (fresco larger).Similarly, the mothers of children exposed toatole in early life were 148.9 cm tall, nearlyidentical to mothers from fresco villages whowere 149.0 cm tall, with a pooled standarddeviation of 5.3 cm (11). Children exposed toatole throughout their lives were 3.25 cm and2.55 cm taller in the large and small village,respectively, whereas those exposed to frescochanged little, increasing by 0.70 cm and 0.20cm, respectively. The small change in frescovillages may be attributed to chance, butcould be due also to energy and other nutri-ents in the fresco, to the effects of fresco onbirthweight, to the medical care program, orto any combination of these factors. The dif-ferences in net change (atole differencesminus fresco differences with respect to base-line values) were 2.55 cm in the large villagesand 2.35 cm in the small villages. The mean ofthese differences was 2.45, and the standarddeviation was 0.10 cm. Despite having onlytwo degrees of freedom, the t-test was 24.5,with a two-tailed probability of p < 0.005. Be-cause the analysis used the randomized de-sign, the potential effects of confounding fac-tors were incorporated into the probability

Martorell 7

TABLE 2. Lengtha of 3-year-old children before and after supplementation byvillage size and type of supplement.

Large villages Small villages

Atole Fresco Atole Fresco

Afterb 86.70 84.00 85.95 84.35Beforec 83.45 83.30 83.40 84.15Change 3.25 0.70 2.55 0.20

Difference in change 2.55 2.35

Overall difference in change: mean = 2.45 ± 0.10, t-test = 24.50, p < 0.005 (two-tailed probabil-ity; df = 2).

aMeans of sex-specific data calculated from Table 3 in Martorell, Habicht, and Klein (6). bBorn between 1969 and 1973.cMeasured in 1968.Source: Habicht JP, Martorell R, Rivera JA. Nutritional impact of supplementation in the INCAP lon-

gitudinal study: Analytic strategies and inferences. J Nutr 1995;125(Suppl 4):1042S–1050S.

statement as was the medical care program.Few other analyses published from the studyhave used the randomized design becausepower becomes very limiting, even though itis reassuring that the evidence for an effect onchild length is robust.

A better sense of the public health signifi-cance of the findings is presented in Figure 1(12), which gives, by supplement type, thepercentage of children who were severelystunted (defined as more than 3 standard de-viations below the median in the WHO/NCHS reference population) for 1969, whenthe study began, and for 1976–1977, the tailend of the study. In the reference population,about one in 1,000 children would be thisshort; about the same proportion as found inMexican-American preschool children mea-sured in the 1982 to 1984 Hispanic Health andNutrition Examination Survey (HHANES).The prevalence of severe stunting in thestudy villages was extremely high in 1969,when the study began, around 45%; but sim-ilar in atole and fresco villages (Figure 1) (12).Since the racial ancestry of Mexicans andGuatemalans is similar (i.e., mixed Europeanand indigenous), the unusual shortness ofthe study children cannot be attributed to ge-

netics. At the end of the study, the prevalenceof severe stunting was reduced by half inatole villages but stayed at about the samelevel in fresco villages. Trends by year group-ings (1969, 1970–1971, 1972–1973, 1974–1975,and 1976–1977) are presented elsewhere (12).The analyses of these data showed statisti-cally significant declines in severe stuntingin atole villages (n = 451), to a greater extentin girls, but not in fresco villages (n = 429).

There were other biological effects beyondphysical growth. Infant mortality rates weremarkedly reduced; compared with ratesbetween 1949 and 1968, infant mortalityfrom 1969 to 1977 declined by 66% in atolevillages and 24% in fresco villages (13). While the number of days children were illwith diarrhea was not reduced by the nutri-tion intervention, diarrhea did not retardphysical growth in children consuming atole, but did so in children consuming fresco(14). A similar protective effect of nutritionalsupplementation has been reported in astudy of Colombian children (15). Childrenwho were wasted (i.e., very thin) regainednormal weight-for-height proportions soonerafter ingesting atole than they did with fresco (16).

The effect of atole on mental developmentwas minor, certainly much less than antici-pated in the 1960s when the study wasconceived. Pollitt et al. (17) reviewed the ex-tensive battery of psychological tests admin-istered during infancy and the preschool pe-riod. A Composite Infant Scale was used toassess mental and motor development at 6,15, and 24 months, employing adaptationsfrom well-known scales and adjusting theseto the local setting. The preschool batteryconsisted of 10 tests administered annuallyto all children 3 to 7 years and an additional12 tests administered annually to all children5 to 7 years. The battery was designed to testtraditional indices of cognitive developmentas well as Piagetian concepts. Again, testswere adapted to the local situation. Perfor-mance on the preschool battery correlatedwith village adults’ judgments of the


0

10

20

30

40

50

1969 1976–1977

AtoleFresco

FIGURE 1. Percentage of 3-year-old children withsevere growth failure (> 3 standard deviations

below the reference median) in 1969, when thestudy began, and in 1976–1977, when it ended,

by supplement type.

“brightness” of particular children and alsowith their ability to carry out chores, sug-gesting validity for the local context.

The Pollitt et al. study (17) reviewed pre-vious efforts by INCAP researchers to relatethe nutrition intervention to child develop-ment and concluded that despite the varietyof approaches followed, with differences inthe analytic design, sample sizes, and out-come variables, the results of the variousstudies all showed small, but consistent, pos-itive effects of atole supplementation. The au-thors also reanalyzed the INCAP data, usingfactor analysis in the case of the preschoolbattery in order to reduce the informationcontained in the large number of tests to oneor more factors. Atole exposure in the first 24months was related to better motor perfor-mance, as previous analyses had shown.Also, the results with the preschool batterywere consistent with prior findings, suchthat the authors concluded that: “The resultsof previous analyses as well as the reanalysespresented here indicate that there were a fewmoderately beneficial effects from exposureto the Atole supplement” (17).

The results were disappointing to thepsychologists who participated in the INCAP longitudinal study. Despite wide-spread acknowledgment that all that mattersfor scientific progress is that important ques-tions be posed and answered rigorously, it ishuman nature to desire dramatic findings.The latter are more likely to advance careersand to be accepted for publication in leadingjournals.

FOLLOW-UP AND OTHER STUDIES

As matters stood at the end of the INCAPlongitudinal study in 1977, the conclusionwas that improving the diets of preschoolGuatemalan children reduced growth failuredramatically during the first three years oflife, but only modestly influenced mental de-velopment. The INCAP longitudinal studymight have been largely forgotten had its use-

fulness not been notably enhanced by follow-up studies that are tracing to this day the rip-ple effects of the nutrition intervention of the1970s. The follow-up studies have permittedus to ask whether the benefits found in earlychildhood persist into adulthood. A novelcontribution is that of allowing examinationof functional effects that can only be mea-sured later in life, thereby extending the hori-zon for evaluating nutrition interventions.

The 1988–1989 Follow-up Study

The first study follow-up was carried outin 1988–1989 when the subjects were 11 to 26years of age (4). The intent was to test the hy-pothesis that “Better nutrition during earlychildhood leads to adults with a greater po-tential for leading healthy, productive lives.”The use of the word “potential” was deliber-ate as many of the subjects were then adoles-cents, many were still growing, some werestill in school, and many were not yet mar-ried or working in their chosen occupations.Productivity, therefore, could not be mea-sured in 1988–1989; only potential could.

The subjects of the study were all formerparticipants in the INCAP longitudinalstudy who had been born between 1962 and1977 (4). Migrants were included, but onlythose who had migrated to Guatemala Cityor to the provincial capital near the studyarea. The target sample in the four study vil-lages consisted of nearly 2,000 subjects, andthe coverage rate was 72%. Excluding mi-grants, the coverage rate was 89%. The datacollected included body size and composi-tion; skeletal age; physical health; strength;work capacity and physical activity; fertility;school attendance and migration histories;and intelligence, reading, numeracy, andother functional performance tests.

Data were collected for many functionaloutcomes, but in this brief overview of re-sults, only four aspects will be emphasized:body size and composition, work capacity,fertility milestones, and intellectual perfor-mance. All four areas are very important,

Martorell 9

and improvements in one or all would be seen as contributing to human capitalformation.

Three aspects of the body size and compo-sition results stand out. First, adolescentswho were exposed to the atole during thefirst three years of life were taller and hadgreater fat-free masses than those who re-ceived fresco (11). However, there was someattenuation of the effects observed at age 3caused by slightly greater growth from 3years to adulthood in fresco villages com-pared to atole villages. It is interesting to notethat the greatest anthropometric effects wereobserved in women. The cutoff point of lessthan 149 cm, equivalent to a height of 4 feet11 inches, is often used as a criterion of ob-stetric risk in women. In women who wereexposed to the supplements from birth to 3years of age, 49% of fresco subjects had veryshort stature compared to 34% of atolewomen (18). Differences in fat-free mass alsostand out. Women from atole villages had 2.1kg more in fat-free mass than women fromfresco villages, or about 0.5 standard devia-tion units (11); what Cohen, the author of apopular book on statistical power (19),would define as a medium effect.

The follow-up study suggests that thecharacteristic short stature of Guatemalanadults is largely due to growth failure inearly childhood (20). This analysis starts bydividing the women of the follow-up intothree groups according to the level of stunt-ing at 3 years of age: mild (above the cutoffpoint of –2 standard deviations below theWHO/NCHS reference mean), moderate(between –3 and –2 standard deviationsbelow), and severe (below –3 standard devi-ations). The mean values for height at 3 yearsof age (1 cm was subtracted from length val-ues) for the three Guatemalan groups aredesignated as the first component of height(Figure 2). Data are also included forMexican-American children from the 1982–1984 HHANES survey earlier mentioned.Mexican-American children have similarheights prior to puberty (~ 12–13 years) to

the U.S. general population, but end up atthe 25th percentile of height at adulthood.These patterns have not changed in recentU.S. data. It is unlikely that the deviation thatoccurs in adolescence is due to nutrition orhealth; rather, the cause may be genetic inorigin (20). Mexican-American children havesimilar ancestry, a European-indigenous ad-mixture, and may be an appropriate refer-ence for assessing growth during puberty inour Guatemalan sample. One can askwhether there was a catch-up in growth from3 years to adulthood (18 years of age orolder), designated as the second componentof height in Figure 2. Clearly, there was nocatch-up in growth. All three Guatemalangroups grew the same from 3 years to adult-hood, and their growth was similar to that ofMexican-Americans. Similar results werefound in men as in women. These data sug-gest that the period of early childhood is theonly period of growth failure in theGuatemalan population.

Work capacity was significantly improvedin subjects exposed to the supplements intheir first three years of life, but only in men(21). Atole men had maximal oxygen con-sumptions (VO2 max) that were 0.38 L/mingreater than those of the fresco men. The dif-ference is equivalent to about 0.7 standarddeviation units, approaching what Cohen(19) would call a large effect size. Another in-teresting finding is that the larger workingcapacity of atole men could not be explainedby differences in fat-free mass (i.e., VO2max/kg of fat-free mass was still greater inatole villages). The nature of these qualitativetissue differences between atole and frescosubjects is unclear.

Exposure to the atole did not lead to earliermenarche (22), but did lead to hastening firstintercourse and first birth by about a year;however, the nutritional effects on fertilitymilestones were smaller in comparison to thedelaying effects of schooling (23). The me-dian age at first birth was more than fouryears later for those who completed primaryschool compared to those who did not.


A feature of all analyses carried out todate with respect to measures of intellectualperformance is that they control for years ofschool because the villages differed in pat-terns of school attendance since before thestudy began. This analysis may underesti-mate effects on intellectual performance ifthe intervention also influenced school atten-dance. One of the fascinating discoveries wasthat intellectual performance was more af-fected during adolescence and adulthoodthan during early childhood (17). The atole-fresco differences found in children were lessthan 0.2 standard deviation compared to dif-ferences of around 0.6 standard deviationfound in adolescence using a summary vari-able of intellectual performance (i.e., a factorscore that combines literacy, numeracy, gen-eral knowledge, Raven’s Progressive Ma-trices, reading, and vocabulary). To use

Cohen’s labels, the effects found in childrencan be described as small, while those foundin adolescents can be called medium to large.There are also strong indications that the ef-fects in adolescence were found only in thosecohorts exposed to supplementation duringpregnancy and the first two years of life. Ex-amination of the subcomponents making upthe summary variable shows that effectswere found in four of six tests. Effects werefound in both men and women.

The Birthweight and Generational Studies

In addition to the follow-up study, studieswere carried out in the 1990s that monitoredthe birthweights of newborns of the femalesubjects of the original longitudinal study;also, a longitudinal study of growth and de-

Martorell 11

92.288.6

84.679.5

66.3 66.3 66 66.8

0

10

20

30

40

50

60

70

80

90

100

Mild(> 2 sd)

Severe(< 3 sd)

Moderate(–3 sd to < –2 sd)

MEX-AM Mild(> 2 sd)

Severe(< 3 sd)

Moderate(–3 sd to < –2 sd)

MEX-AM

2nd component (3 years–adult)1st component (3 years)

GUATEMALA GUATEMALA

FIGURE 2. Components of adult stature (cm) in Guatemalan women in comparison to Mexican-Americans, by level of growth retardation at 3 years of age.

Source: from data in Martorell R. Overview of long-term nutrition intervention studies in Guatemala, 1968–1989. Food Nutr Bull1993;14(3):270–277.

velopment in the first three years of these chil-dren was carried out between 1996 and 1999.Unfortunately, these studies did not includemigrants, and the longitudinal study was re-stricted to women who had children less than3 years of age during the study period.

The nutrition intervention improvedgrowth significantly in the first three years, asshown in Table 2, and the 1988–1989 follow-up study showed that this resulted in largeradult body sizes. In women, exposure to atolecompared to fresco led to a small but consis-tent improvement in the growth of their chil-dren, with this effect being mediated throughgreater maternal body size. Unpublishedanalyses show that newborns born to womenexposed to atole in early life were heavier (60 g) and longer (0.23 cm) at birth. Postnatalgrowth was improved as well. Children ofmothers receiving atole as children were onaverage 0.80 cm taller than children fromwomen who received fresco (24).

The 1996–1999 longitudinal study in-cluded updates of schooling histories and ofintellectual functioning in women, whichmade it possible to reconfirm the findings ofPollitt et al. (17) from the 1988–1989 follow-up a decade later (25). Five tests of educa-tional achievement (reading, vocabulary,comprehension, numeracy, and generalknowledge) were combined into a singlescore with possible values of 0 to 100 (me-dian was 71, Table 3). Li et al. (26) found ahighly significant interaction between treat-ment and schooling on the educational score.The median scores for educational achieve-ment are given in Figure 3 for the fourgroups involved in the interaction: womenwho did not finish primary school (< 6 yearsof schooling) and who were exposed to atoleor fresco in the first two years of life andwomen who finished grade school and wereexposed to either atole or fresco. The atole ef-fect was –1 point when women did not finishschool, but 9 points when they did. The im-pact of completing primary school was verypronounced; it was 13 points without expo-sure to atole, but 23 points when women

were exposed to atole. Thus, nutrition inearly life is important for educational perfor-mance only when children go to school, and,also, the payout from completing school ismagnified when preceded by improved nu-trition in early life.

A cardiovascular risk factor study(1998–1999) provided the data to tease apartthe relative importance of prenatal and earlypostnatal growth failure, defined by Li et al.(26) as birth to 2 years of age, for adult bodysize and composition of men and women. Itwas found that both prenatal and postnatalgrowth retardation were equally importantdeterminants of reduced height, weight, andfat-free mass in adulthood; on the otherhand, neither aspect was related to fatness orfat patterning (27). Similar analyses were car-ried out for educational achievement usingdata from the 1996–1999 longitudinal study(27). In contrast to the findings about bodysize, only the postnatal component was asso-ciated with educational achievement. Thus,prenatal growth failure affects adult bodysize and composition, but not educationalachievement; postnatal growth failure, onthe other hand, impacts on both size and ed-ucational achievement.

The relationship between early childhoodnutrition and risk factors of cardiovasculardisease in adulthood has also been investi-gated. The idea that poor nutrition in early


TABLE 3. Summary measure of educationalachievement.a

Tests Points

Readingb 20Vocabularyb 20Comprehensionb 20Numeracy 20General knowledge 20

100

aRange 10–95, median 71; divided into a 5-point ordinal scalefor analyses.

bIlliterates receive a score of “0” in these tests. Vocabulary andcomprehension are part of the Interamerican Reading Series test.

Source: Li H, Stein AD, Barnhart HX, Ramakrishnan U, Mar-torell R. Associations between prenatal and postnatal growth andadult body size and composition. Am J Clin Nutr 2003;77(6);1498–1505.

childhood increases risk of the metabolicsyndrome later in life, the so-called Barkerhypothesis (28), has become a popular topicof study. As noted above, no relationship wasfound in our data between prenatal or post-natal growth and fatness or fat patterning inadulthood (27). Also, we do not find birth-weight to be related to the prevalence of car-diovascular disease risk factors, such as lipidlevels, fasting glucose, and blood pressure(29). Similarly, the relationships betweensupplementation and cardiovascular diseaserisk factors were weak and inconsistent (30).Thus, contrary to the findings of others, wedo not find that early childhood nutrition isassociated with risk factors of adult chronicdiseases of dietary origin. The study popula-tion is still relatively young, and this may notallow us at this time to uncover these rela-tionships. However, such relationships havebeen found by others even at younger ages.Perhaps relationships between nutrition inearly childhood and later disease depend onhost or environmental factors we do not yetunderstand.

The 2002–2004 Follow-up Study

A second cross-sectional follow-up studywas carried out in 2002–2004 in the same

four villages as the 1969–1977 INCAP longi-tudinal study and in the places to which theparticipants in the original study had mi-grated. This time, migrants to all towns andvillages in Guatemala, and not only toGuatemala City and to the provincial capitalnear the study area, were included. At thetime data collection began for the 2002–2004follow-up study the subjects were between27 and 42 years of age. This recent follow-upgave us an opportunity to update life histo-ries and establish current status for many ofthe aspects included in the first follow-upstudy. More importantly, we were able tofocus on economic aspects, since all subjectswere by then adults in their chosen profes-sions. We were able to study marriage for-mation. Specifically, data were collected onhousehold structure and composition; vil-lage characteristics, including facilities andservices as well as village developmentalhistories; schooling history; intellectualfunctioning (Interamerican Reading Seriestest and Raven test); anthropometry; diet;physical activity; physical fitness; reproduc-tive history; medical history and physicalexamination; blood test (lipid levels, fastingglucose, hemoglobin); marital history andassets brought by marriage; household con-sumption; current economic activity; occu-

Martorell 13

65

78

64

87

0

20

40

60

80

100Score Interaction

p = 0.003

Fresco Atole Fresco Atole< 6 yrs schooling ≥ 6 years schooling

• Atole effect< 6 years: –1 (64–65)≥ 6 years: 9 (87–78)

• Effect of ≥ 6 years schoolwithout atole: 13 (78–65)with atole: 23 (87–64)

Source: from data in Martorell R, Rivera JA, Schroeder DG, Ramakrishnan U, Pollit E, Ruel MT. Consecuen-cias a largo plazo del retardo en el crecimiento durante la niñez. Archivos Latinoamericanos de Nutrición1995;45(1S):109S–113S.

FIGURE 3. Median scores for educational achievement (summary variable: 0–100 points) by schooling and type of supplement.

pation and migration history; wage income;nonagriculture and own business activities;and participation in agricultural activities.Data were collected between January 2002and April 2004, and at the time of this writ-ing, data-cleaning and summary variablegeneration are nearly complete and analyseshave begun. The 2002–2004 follow-up willextend our previous findings linking earlychildhood nutrition to human capital forma-tion, measured by physical and educationalcapital, to income and wealth. This will per-mit a more comprehensive evaluation of thelong-term significance of nutrition in earlychildhood.

CONTRIBUTION OF THE INCAPSTUDIES TO PROGRAMS

AND POLICIES

The INCAP studies have important impli-cations for policies and programs to combatchild malnutrition. We first will review someof the salient lessons learned about how bestto design nutrition programs, and then wewill review how the findings can influenceadvocacy for investments in early childhoodnutrition.

Implications for the Design of Nutrition Interventions

(1) Effects can be achieved with relativelysmall amounts of food. The first lesson learnedis that improving the dietary intakes ofwomen and children can have important ef-fects on birthweight and on growth in lengthof young children. These effects can beachieved with relatively small amounts offood, the equivalent of about 100 kcal of netimprovement per day in women and chil-dren. The successful Tamil Nadu IntegratedNutrition project (TINP) provided 140 kcaland 6 g of protein per day to children lessthan 2 years (31). The also-successful Pro-gresa program of Mexico provided 194 kcal

and 6 g of protein per day to children under2 years of age (32).

It is important that care be taken to reducereplacement of food consumption at home.Many food aid programs provide largeramounts per person per day than the aboveprograms, but leakage, substitution, andpoor nutrient quality decrease the net nutri-ent contribution (33).

The Guatemalan experiment used foodsupplementation as the experimental ma-nipulation because it could be delivered andmeasured easily. The findings should not beviewed to narrowly apply to only food sup-plementation; other interventions that effec-tively improve dietary intakes, includingwell-designed nutrition education pro-grams, would also be expected to improvegrowth. The findings can be generalized toprograms that effectively increase consump-tion of foods of better quality than those reg-ularly consumed at home, as opposed tospecific micronutrient interventions, such assupplementation or fortification, that haveproduced much smaller effects on growth. Ameta-analysis of daily zinc supplementationand child growth found an average effectsize of 0.3 standard deviation units (34). Arecent meta-analysis found no effect fromiron or vitamin A interventions and an effectof 0.3 standard deviations from multiple mi-cronutrient interventions (35). Since the lat-ter interventions all provided zinc, it is pos-sible that zinc may be the only micronutrientthat can improve growth. The INCAP foodsupplementation intervention found a dif-ference of 2.6 cm at 3 years of age, or an ef-fect size of 0.7, a large effect. The atole, itshould be recalled, was not a good source ofzinc.

It is encouraging that Progresa, whichused a food supplement in powder form thatcould be easily prepared by just addingwater, found important effects on physicalgrowth and iron status (32). As in the atole,milk was a main ingredient; the Progresasupplement was fortified with micronutri-


ents of good bioavailabilty except in the caseof iron, which was provided in the form ofreduced iron. An improvement of 1.1 cm inlength was found after one year in childrenless than 6 months at baseline and of low so-cioeconomic status. Despite not using a goodsource of bioavailable iron, anemia rateswere better one year after supplementation(55% in supplemented vs. 44% in controls).TINP used a food specially prepared for tod-dlers, but that was plant-based and not forti-fied with micronutrients; however, TINP ef-fectively reduced the extent of severe andmoderate underweight (31).

(2) The target of programs to eliminate childmalnutrition should be children younger than 2years. A lesson from the INCAP longitudinalstudy is that the target of nutrition programsaimed at reducing growth failure and malnu-trition should be children less than 2 years ofage. Such programs need to improve birth-weight, promote exclusive breast-feeding inthe first sixth months, and work very hard toimprove complementary feeding of children6 to 24 months of age. While the INCAPstudy found that there was a response tosupplementation up to the third year of life,the effects were larger on children youngerthan 2 years. Also in most settings of malnu-trition, including rural Guatemala, z-scoresof length for age decline rapidly in infancyand reach stability by about 2 years of age,indicating that growth failure occurs beforeage 2.

TINP (31) and Progresa (32) are examplesof programs that were designed to reachyoung children under 3 and 2 years, respec-tively. The targeting of young children maybe a key reason why these two programs suc-cessfully improved growth while manyother supplementation programs did not(34). Other reasons may be that nutritiousfoods suitable for young children were oftennot provided and that efforts to reduce leak-age were either not undertaken or wereineffective.

Why are young children more responsiveto improved nutrition, whereas older chil-dren are less so? The answer has to do withthe greater rates of growth and greater rela-tive nutritional needs of younger childrenand with their greater susceptibility to infec-tions such as diarrheal diseases. The INCAPstudy demonstrated that the atole, while notpreventing diarrhea, did negate the effects ofdiarrheal diseases on growth.

(3) Implication for growth monitoring pro-grams: growth monitoring programs have tra-ditionally focused on preschool children; thatis, on children 5 years or younger. Growthmonitoring programs often fail to reach themost needy children, including the poorestand those younger than 2 years of age. Com-bined with poor efforts at promoting bettergrowth through health and nutrition educa-tion or through specific interventions, mostgrowth monitoring programs of the past canbe characterized as failures. Growth monitor-ing and promotion programs should be fo-cused on young children and aim to increaserates of exclusive breast-feeding in the first sixmonths and to improve complementary feed-ing, child care, and access and use of preven-tive and curative health services. In addition,such programs should be anchored on solidefforts to improve the nutrition of womenduring pregnancy and lactation. One can onlyspeculate how much could be achieved by aprogram such as Progresa if it also included astrong educational component. TINP used aless nutritious supplement but did include astrong educational component. Thus, an im-portant question, particularly for the portionsof Latin America and the Caribbean whichcan afford to include foods in programs, is theextent to which the impact of nutritious sup-plements is enhanced by growth monitoringand promotion.

(4) Implication for school feeding programs: itis not unusual to hear proponents of schoolfeeding programs argue that they are needed

Martorell 15

in order to improve rates of growth and to re-verse the growth failure incurred duringearly childhood. There is no evidence for theseclaims. We have seen how the INCAP studiesshow that children from rural Guatemala, whowere very growth retarded at 3 years of age,were nonetheless able to grow from 3 years toadulthood as well as Mexicans living in theUnited States. The only periods of widespreadgrowth failure that are known to exist in de-veloping countries are intrauterine life and thefirst two years of life.

This is not to say that school feeding orschool nutrition programs are not needed orare not useful. School feeding may be a cost-effective intervention to increase school at-tendance and to improve attention andlearning. Foods or supplements, dependingon their nutritional content, may reduce ane-mia and other micronutrient deficiencies,and in this way impact on learning.

Long-term Effects and Their Impact on Advocacy

The INCAP studies demonstrate that nu-trition interventions during the critical stagesof pregnancy and the first two years of lifehave an immediate impact on such key out-comes as child survival, birthweight, childgrowth, and motor development. These find-ings have obvious uses in promoting mater-nal and child nutrition programs but are notunique to the INCAP studies. The uniquenessof the INCAP studies is that they provide in-formation about the long-term significance ofimproving early childhood nutrition. Hence,emphasis is given here to the possible uses ofthis unique contribution for advocacy.

Examples of many long-term effects werepresented, but only some need to be empha-sized here. First, early childhood nutrition isdirectly related to adult body size and compo-sition. The short stature that is often seenamong people living in poverty in many LatinAmerican and Caribbean countries, who areoften more indigenous in ancestry than indi-viduals of other socioeconomic classes, is

largely a product of poor nutrition and infec-tion prior to 2 years of age. The INCAP studyshowed that improving the diets of mothersand children will improve adult body sizeand muscle mass. These effects have func-tional significance. Greater body size and in-creased fat-free mass among women will im-prove birthweight and postnatal growth ofthe next generation, as the INCAP studieshave shown. Short stature is a risk factor forcephalo-pelvic disproportion and maternalobstetric mortality, and one would expect thatearly childhood nutrition programs woulddecrease future delivery complications andimprove maternal survival.

The INCAP 1988–1989 follow-up studyshowed that improved child nutrition in-creased adult fat-free mass and work capac-ity. One would expect improved work capac-ity to result in increased productivity amongthose engaged in hard physical labor.

Not all effects of improved early child-hood nutrition will be considered desirableby all readers. The INCAP interventionshowed that improved childhood nutritionled to earlier age at marriage and earlier ageat first birth, but it needs to be pointed outthat this occurred in a population that hadlow rates of use of modern contraceptives.These findings speak to better biological po-tential to attract a mate and to conceive anddeliver a child at younger ages and are notreasons to be against nutrition programs inearly childhood. The obvious solution is toimprove child nutrition while promoting re-productive health programs, including fam-ily planning.

On the other hand, the effects on intellec-tual functioning will be viewed as positiveby all readers. One of the most interestingfindings of the INCAP studies was the con-trast between early childhood and follow-upresults regarding effects on mental develop-ment. The influence of early childhood nutri-tion on psychological test performance in thepreschool period was found to be small,whereas that on educational achievement inadolescence and adulthood was more sub-


stantial. Of particular significance is that theintervention interacted with years of school.The data can be presented to ministers of ed-ucation to convincingly argue that the re-turns to schooling can be magnified by in-vesting in early childhood nutrition. Thecorollary is also true. Investments in child-hood nutrition will never impact on intellec-tual functioning if children receive little orno schooling. The best outcome is providedby a good nutritional start in early life andthe opportunity to advance beyond primaryschool. Skilled minds are valued by all soci-eties and by parents everywhere in recogni-tion that improvements in intellectual per-formance are bound to improve the capacityof individuals to function in a variety of set-tings. This allows us to consider two furthersuggestions. One is that such improvementsmight lead to better employment opportuni-ties and greater earnings. Another is thatbetter intellectually endowed adults will bebetter parents, by virtue of being betterproviders as well as by possessing a highercapacity to meet the developmental needs oftheir children. The data from the 2002–2004follow-up and other newly funded studieswill permit testing of these expectations.

CONCLUDING THOUGHTS

The INCAP studies will be rememberedfor their unique contributions to programsand policies. They represent the only settingin which the effects of a nutrition interven-tion in early childhood are being tracedthroughout the life cycle. Their findings offervaluable input to program managers con-cerning the design of nutrition programs andprovide persuasive evidence of the long-termbenefits of nutrition interventions in earlylife. The 2002–2004 follow-up study will tracethe influence of improved nutrition in earlychildhood beyond better human capital for-mation to increased income and wealth.

The rationale for maternal and childhealth programs may be approached fromtwo perspectives. The first is that adequatehealth and nutrition are basic human rights.Governments have an obligation to meetthese needs, and economic development it-self should be ultimately justified andjudged by the degree to which it improvesthe quality of life of populations. The INCAPstudies, although incomplete at the time ofthis writing, are providing an additional,powerful rationale (Figure 4). Health and nu-

Martorell 17

Programs in health andnutrition aimed at women

and young children

Better growth anddevelopment

Improved humancapital

Increasedproductivity

FIGURE 4. Interrelationships among early child nutrition programs, the formation of human capital, and economic productivity.

Source: data from Li H, Stein AD, Barnhart HX, Ramakrishnan U, Martorell, R. Associations between prenatal and postnatal growth andadult body size and composition. Am J Clin Nutr 2003;77(6):1498–1505.

trition programs aimed at mothers and chil-dren lead to enhanced human potential andshould therefore be viewed as long-term eco-nomic development strategies because theymay improve economic productivity. Ongo-ing analyses will test the missing piece of thiscascade of effects and test the hypothesis thatimproved early childhood nutrition will leadto greater incomes and wealth through agreater accumulation of physical and educa-tional capital.

REFERENCES

1. Standing Committee on Nutrition. 5th Report on theWorld Nutrition Situation. Nutrition for Improved De-velopment Outcomes. Geneva: SCN; 2004.

2. Rivera Dommarco J, Shamah Levy T, VillalpandoHernández S, González de Cossío T, HernándezPrado B, Sepúlveda J. Encuesta Nacional de Nutrición1999. Estado nutricio de niños y mujeres en México. Cuer-navaca: Instituto Nacional de Salud Pública; 2001.

3. The United Nations Children’s Fund. The State of theWorld’s Children 2003. Child Participation. New York:UNICEF; 2003.

4. Martorell R, Habicht JP, Rivera JA. History and de-sign of the INCAP longitudinal study (1969-77) andits follow-up (1988-89). J Nutr 1995;125(Suppl 4):1027S–1041S.

5. Martorell R. Results and implications of the INCAPfollow-up study. J Nutr 1995;125(Suppl 4):1127S–1138S.

6. Martorell R, Habicht JP, Klein RE. Anthropometricindicators of changes in nutritional status in mal-nourished populations. In: Underwood B, ed. Pro-ceedings, Methodologies for Human Population Studiesin Nutrition Related to Health. Washington, DC: USDepartment of Health and Human Services, Na-tional Institutes of Health; 1982:96–110. (NIH Publi-cation 82-2462).

7. Lechtig A, Habicht JP, Delgado H, Klein RE,Yarbrough C, Martorell R. Effect of food supple-mentation during pregnancy on birthweight. Pedi-atrics 1975;56:508–520.

8. Schroeder DG, Martorell R, Rivera JA, Ruel MT,Habicht JP. Age differences in the impact of nutri-tional supplementation on growth. J Nutr 1995;125(Suppl 4):1051S–1059S.

9. Martorell R, Schroeder DG, Rivera JA, KaplowitzHJ. Patterns of linear growth in rural Guatemalanadolescents and children. J Nutr 1995;125(Suppl 4):1060S–1067S.

10. Habicht JP, Martorell R, Rivera JA. Nutritional im-pact of supplementation in the INCAP longitudinalstudy: analytic strategies and inferences. J Nutr1995;125(Suppl 4):1042S–1050S.

11. Rivera JA, Martorell R, Ruel MT, Habicht JP, HaasJD. Nutritional supplementation during the pre-school years influences body size and compositionof Guatemalan adolescents. J Nutr 1995;125(Suppl4):1068S–1077S.

12. Martorell R. Overview of long-term nutrition inter-vention studies in Guatemala, 1968-1989. Food NutrBull 1993;14(3):270–277.

13. Rose D, Martorell R, Rivera JA. Infant mortalityrates before, during, and after a nutrition and healthintervention in rural Guatemalan villages. Food NutrBull 1993;14(3):215–220.

14. Martorell R, Rivera J, Lutter CK. Interaction of diet anddisease in child growth. In: Atkinson SA, Hanson LA,Chandra RK, eds. Breastfeeding, Nutrition, Infection andInfant Growth in Developed and Emerging Countries. St.John’s, Newfoundland, Canada: ARTS BiomedicalPublishers and Distributors; 1990:307–321.

15. Lutter CK, Mora JO, Habicht JP, Rasmussen KM,Robson DS, Sellers SG, et al. Nutritional supplemen-tation: effects on child stunting because of diarrhea.Am J Clin Nutr 1989;50(1):1–8.

16. Rivera JA, Habicht JP, Robson DS. Effect of supple-mentary feeding on recovery from mild to moderatewasting in preschool children. Am J Clin Nutr 1991;54(1):62–68.

17. Pollitt E, Gorman KS, Engle PL, Martorell R, RiveraJ. Early supplementary feeding and cognition: ef-fects over two decades. Monogr Soc Res Child Dev1993;58(7):1–99;discussion 111–118.

18. Martorell R. Enhancing human potential in Guate-malan adults through improved nutrition in earlychildhood. Nutr Today 1993 (Jan-Feb):6–13.

19. Cohen J. Statistical Power Analysis for the BehavioralSciences. Revised edition. New York: AcademicPress; 1977.

20. Martorell R, Rivera JA, Schroeder DG, Ramakrish-nan U, Pollitt E, Ruel MT. Consecuencias a largoplazo del retardo en el crecimiento durante la niñez.Archivos Latinoamericanos de Nutrición 1995;45(1S):109S–113S.

21. Haas JD, Martínez EJ, Murdoch S, Conlisk E, RiveraJA, Martorell R. Nutritional supplementation dur-ing the preschool years and physical work capacityin adolescent and young adult Guatemalans. J Nutr1995;125(Suppl 4):1078S–1089S.

22. Khan AD, Schroeder DG, Martorell R, Rivera JA.Age at menarche and nutritional supplementation. J Nutr 1995;125(Suppl 4):1090S–1096S.

23. Ramakrishnan U, Barnhart H, Schroeder DG, SteinAD, Martorell R. Early childhood nutrition, educa-tion and fertility milestones in Guatemala. J Nutr1999;129(12):2196–2202.

24. Stein AD, Barnhart HX, Hickey M, RamakrishnanU, Schroeder DG, Martorell R. Prospective study ofprotein-energy supplementation early in life and ofgrowth in the subsequent generation in Guatemala.Am J Clin Nutr 2003;78(1):162–167.


25. Li H, Barnhart HX, Stein AD, Martorell R. Effects ofearly childhood supplementation on the educa-tional achievement of women. Pediatrics 2003;112(5):1156–1162.

26. Li H, Stein AD, Barnhart HX, Ramakrishnan U,Martorell R. Associations between prenatal andpostnatal growth and adult body size and composi-tion. Am J Clin Nutr 2003;77(6):1498–1505.

27. Li H, DiGirolamo AM, Barnhart HX, Stein AD, Mar-torell R. Relative importance of birth size and post-natal growth for women’s educational achievement.Early Hum Dev 2004;76(1):1–16.

28. Barker DJP. Mothers, Babies, and Disease in Later Life.London: BMJ Publishing Group; 1994.

29. Stein AD, Conlisk A, Torun B, Schroeder DG, Gra-jeda R, Martorell R. Cardiovascular disease risk fac-tors are related to adult adiposity but not birthweight in young Guatemalan adults. J Nutr 2002;132(8):2208–2214.

30. Conlisk AJ, Barnhart HX, Martorell R, Grajeda R,Stein AD. Maternal and child nutritional supple-mentation are inversely associated with fastingplasma glucose concentration in young Guatemalanadults. J Nutr 2004;134(4):890–897.

31. Balachander J. Tamil Nadu’s successful nutrition ef-fort. In: Rohde J, Chatterjee M, Morley D, eds. Reach-ing Health for All. Delhi: Oxford University Press, 1993.

32. Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T,Villalpando S. Impact of the Mexican program foreducation, health and nutrition (Progresa) on ratesof growth and anemia in infants and young chil-dren: a randomized effectiveness study. JAMA2004;291(21):2563–2570.

33. Beaton GH, Ghassemi H. Supplementary feedingprograms for young children in developing coun-tries. Am J Clin Nutr 1982;35(Suppl 4):863–916.

34. Brown KH, Peerson JM, Rivera J, Allen LH. Effect ofsupplemental zinc on the growth and serum zincconcentrations of prepubertal children: a meta-analysis of randomized controlled trials. Am J ClinNutr 2002;75(6):1062–1071.

35. Ramakrishnan U, Aburto N, McCabe G, Martorell R.Multimicronutrient interventions but not vitamin Aoriron interventions alone improve child growth: resultsof 3 meta-analyses. J Nutr 2004;134(10):2592–2602.

Martorell 19

In this chapter we will review how re-search carried out in Latin America con-tributed to shaping regional and global pol-icy regarding infant feeding during the lastthree decades of the twentieth century. Inparticular, we will address the role of studiesshowing how breast-feeding promotes infantand child health and growth. We will not ad-dress studies on the determinants of infantfeeding practices, nor those on the benefits ofbreast-feeding for the mother. Latin Americahas also provided seminal research on how tobest promote breast-feeding, which, in turn,has influenced global policy. These studiesare covered elsewhere in this book (1).

Interest in breast-feeding research con-ducted within Latin America was influencedby the decline in breast-feeding rates ob-served in many countries during the firstthree-quarters of the last century, which re-sulted, by the 1970s, in the Region of theAmericas presenting some of the shortestdurations of breast-feeding in the developingworld (2–7).

The prevailing trend at that time was toassociate modern lifestyles with bottle feed-ing (2). This motivated several researchersfrom the fields of child health, nutrition, andpublic health to investigate the possibledetrimental effects of artificial feeding onchild health, resulting in a strong tradition of

breast-feeding research that has persisteduntil the current time.

In the next section we will highlight someof the key research findings from countries inLatin America which have helped shape re-gional and global infant feeding policies. Toprepare this chapter, we conducted literaturesearches on Medline (since 1966) and ISI(since 1981) using the search terms “breast-feeding,” “breast feeding,” and “infant feed-ing,” in search of authors based in any of thecountries of Latin America. In the ISI search,papers fulfilling these criteria were orderedby the number of citations. It should be rec-ognized that both Medline, and, in particularISI, are biased towards English-language ar-ticles appearing in a relatively small numberof journals, and that these articles are notnecessarily those which bring about policychanges at the national level. The literaturesearch was therefore complemented withsearches in the Latin American medical data-base, LILACS, and with a comprehensive re-

THE ROLE OF RESEARCH IN THE FORMULATION OF INFANT FEEDING

POLICIES IN LATIN AMERICA

Cesar Victora,1 Elaine Albernaz,2 and Chessa Lutter3

21

1Professor of Epidemiology, Post-Graduate Programin Epidemiology, Universidade Federal de Pelotas,Pelotas, Rio Grande do Sul, Brazil.

2Associate Professor, Post-Graduate Course on Healthand Behavior, Universidade Católica de Pelotas, Pelotas,Rio Grande do Sul, Brazil.

3Regional Food and Nutrition Advisor, Area of Familyand Community Health, Pan American Health Organi-zation, Washington, D.C., U.S.A.

view carried out by the Pan American HealthOrganization (PAHO) (8).

The Medline search resulted in eight pa-pers published between 1966 and 1969; 58from 1970 to 1979; 193 between 1980 and1989; 366 from 1990 to 1999; and 194 between2000 and mid-2004 (corresponding to justover 400 papers in the decade, assuming aconstant rate of publication). Many of thesepapers refer to maternal effects of breast-feeding, or to breast-feeding determinantsand promotion, but nevertheless, the sharpincrease is remarkable. A similar search inthe LILACS database (1981–2004) resulted in820 publications, approximately the sameoverall total as the Medline search.

The remainder of this chapter is organizedin chronological order, highlighting the mainpublications and their impact on policy.

THE 1970s: BREAST-FEEDING REDUCES MORBIDITY

Starting around 1970, a number of pio-neering studies came out by researchers affil-iated with the Institute of Nutrition ofCentral America and Panama (INCAP),headquartered in Guatemala City, Guate-mala. Leonardo Mata and colleagues de-scribed the intestinal flora of breast-fed andweaned infants (9, 10) and later documentedthe protection against diarrheal diseasesafforded by breast-feeding (11, 12). Mata’sstudy of the children of Santa María Cau-qué remains a classical publication to thisdate (13).

Latin American researchers also started tohighlight the role of breast-feeding in con-tributing to child nutritional status (14).

Evidence of a protective effect of breast-feeding against mortality also started tomount. Although studies from Europe andthe United States, carried out in the first halfof the twentieth century, already docu-mented important mortality differentials re-lated to breast-feeding (15), it was necessaryto replicate these findings through local

studies. In rural Chile, Plank and Milanesiinterviewed mothers who had given birth inthe three years preceding a survey; their re-sults showed that babies given bottles beforethe age of 3 months were three times morelikely to die in infancy than those who werewholly breast-fed (16).

A number of reviews and commentariesalso appeared in the mid-1970s by highly re-spected authors who worked in Latin Amer-ica stressing the importance of breast-feedingand of influencing the attitudes of pediatri-cians and public health workers (17–19).

Some of the studies carried out in the1970s, if judged by today’s standards for epi-demiological research, would be criticizedfor failing to address sources of bias, such aslack of representativeness and confoundingor reversing causality (that is, an illness lead-ing to the interruption of breast-feeding,rather than the opposite). Nevertheless,these studies played an important role in in-fluencing policy, and most of their resultswere later confirmed by carefully designedstudies.

POLICY DEVELOPMENTS IN THE 1970s

The evidence accumulated during the1970s, from Latin America as well as fromother parts of the world, led to major policybreakthroughs. In 1979, the World HealthOrganization (WHO) and the United Na-tions Children’s Fund (UNICEF) organized ajoint meeting on infant and young child feed-ing to address growing concerns about theglobal decline in breast-feeding. The recom-mendations from this meeting contributed tothe preparation of the International Code ofMarketing of Breast-milk Substitutes, ap-proved in 1981 at WHO’s Thirty-fourthWorld Health Assembly (20). The Code hadas its objective “to contribute to the provisionof safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of

22 The Role of Research in the Formulation of Infant Feeding Policies in Latin America

breast milk substitutes, when these are nec-essary, on the basis of adequate informationand through appropriate marketing and dis-tribution.” It has proven to be an essentialtool for counteracting the strong pressure ex-erted by the infant foods industry on moth-ers and on health workers.

Three Latin American countries—Brazil,Cuba, and Guatemala—were represented at the 1979 WHO-UNICEF meeting. LatinAmerican countries were also among thefirst to give effect to the International Codeof Marketing of Breast-milk Substitutes, byincorporating the Code as a law (Brazil,Costa Rica, Dominican Republic, Guatemala,Panama, and Uruguay) or by having manyof the Code’s provisions incorporated as alaw (Colombia and Mexico).

THE 1980s: CAUSE-SPECIFIC STUDIESAND THE ROLE OF EXCLUSIVE

BREAST-FEEDING

In the 1980s, the number of Medline-listedstudies from Latin America on breast-feeding and related issues increased sharplyto nearly 200.

Several authors investigated the role ofbreast-feeding in providing protection againstdiarrhea morbidity, both for the overall num-ber of episodes (21, 22) or for those due to spe-cific etiologic agents (23, 24).

Latin American researchers also reportedthat breast-feeding in infancy was associatedwith improved nutrition (25, 26), althoughother studies warned that children who werebreast-fed for more than 12 months hadlower weight for height than those who hadalready been weaned (27), possibly due to aninadequate intake of complementary foods(this is the fifth most-often cited paper fromLatin America, with 58 ISI citations).

In 1984, Feachem and Koblinsky (15) re-viewed the literature on breast-feeding anddiarrhea. This was one of a series of land-mark review papers commissioned by WHOto help identify priority preventive interven-

tions against diarrheal diseases. When quan-tifying the impact of breast-feeding on mor-bidity, the authors included studies fromColombia (12), Guatemala (28), and CostaRica (29). They concluded that the existingevidence was highly suggestive of an impactby breast-feeding—particularly by exclusivebreast-feeding—on diarrhea morbidity, butcalled for better-designed studies in general,and for cause-specific mortality studies, inparticular.

A retrospective study, carried out in north-eastern Brazil, confirmed the association be-tween breast-feeding and overall child mor-tality (30). However, there was limitedevidence on how much breast milk mightprotect against different causes of mortality.In 1987, Victora et al. published the first re-sults of a case-control study carried out insouthern Brazil investigating this issue, usinga modern epidemiological approach—apopulation-based case-control design (31).Feeding patterns were investigated for cases(357 children who died due to an infectiousdisease) just before the onset of the fatalepisode and for controls at a similar age. Theodds ratios for diarrhea deaths were 14.2 fornon-breast-fed infants and 4.2 for those whowere partially breast-fed, relative to thosewho received breast milk as the only type ofmilk. The corresponding odds ratios were 3.6and 1.6 for pneumonia deaths. For other in-fectious diseases, children who were fullyweaned were 2.5 times more likely to die thanthose who were breast-fed. These differenceswere adjusted for several confounding vari-ables. This paper became the most widelycited reference on breast-feeding from LatinAmerica, with 234 ISI citations by mid-2004.In a second paper, the authors showed thatadding herbal teas or water to the diet of abreast-fed infant resulted in a significant in-crease in diarrhea mortality (32).

Shortly afterwards, a group of researchersbased in Peru and in the United Statesshowed a similar impact of exclusive and par-tial breast-feeding on morbidity (33). Brownand colleagues showed that among children

Victora, Albernaz, and Lutter 23

aged under 6 months, diarrhea prevalence (% days ill) was twice as high—15.2%—inchildren who were partially breast-fed thanamong those who were exclusively breast-fed—7.1%. Children who were no longerbreast-fed had a prevalence of 27.6%. A cleardose-response pattern with the exclusivenessof breast-feeding was identified. Similar dose-response gradients were also observed forupper and lower respiratory tract infections.This paper became the second most fre-quently cited breast-feeding paper from theRegion, with 154 hits by mid-2004.

Both of these studies, as well as a thirdpaper from the Philippines (34) which ap-peared in 1990, used modern epidemiologi-cal methods to document how the introduc-tion of any fluids or foods in addition tobreast milk led to an important increase indiarrhea incidence, severity, and mortality.The impact of these papers on global and re-gional policy is discussed below.

POLICY DEVELOPMENTS IN THE 1980s

Inarguably the major advance in policy inthe 1980s was the shift in emphasis from thepromotion of breast-feeding to the specificpromotion of exclusive breast-feeding. Thiswas recognized by a major meeting held inFlorence, Italy, in 1990, which resulted inwhat became known as the Innocenti Decla-ration (35). This highly influential documentrecognized that breast-feeding “reduces inci-dence and severity of infectious diseases,thereby lowering infant morbidity and mor-tality,” and that “recent research has foundthat these benefits increase with increasedexclusiveness of breast-feeding during thefirst six months of life, and thereafter with in-creased duration of breast-feeding with com-plementary foods. . . .”

The shift from endorsing breast-feeding ingeneral to the promotion of exclusive breast-feeding had wide impact on global and re-gional policies. As a follow-up to the Inno-centi Declaration, in 1991 the Baby-friendly

Hospital Initiative (BFHI) was launched in-ternationally by UNICEF and WHO as astrategic means to help achieve the breast-feeding goals for the 1990s (36).

Breast-feeding experts from Latin Amer-ica were active in the planning and imple-mentation of a series of international meet-ings leading up to the Innocenti Declaration,and seven countries—Brazil, Chile, Colom-bia, Ecuador, Guatemala, Honduras, andMexico—were signatories to the Declaration.Both the Innocenti Declaration and BFHI gal-vanized action in Latin America. Between1981 and 1986, Brazil implemented a mediacampaign, created the position of a nationalbreast-feeding coordinator, and mobilizedsocial and community action to foster breast-feeding (37). National efforts were also un-dertaken to educate health providers, imple-ment rooming-in policies, and restrict thedistribution of infant formula to new moth-ers. In Honduras, a national campaign im-plemented over a five-year period in themid-1980s promoted breast-feeding throughchanges in hospital norms, training of healthcare providers, pre- and postnatal maternalcounseling, educational talks in the commu-nity, and print materials (38). These effortswere complemented by a mass media cam-paign. Numerous other countries in the Re-gion of the Americas also implementedhighly successful media campaigns, certifiedhospitals as “Baby Friendly,” trained healthproviders, and developed print material.

A number of countries in Latin Americaalso were active in monitoring the Interna-tional Code of Marketing of Breast-milk Sub-stitutes and disseminating their findings tohealth authorities, the media, and interna-tional organizations.

STUDIES IN THE 1990s: OPTIMAL DURATION OF

EXCLUSIVE BREAST-FEEDING

By the early 1990s, it was widely acceptedthat exclusive breast-feeding was the optimal


diet in the first few months of life due to theprotection it provided against infectious dis-eases, particularly diarrhea. There was concern,however, about whether or not breast milkalone could provide all the nutrients neededby children aged 4–6 months, because studiesfrom developing countries showed that exclu-sively breast-fed infants grew less rapidly inthis age range than formula-fed infants (39), afinding that was confirmed in Latin America(40). However, during this time, internationalagencies did not agree on the recommendedduration of exclusive breast-feeding: should itbe “about six months,” as then proposed byUNICEF (41), or four to six months, as then rec-ommended by WHO (42, 43)? The differencebetween the two recommendations may ap-pear to be small, but a possible change in theWHO recommendation could have had an im-portant economic impact on the marketing ofindustrialized infant foods (20) that would beno longer allowed in the age range of 4–6months.

A study carried out in Honduras in themid-1990s played a major role in helpingsolve this controversy. It was one of the veryfew randomized trials to report on the effectof breast-feeding on health and growth byaddressing specifically the optimal durationof exclusive breast-feeding. Cohen and col-leagues randomized mothers to either re-ceive strong support to continue breast-feeding exclusively until the age of 6 months,or to receive hygienically prepared comple-mentary foods, as well as breast milk, fromthe age of 4 months. Their results were nega-tive: both groups did equally well in terms ofgrowth (44). With 65 citations, this is thefourth paper in the ISI ranking of breast-feeding in Latin America. Additional publi-cations by the same authors provided furtherdetails (45), and a second trial was later con-ducted among full-term low-birthweight in-fants, with similar conclusions (46). As willbe discussed below, the Honduras studieshad a major impact on WHO policy.

Many other studies from Latin Americawere reported in the 1990s. The effect of

breast-feeding against all-cause infant mor-tality was confirmed in analyses from Mex-ico (47) and Brazil (48), while the protectionafforded against different causes of deathwas quantified by a meta-analysis of datafrom six developing countries coordinatedby Brazilian investigators (49). The latterpublication is ranked third in the ISI listingof breast-feeding papers from Latin America,with 106 citations.

Several other studies confirmed the pro-tection provided by breast-feeding againstmorbidity due to diarrheal, respiratory, andother infections (50–58). Other Latin Ameri-can studies contributed to the understandingof which components in breast milk may ex-plain the protection provided against infec-tions (59).

A particularly well-designed paper thatappeared in the late 1990s was a randomizedtrial of breast-feeding promotion by peercounselors in Mexico that showed not onlyan effect on the duration of breast-feedingbut also on diarrhea morbidity (60). This be-came the sixth paper from Latin America interms of ISI citations, with 53 hits.

THE 1990s AND AFTER: POLICY IMPLICATIONS

The intense debate over the optimal dura-tion of exclusive breast-feeding mobilized thescientific and policy communities as a newcentury began. In 2000, PAHO organized a“Technical Consultation on the Recom-mended Length of Exclusive Breast-feeding:Scientific Evidence and Research Priorities,”and in March of 2001, WHO organized a“Technical Consultation on Infant and YoungChild Feeding.” The background publicationfor the WHO meeting was a systematic re-view of the literature dealing specificallywith exclusive breast-feeding and growthfrom 3–6 months (61). The results of the Hon-duras studies (44, 46) played a prominent rolein this review, which also relied on otherLatin American studies (49, 62–64).


The consultation led to the adoption, in2002, of a Global Strategy for Infant andYoung Child Feeding (65), developed jointlyby WHO and UNICEF, which was approvedat the Fifty-fifth WHO World Health Assem-bly. The Strategy states that “infants shouldbe exclusively breast-fed for the first sixmonths of life to achieve optimal growth, de-velopment and health.”

The majority of the Latin American coun-tries had as a recommendation and norm ex-clusive breast-feeding for six months wellprior to the WHO systematic review. Of 19countries, only two continued to recommendthe four-to-six-month period in 2000 (66),and most had changed their recommenda-tion during the 1990s.

CURRENT TRENDS IN BREAST-FEEDING: EVIDENCE OF SUCCESS

At the beginning of this chapter, we pro-vided evidence of negative trends in breast-feeding duration in the Region of the Ameri-cas from the first three-quarters of the lastcentury. If—as we argue in this chapter—research carried out in Latin America made amajor contribution to global and regionalpolicies, then one should expect these nega-tive trends to be reversed. It is now evidentthat this indeed took place.

Several analyses, based on population-basedsurveys carried out since the 1970s, suggest thattotal breast-feeding duration has been increas-ing in the Region (67–70). Recently, Pérez-Escamilla analyzed data from 23 Demo-graphic and Health Surveys from countries inthe Region that had more than one survey con-ducted at different times (71). There was a def-inite trend towards increased durations ofbreast-feeding, particularly among morehighly educated women, and the author sug-gested that the positive trend may be attributedto measures aimed at promoting, protecting,and supporting breast-feeding.

The possible impact of lactation promo-tion programs on mortality had already been

the subject of Latin American studies. InCosta Rica, a likely impact was reported inthe 1970s by Mata and colleagues (72). Mon-teiro et al. estimated the impact of breast-feeding promotion on the reduction of infantmortality rate in São Paulo, Brazil, conclud-ing that improved breast-feeding practiceswere estimated to account for one-quarter ofthe mortality decline between 1981 and 1987(37, 73). In a recent analysis using a similarmethodology, Betrán concluded that 55% ofinfant deaths from diarrhea and acute respi-ratory infections in Latin America are pre-ventable by improving breast-feeding prac-tices (74).

CONCLUSIONS

Ongoing and future research on breast-feeding in the Region of the Americas islikely to have a continued impact on policies.One such example is the WHO MulticenterGrowth Reference Study, a six-country proj-ect that includes one Latin American site (75,76). This study will produce, by the end of2005, new sets of growth curves for assessingthe growth of children under 5 years, basedon breast-fed infants and replacing existingreferences that are based on predominantlybottle-fed infants.

Latin American researchers have made es-sential contributions to regional and globalinfant feeding policies during the last threedecades of the twentieth century. Improvedpolicies have helped revert the downwardtrend in breast-feeding duration observed inthe Region. Although there is still muchroom for improvement, particularly regard-ing the duration of exclusive breast-feeding,the present review has shown how researchcan be effectively translated into action forimproving public health.

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Micronutrients: Successful Interventions for the Correction

of Specific Deficiencies

INTRODUCTION

Iodine deficiency is one of the world’smajor public health problems in the area ofnutrition. The nutritional disorders causedby this deficiency have tremendous healthrepercussions that directly affect the socialand economic development of current andfuture populations.

Several decades ago, when the impor-tance of iodine deficiency disorders (IDDs)began to be recognized, they only were per-ceived in their most visible manifestation—goiter—which today is considered the indi-cator of the severity of the deficiency. Ac-cording to current information, IDDs rangefrom impaired fetal development to irre-versible, lifelong neurological damage, run-ning the gamut from congenital abnormali-ties to increased perinatal and infantmortality, neurological cretinism accompa-nied by mental retardation, deaf-mutism,spastic diplegia, myxoedematous cretinism,and psychomotor developmental delays (1).

In the early 1990s, it was estimated that atleast 1.5 billion people worldwide were atpermanent risk of some iodine deficiencydisorder (2). In the year 2000, 159 countriesrecognized IDDs as a public health problemand set goals for their reduction and control(3). At that time, all the countries considered

that simply ensuring sustainable universalaccess to iodized salt for the entire popula-tion would guarantee the control of IDDs.

Almost every country in the Americaslaunched effective salt iodization programs,and today, more than 80% of this populationregularly consumes iodized salt. Theseachievements did not occur by chance, sinceit was precisely in Latin America, and inEcuador in particular, where it was demon-strated that sustained control of iodine defi-ciency can be guaranteed with a very simpleand inexpensive measure: adding iodine tosalt.

Based on Ecuador’s successful experiencein controlling iodine deficiency, this chapterwill show how it is possible to link scientificdevelopment with action. In the 1980s, whenan intense debate arose between those who de-fended the use of a purely biological basis tosolve the problems associated with iodine de-ficiency and those more inclined toward an epi-demiological public health approach, Ecuadorshowed that shifting the paradigm for IDD

CONTROL OF IODINE DEFICIENCYDISORDERS: THE CONTRIBUTION OF

THE ECUADORIAN EXPERIENCE

Wilma B. Freire,1 Koenraad Vanormelingen,2and Joseph Vanderheyden3

33

1Co-Director, Institute of Research in Nutrition andHealth, Universidad San Francisco de Quito, Ecuador.

2Chief, Department of Health and Nutrition, UnitedNations Children’s Fund, Beijing, China.

3Official, Belgian Survival Fund, Belgian Federal Pub-lic Service for Foreign Affairs, Foreign Trade, and Devel-opment Cooperation, Brussels.

management from a biomedical to a predictiveapproach would make it possible to control apublic health problem and protect thousandsof individuals and new generations (4).

Although it was already known thatiodized salt was an excellent vehicle for en-suring the availability and daily intake of io-dine, the Ecuadorian experience is one of themost significant contributions for demon-strating the effectiveness of the salt iodiza-tion strategy in controlling IDDs, because itinvolved applying an operational methodol-ogy based on scientific evidence that guidedthe process from the characterization of theproblem up to its management and control.

This chapter begins with a summary ofthe causes of IDDs, then describes theEcuadorian experience, and finally, brieflystates the lessons learned.

BACKGROUND

Goitrogenic geographical areas are char-acterized by soils poor in iodine. The greatestconcentration of iodine in nature is found inthe oceans. Iodine is absorbed by the atmo-sphere and reaches mountainous areasthrough rain, snow, and other factors; how-ever, it then flows once more to the sea,transported by rivers. There is no balance be-tween the iodine that reaches the mountainsthrough the atmosphere and that whichflows to the sea. Frequent rain and snowcause the iodine content of soil to be de-pleted at a faster rate, which means that thefood crops grown in these soils contain littleiodine. The lack of iodine in the soil is acutein these mountainous zones (5, 6).

This description is the case in Ecuador,whose narrow Andean valley corridor ispoor in iodine. The rural population, muchof which until a few years ago was concen-trated in this mountainous zone, would con-sume food poor in iodine and seasoned ei-ther with rock salt, which is also poor in thisnutrient, or refined sea salt that had lost itsiodine content during cleaning and process-

ing. Thus, the problems stemming from io-dine deficiency had existed since time imme-morial, and their most obvious sign, goiter,was a condition very familiar to rural popu-lations in mountainous regions (7).

Ecuador, like Peru and Bolivia, is one ofthe countries most affected by iodine defi-ciency disorders (5). Numerous studies haverepeatedly shown that goiter used to be anenormous problem in the population of thehighlands (8–10). A 1983 survey of school-children in 10 highland provinces indicatedthat 36.5% of them had goiter. The reportedprevalencies ranged from 29.9% in Cañar to48% in Tungurahua (Table 1). It was observedthat the prevalence of goiter increased as thealtitude increased and urinary iodine levelsdecreased. The survey results indicated that avery high proportion of schoolchildren livingin the narrow Andean valley corridor, espe-cially in rural areas, suffered from goiter, with5% also suffering from neurological cre-tinism. This population was found especiallyin rural parts of the central Andes (11).

THE ECUADORIAN-BELGIANPROGRAM TO FIGHT ENDEMIC

GOITER AND CRETINISM

In 1984, the Ministry of Health, with tech-nical assistance and financing from theGovernment of Belgium, launched a pilotprogram known as the Bilateral Ecuadorian-Belgian Operational Project to Fight EndemicGoiter and Cretinism. This effort was joinedby the International Council for the Controlof Iodine Deficiency Disorders (ICCIDD), theUnited Nations Children’s Fund (UNICEF),and the Pan American Health Organization(PAHO). This pilot phase, which lasted threeyears, was carried out in three provinces inthe country’s central region: Cotopaxi, Tun-gurahua, and Chimborazo. In 1987, the pro-gram was expanded to all of the Andeanpopulation (4).

During the program’s execution, a part-nership was established between the Min-

34 Control of Iodine Deficiency Disorders: The Contribution of the Ecuadorian Experience

istries of Health and Education, which werethe executing institutions. The Ministry ofHealth placed the program under an opera-tional unit that received technical assistancefrom the Government of Belgium and the in-ternational organizations mentioned above.

In the 1970s, Ecuador, like the majority ofthe countries in the Region of the Americas,enacted legislation requiring the addition ofiodine to salt for human consumption (12).However, these laws were neither univer-sally nor routinely applied, which meant thata very high proportion of the population wasat permanent risk for developing IDDs.Moreover, the health authorities and thepopulation in general were as yet unaware ofthe causes or the consequences of a lack of io-dine, and even though they were accus-tomed to seeing people with goiter, they didnot connect the solution of this problem tothe application of so simple a measure as en-suring the consumption of iodized salt.

During this time, the national and interna-tional scientific community already had ar-guments for promoting salt iodization as aneffective public health measure. The firststudies, conducted in the U.S. state of Michi-gan (13) and Switzerland (14), showed thatthe administration of iodized salt could con-trol goiter. In the ensuing years, Australia,Canada, New Zealand, and Norway, amongother countries, obtained the same results. In

the Americas, Guatemala had succeeded inreducing the prevalence of goiter from 74%to 5.2% in the 1950s, figures similar to thoseobtained in Colombia; however, the absenceof effective quality control systems and epi-demiological surveillance led to reversals inthese gains. Despite this, the information ob-tained from these experiences made it clearthat it was both possible and necessary to ex-pand activities to other countries (5, 12).

It was within this context that the Gov-ernment of Belgium made a commitment tosupport a program for the elimination of en-demic goiter in Ecuador, and the two coun-tries signed an agreement for the eradicationof endemic goiter and cretinism. Another ob-jective of this joint initiative was to con-tribute to the design and implementation ofnutrition education programs.

The program’s success lay in the develop-ment and application of an operational riskassessment methodology that was fine-tuned during the execution of the program,the progressive adoption of control measuresbased on the level of risk, and the use of so-cial marketing strategies targeted to popula-tion groups that could facilitate and supportthe program. At the same time, a system forthe surveillance of iodine deficiency in thepopulation was put in place, techniques toensure quality control of iodized salt wereapplied, and support from the highest politi-cal authorities was obtained (4).

The operational methodology took shapeduring the pilot phase of the program. Itbegan with a classical clinical diagnosisbased on two indicators: palpation of thethyroid gland and urinary concentration ofiodine. The data was used to confirm thepresence of goiter and iodine deficiency;however, the methodology used was veryexpensive for use in the entire population.This consideration led to the adoption of anepidemiological diagnosis in which the typeof salt consumed was taken as an additionalindicator. There were two types of salt—thatof industrial origin, known as refined salt;and crude, or rock, salt, obtained from mines.

Freire, Vanormelingen, and Vanderheyden 35

TABLE 1. Prevalence of goiter in schoolchildren.Province Prevalence of goiter (%)

Carchi 39.0Imbabura 40.0Pichincha 30.0Cotopaxi 43.0Tungurahua 48.0Chimborazo 30.0Bolívar 37.0Cañar 29.9Azuay 36.0Loja 33.0

Average 36.5

Source: Rivadeneira M. Bocio y cretinismo endémicos en elEcuador. In: Argüello S, Breilh J, Campaña A, Freire W, Granda E,Hermida C, et al. Geografía de la salud en el Ecuador. Quito: In-stituto Geográfico Militar; 1991.

It was initially thought that, applied to thecommunity, this indicator would permit bet-ter discrimination of risk levels in the popu-lation. However, while this methodology re-duced costs and improved the specificity andnegative predictive value of the indicator, itwas not sensitive enough (4).

When the program was expanded nation-wide, the indicators were refined and theprocess for selecting the populations at riskwas simplified. To this end, once the col-lected information was analyzed, it was dis-covered that the most useful indicator for se-lecting communities was the size of primaryschools in relation to the intake of uniodizedsalt. It was determined that if a school hadmore than 120 students, the probability thatuniodized salt intake was less than 20% was84%, with a sensitivity of 86%. Based onthese indicators, a risk selection matrix was

created that divided communities into fourrisk levels: latent, low, moderate, and high,as observed in Figure 1 (4). Once the commu-nities were classified, the intervention strat-egy was selected (Figure 2). The choicescould range from the least complex measure(salt iodization) up to a package of four inter-ventions: salt iodization, radio announce-ments, teacher education, and intensive com-munity education (4).

Salt iodization required the creation of op-portunities for dialogue and negotiationswith producers of refined salt to secure theiragreement and commitment to add iodine tosalt. This dialogue led to negotiations be-tween the Government and private compa-nies to reach an agreement on commitments,rights, and duties to ensure the iodization ofall salt for human consumption. While thecompanies committed to iodizing salt, the


Preliminary positivesample

Consumption of rock salt< 50% of households

Median ioduria< 3 g of iodine

High risk

no

no

no

no

School < 120 children

Latent risk

Latent risk

Low risk

Moderate risk

Information sources

Ministry of Education:information from

the provinces

Teachers: surveyof schoolchildren

Ministry of Health:30 urine samples

Yes

Yes

Yes

Yes

FIGURE 1. Selection strategy.

Source: From Vanormelingen K, Vanderheyden JM. Innovative Aspects in Controlling Iodine Deficiency Disorders: The Case of Ecuador.Quito: Pan American Health Organization; 1994. (PAHO/HPN/ECU 94-1). Adapted by Vanormelingen for this publication.

Government assumed responsibility for en-suring that all refined salt was iodized andreached the entire population. Thus, a qual-ity control system for iodized salt was set upto identify producers who did not meet thecommitments and obligations established bylaw, and when instances of this type oc-curred, a fine was imposed, and the manu-facturer was publicly denounced in themedia (4).

Radio announcements were preparedboth in Spanish and in Quechua—this latterthe native tongue of most of the rural popu-lation—for broadcast throughout the coun-try. The announcements were developedwith the assistance of experts, who usedfocus groups from the target population tocollect information on beliefs, practices, andattitudes toward salt consumption and onproblems stemming from iodine deficiency(4). In addition, two anthropologists werehired, who lived for several months in the

various communities of one of the affectedprovinces, Bolívar, and studied the symbolicand cultural value of salt in rural life. Withthis information in hand, the advantages anddisadvantages of iodized and uniodized saltwere studied jointly with the communities.This exercise yielded announcements con-taining information about the “new” advan-tages of salt iodization, which were used inthe social marketing campaigns conductedin the various media. The announcementstargeted specific population groups andwere produced with participatory tech-niques that included using people from thesecommunities to record the messages.

At the same time, health workers pro-vided schoolteachers with training and in-formation about the radio announcements inorder to enable them to discuss what theyhad learned with their students in the class-room. Specific training modules were de-signed, one of which emphasized the use of


Source: From Vanormelingen K, Vanderheyden JM. Innovative Aspects in Controlling Iodine Deficiency Disorders: The Case of Ecuador.Quito: Pan American Health Organization; 1994. (PAHO/HPN/ECU 94-1). Adapted by Vanormelingen for this publication.

FIGURE 2. Progressive intervention strategy.

PARTICIPATION

SALT IODIZATION

RADIOANNOUNCEMENTS

TEACHEREDUCATION

INTENSIVEEDUCATION

COST

RISK

iodized salt to protect against goiter and cre-tinism (4). Teachers were given the task ofconducting surveys on salt consumption intheir communities; this was done by asking30 children to bring salt from their homes todetermine what type of salt they used: veryfine-grained refined white salt or the dark,coarse-grained rock salt from the mines. Thisinformation alone had a tremendous impacton salt consumption patterns.

Similarly, health workers in charge of in-tensive community instruction were trainedin communication techniques, and they wereprovided with audiovisual materials to facil-itate their teaching activities and help fosterchanges in behavior in the families visited inthe high-risk geographical areas (4). The ed-ucation, communication, and informationactivities were based on the level of riskidentified in the population. Thus, evenwhen a population did not present latentrisk, it was necessary to ensure that it had ac-cess to iodized salt. In low-risk populations,radio campaigns promoting the use of io-dized salt were conducted in both Quechuaand Spanish. In communities at moderaterisk, teachers were given basic training sothat they could convey the information dur-ing classroom instruction and during meet-ings with parents and other local groups. Inhigh-risk populations, highly intensive edu-cational activities were added at the commu-nity and household level. At the start of theprogram, intramuscular injections of iodizedoil were administered in homes, an activitythat became unnecessary when the commu-nities were no longer at high risk (4).

In parallel with these activities, the qualityof iodized salt was constantly monitored toensure that it maintained the recommendedamounts of iodine during production, distri-bution, and retail sale. A system was also setup to monitor program advances and pro-vide follow-up, permitting timely adjust-ments with the rational use of resources andthus, substantial savings (4). This informa-tion was continuously communicated to thehighest political authorities, who, convinced

of the benefits of salt iodization, continued tolend their support to the program, whosecosts, moreover, were relatively low.

In 1993, a commission with representa-tives from PAHO, UNICEF, the U.S. Centersfor Disease Control and Prevention, ICCIDD,Belgian Agency for Development Coopera-tion, Ecuadorian Ministry of Health, andother national and international experts eval-uated the program. The evaluation teamnoted that around 1992, 90% of the salt for re-tail sale contained adequate levels of iodine,equivalent to 20 ppm, and that the medianioduria had increased from 8.6 µg/dL to 15.6µg/dL, changes that reversed the highprevalencies of goiter in the highlands ofEcuador (4).

The evaluation showed that it is feasibleto control IDDs on a national scale and at arelatively low cost by means of a strategybased on the development and application ofrisk analysis, the use of nonbiological predic-tive indicators, and the adoption of progres-sively intensive control measures commen-surate with the level of risk detected—all thiscombined with the diagnosis and measure-ment of impact and social marketing activi-ties designed to guarantee support for theprogram (4). To this was added the use of anongoing evaluation and feedback system topermit timely adjustments in the various di-agnostic, intervention, and monitoring activ-ities, in addition to lowering costs and pro-ducing measurable results with an impact onthe population’s nutritional status with re-spect to iodine.

CONCLUSIONS AND LESSONS LEARNED

The iodine deficiency control program inEcuador has not been the only successful saltiodization project. However, the extensivedocumentation that accompanied it from theoutset helps distinguish what made it possi-ble to obtain spectacular results. Vanormelin-gen’s and Vanderheyden’s (4) summary of


the project makes it possible to identify theseaspects and demonstrates that scientific pro-cedures can yield concrete solutions. Themethodology was also based on the principlethat the solution to the problem of IDDs wasnot exclusively medical, but required the co-operation of other sectors, such as educationand private enterprise, which had to assumespecific responsibilities that were not the solepurview of the health sector.

The starting point was the characteriza-tion of the problem. The available informa-tion and the data obtained from a surveyconfirmed that the prevalence of endemicgoiter was an enormous problem that partic-ularly affected rural populations in the An-dean valley corridor.

A second major element was the compila-tion of information on other countries’ expe-riences, which showed that salt is an excel-lent vehicle for ensuring mass daily intake ofbasic quantities of iodine; however, it wasnecessary to collect data on local consump-tion patterns. From that information it fol-lowed that virtually all of the most affectedpopulation consumed uniodized salt, whichis an unrefined, coarse-grained coffee-colored product.

The price of iodized salt was 2.5 timeshigher than that of the uniodized productand was therefore less accessible to thepoorer population groups. Unrefined unio-dized salt, in contrast, was sold retail in themarkets of rural communities at accessibleprices and was packaged in different vol-umes to meet customer demands (pounds,half-pounds, ounces, and portions). The waythat iodized salt was distributed guaranteedthat it would be more available in urbanareas than rural areas. Based on these data, adialogue was opened with refined salt pro-ducers to ensure the iodization of all salt forhuman consumption, in the recommendedlevels, and its distribution to rural areas. Ne-gotiations were also held between the Gov-ernment and salt producers on ensuring anadequate supply of iodine to guarantee theproduction of iodized salt so that salt dealers

could market the salt and the populationcould obtain it.

The negotiations concluded when, by mu-tual agreement, a permanent system was es-tablished for quality control and monitoringof the population’s nutritional status with re-spect to iodine. All this was possible becauseinformation was also available on the infra-structure of both the industry and the healthsector, the latter of which was responsible forensuring that program implementation fol-lowed the established work plans. The saltproducers numbered only nine in all, andone of them supplied 80% of the market,which facilitated the negotiations. The nego-tiations were buttressed by a monitoring sys-tem that imposed sanctions and informedthe public about industry noncompliancewith the law and its regulations.

A third element that contributed to thesuccess of the program was the training pro-vided to the staff of the Ministries of Healthand Education responsible for educationalactivities at the central and local levels. In ad-dition, the two ministries engaged in inter-sectoral efforts based on the principle thatIDDs were not just a medical problem, butone involving raising awareness among thegeneral populace. To this end, a variety ofongoing training activities, using materialsdesigned for this purpose, was carried outfor all staff at the different levels of theprogram.

The fourth element was the use of socialmarketing techniques targeting various spe-cific population groups, so that these would,in turn, facilitate and support the program.These techniques also served to keep thepublic informed about the progress of theprogram, to disseminate information aboutthe advantages of consuming iodized salt,and to report producers who failed to meettheir public obligations.

It was also very important to recognizethat simple indicators were sufficient to mea-sure the program’s impact and to organizean inexpensive, easily implemented surveil-lance system to guarantee that salt is ade-


quately iodized and reaches all populationgroups and to ensure that the iodine needs ofthe population are met (4).

Finally, it was fundamental to have a com-mitted managerial component, consisting of acoordinating group highly skilled in promot-ing the program’s work; in facilitating part-nerships and securing agreements among theGovernment, private sector, and internationalorganizations; and in securing the commit-ment of all the program partners, includingpolitical authorities at the highest level (15).

In short, execution of the IDDs controlprogram in Ecuador followed the recom-mended steps for a successful program,which are valid for any fortification program

(1). The design of a predictive model, the col-lection and use of data, and the flexibility toadapt the activities were key. Therefore, thisand the other successful experiences in IDDscontrol can serve as the foundations for pro-moting micronutrient fortification programsin both the Americas and other regions of theworld.

REFERENCES

1. UNICEF/WHO Joint Committee on Health Policy.Strategic approach to operationalizing selected enddecades goals: reduction of iron deficiency anemia.JCHP 30/95/4.5. Geneva: WHO; 1995.

2. WHO/UNICEF/ICCIDD. Global Prevalence of IodineDeficiency Disorders. Geneva: World Health Organi-zation; 1993. (MDIS Working Paper 1).

3. United Nations. 1990 World Summit for Children.New York: UNICEF; 1990.

4. Vanormelingen K, Vanderheyden JM. Innovative As-pects in Controlling Iodine Deficiency Disorders: TheCase of Ecuador. Quito: Pan American Health Orga-nization; 1994. (PAHO/HPN/ECU 94-1).

5. Hetzel BS, Pandav CS, eds. S.O.S. for a Billion: TheConquest of Iodine Deficiency Disorders. Delhi: OxfordUniversity Press; 1996.

6. Hetzel BS. The Story of Iodine Deficiency: An Interna-tional Challenge in Nutrition. New Delhi: Oxford Uni-versity Press; 1989.

7. Kelly FC, Snedden WW. Prevalence and geographi-cal distribution of endemic goitre. Monogr Ser WorldHealth Organ 1960;44:27–233.

8. Fierro Benítez R. Anotaciones sobre profilaxis del bocioendémico. Quito: Editorial Universitaria; 1959.

9. Fierro Benítez R. Las enfermedades por deficienciade yodo en el siglo XVIII y en el Ecuador actual. Cul-tura 1986;8(24c):1125–1141.

10. Fierro Benítez R. Historia de la deficiencia mentalendémica en la región andina. Politécnica (Quito)1983;8(1):7–45.

11. Rivadeneira M. Bocio y cretinismo endémicos en elEcuador. In: Argüello S, Breilh J, Campaña A, FreireW, Granda E, Hermida C et al. Geografía de la saluden el Ecuador. Quito: Instituto Geográfico Militar;1991.

12. Noguera A, Viteri FE, Daza CH, Mora JO. Evalua-tion of the current status of endemic goiter and pro-grams for its control in Latin America. In: Duna JT,Pretell EA, Daza CH, Viteri FE, eds. Towards theEradication of Endemic Goiter, Cretinism, and IodineDeficiency. Washington, DC: Pan American HealthOrganization; 1986:217–270. (Scientific Publication502).

13. Marine D, Kimball OP. The prevention of simplegoiter in man. Arch Intern Med 1920;25:661–672.


TABLE 2. Components of a fortification proposal.Components

Reasons for the fortification AdvantagesOpportunitiesLimitations

Target population Total populationPregnant womenChildren under 2Adolescents

Selection of vehicle Food staples; low cost

Definition of responsibilities LegislativeQuality assuranceEpidemiological

surveillanceFinancing

Infrastructure IndustrialHealth sectorTechnology

Selection of fortificant CostAvailability and accessEffect on food preparation

in the homeAcceptability

Communication PromotionSocial marketingEducation

Monitoring of the process At the industrial levelAt the consumer level

Impact assessment Population at riskTotal populationSustainability

Source: Adapted from UNICEF/WHO Joint Committee onHealth Policy. Strategic approach to operationalizing selected enddecades goals: reduction of iron deficiency anemia. JCHP30/95/4.5. Geneva: WHO; 1995.

14. Bürgi H, Supersaxo Z, Selz B. Iodine deficiency dis-eases in Switzerland one hundred years afterTheodor Kocher’s survey: a historical review withsome new goitre prevalence data. Acta Indocrinol(Copenh) 1990;123(6):577–590.

15. de Benoist B, Andersson M, Egli I, Takkouche B,Allen H, eds. Iodine Status Worldwide. WHO GlobalDatabase on Iodine Deficiency. Geneva: World HealthOrganization; 2004.


INTRODUCTION

Sugar is currently used as a vehicle for vi-tamin A in the form of retinol palmitate in ElSalvador, Guatemala, Honduras, Nicaragua,Nigeria, and Zambia; for this reason, sugarhas become the principal source of vitamin Afor the people of these countries. Costa Rica,India, Malawi, the Philippines, and Ugandahave specific plans for establishing similarprograms. The origin of this practice datesback to 1975, when Costa Rica and Guate-mala began to use the procedure developedby Dr. Guillermo Arroyave and colleagues atthe Institute of Nutrition of Central Americaand Panama (INCAP) on a large scale. A fewyears later, both countries discontinued theprogram. Guatemala reinitiated it in 1988 atthe urging of the Ministry of Public Healthand Social Welfare and with the support of the United Nations Children’s Fund(UNICEF) and INCAP. That year it becamerecognized worldwide that vitamin A is im-portant in the reduction of infant mortality,since it improves not only eye function butalso immune response. Since then and untilthe current time, sugar fortification has beenuninterrupted, and Guatemala is the countrymost experienced in the application of suchprograms. This chapter describes the devel-opment and vicissitudes of sugar fortification

in Guatemala from 1988 to 2005 and comple-ments and updates information found in ear-lier studies published on the subject (1, 2).

The addition of vitamin A to sugar wasone of the recommendations of the report onthe nutritional survey of the population ofCentral America and Panama of 1965–1967(3) as a suitable measure for eliminating vita-min A deficiency, which represented a seri-ous public health problem for these countriesat that time. Sugar was selected because it iswidely consumed by the population, gener-ally in appropriate quantities (at that time, 20to 40 g/day), and because its production wasrelatively centralized at only a few sugar re-fineries operating in the country. Other foodsthat could have been candidates were re-jected for different reasons. Cornmeal flour,despite its high consumption by the popula-tion, was rejected because it was processed inhundreds of small mills. Wheat flour and oilwere rejected because they were not part ofthe routine diet of the region’s poorest sec-tors. Finally, salt was rejected because it was

SUGAR FORTIFICATION WITH VITAMIN A IN GUATEMALA: THE PROGRAM’S

SUCCESSES AND PITFALLS

Omar Dary,1 Carolina Martínez,2 and Mónica Guamuch3

43

1Advisor in Food Fortification, USAID/MOST (Micro-nutrient Operations, Strategies, and Technology) Pro-gram, Arlington, Virginia, U.S.A.

2Technical Manager, Laboratory of Nutritional Bio-chemistry, INCAP, Guatemala City, Guatemala.

3Technical Manager, Laboratory of Food Analysis,INCAP, Guatemala City, Guatemala.

of poor quality and its price would increasegreatly with fortification, in addition tobeing produced in hundreds of small marinesalt flats.

Once the methodology for adding vitaminA to sugar had been developed, the Guate-malan Ministry of Public Health and SocialWelfare and INCAP convinced health profes-sionals of the viability and benefits of this in-tervention. With the backing of health pro-fessionals’ associations, they promoted a lawfor compulsory fortification in Congress. Theinitiative was rejected in September 1973, butwith the pressure brought to bear by theNational Committee for the Defense of theBlind and Deaf-mutes of Guatemala andother social and health institutions, and withthe example of a similar government agree-ment issued by Costa Rica, the law was ap-proved in June 1974.

Sugar fortification with vitamin A beganin 1975, together with a field study to verifyits biological effectiveness. In several ruralpopulations of Guatemala, it was shown thatin less than six months, fortified sugar con-sumption had increased plasma retinol con-centrations, retinol in breast milk, and liverretinol reserves in healthy people who diedaccidentally. In less than one year, vitamin Adeficiency was under control (4, 5). Thus wasborn a classic example of a successful publicnutrition intervention in the world.

THE EVOLUTION OF THETECHNOLOGY

Vitamin A is a liposoluble liquid, and sugaris a dry, crystallized substance that is solublein water. The combination of both substanceswas possible thanks to the development ofwater-dispersible vitamin A compounds (75 gof vitamin per kg of product) that adhere tosugar grains in the form of solid microcapsules,or beadlets, by means of a vegetable oil coat-ing. The premix of sugar with vitamin A is thusformed, which contains 15 g of vitamin A perkg of sugar in the form of retinol palmitate.

This dry premix is then added to sugar in a pro-portion of 1:1,000 to obtain an average theoret-ical content of 15 mg of vitamin A per kg ofsugar. The original vitamin A microcapsulescontained animal gelatin (250-CWS fromHoffman-La Roche and 250-CWD from BASF),but with the appearance of bovine spongiformencephalopathy, and for the purpose of extend-ing this process to populations that do not con-sume animal products, gelatin was replacedwith plant starches. The change was not easy,because the first plant microcapsules producedsegregated (separated) from the grains of sugar,especially in refined sugar. Currently, INCAPrecommends two plant products for fortifyingsugar: 250-SN/B from DSM and 250-MSCWD from BASF.

When sugar fortification began in 1975,the premix was added manually to the cen-trifuges, just before the moist sugar was un-loaded onto the conveyor belt to the dryingturbines, and then it was transported topackaging hoppers. The drying and coolingturbines acted as large mixers. The systemworked well, and the end product had a vari-ation of 15% to 20%, although 20% to 30%was lost during the process. When the pro-gram resumed in 1988, many sugar refinerieshad been modernized and used closed auto-matic centrifuges. Consequently, feeders(dosifiers) that automatically dispensed thepremix into the sugar during its transportfrom the centrifuges to the packaging areawere incorporated. The engineer LeonelAnleu of the Sugar Producers’ Association ofGuatemala (ASAZGUA), with the support ofDr. Oscar Pineda of INCAP, designed severalmodels, first vibratory and then verticalstainless steel hoppers that fed the premixwith a variable speed winder (6). Dosing ofthe premix was controlled satisfactorily.

To reduce the loss of vitamin A duringdrying, the point of application of the premixwas moved closer to the packaging hop-pers. However, these changes increased theheterogeneity of the vitamin A content of the product (7). With the introduction of amixing turbine—also designed by Leonel

44 Sugar Fortification with Vitamin A in Guatemala: The Program’s Successes and Pitfalls

Anleu—before packaging, homogeneity wasrecovered with a variation of approximately30%. The invention of this machinery (feed-ers and mixing turbines) made it possible toseparate the process of sugar fortificationfrom sugar manufacture in refineries. Start-ing in 2002, ASAZGUA agreed that somepackaging centers would begin to fortifysugar. The homogeneity and stability of thevitamin A content improve when fortifica-tion is carried out in packaging centers be-cause they handle smaller volumes of sugarthan refineries, and they use dry sugar. How-ever, most sugar in Guatemala continues tobe fortified in refineries because packagingcenters are insufficient to meet demand andproduction costs are lower.

The cost of the equipment (feeder andmixer/blender) at each fortification site (re-finery or packaging center) is approximatelyUS$ 35,000, which means that the countryhas invested about US$ 800,000 in infra-structure for sugar fortification. Guatemalahas invested around US$ 4.5 million annu-ally to fortify 0.5 million metric tons of sugarfor a population of 12 million inhabitants,equivalent to US$ 0.009 per kg of sugar orUS$ 0.37 a year per person, assuming thatpersonal consumption is 45 kg/year or 120g/day. This includes sugar added to the dietthrough industrially processed food, such asbaked goods, soft drinks, desserts, and othersimilar products. The Nutritional Survey ofMicronutrients conducted in 1995 (8) indi-cated that direct sugar consumption in thehome was 24.6 kg/year or 67.5 g/day/person. The cost of fortification was equiva-lent to 1.8% of the retail price of sugar (US$0.51/kg); the most expensive ingredientbeing the vitamin A compound, which repre-sented 90% of the total cost.

THE EVOLUTION OF TECHNICALSTANDARDS AND REGULATIONS

The Law of Sugar Fortification with Vita-min A of 1974 (Legislative Decree 56-74) was

applied in accordance with the provisions ofthe corresponding regulation (GovernmentAgreement 105-74), which specified thatsugar should contain 15 mg of vitamin A perkg, with a variation of 10% with respect tothis value. In 1990, this measure caused con-flicts between producers and food regulationofficers at the Ministry of Public Health andSocial Welfare of Guatemala because compli-ance was technically impossible in view ofthe usual variation of 30% in fortification inrefineries.

In 1992, a General Foods Fortification Act(Legislative Decree 44-92) was passed, and in1993, a new regulation for sugar fortification(Government Agreement 497-93) was issuedthat raised the range of vitamin A content by33%; that is, from 10 mg/kg to 20 mg/kg.However, this standard failed to reflect thetechnical realities of the program because itdid not take into account that vitamin A islost gradually in a year in a proportion of50%.4 Thus, in 1998 a new regulation (Gov-ernmental Agreement 15-98) stipulated thatsugar should contain a minimum of 5mg/kg of vitamin A for the duration of itsshelf life. Nevertheless, the criterion thatsugar should contain 10 to 20 mg/kg in therefinery was kept, but without specifyingthat it was valid only at the time of fortifica-tion and during the first year of storage ofsugar. Subsequently, to establish a reason-able criterion for homogeneity and safety,and taking into account variations in theprocess, it was recommended that the tolera-ble maximum level of fortification be 25mg/kg. Despite the issue of many other reg-ulations in subsequent years, this measurehas not yet been adopted. To date, the crite-rion of 10 to 20 mg/kg has been followed forsugar samples obtained in the refinery,whether at the point of fortification or in thestorerooms, which continues to generate

Dary, Martínez, and Guamuch 45

4Morales de Canahui E, Dary O, de León L. Retinolstability of fortified sugar in Guatemala. Abstract. In:IVACG Secretariat. Report of the XVII International Vita-min A Consultative Group Meeting. Washington, DC:IVACG; 1996:80.

conflicts between producers and food regu-lation authorities. The reasons for the fre-quent changes in regulations will be dis-cussed later in this chapter in the sectionhighlighting the sugar fortification pro-gram’s various political and economic crises.

Guatemalan legislation in force requiresvitamin A fortification of all sugar consumeddomestically, regardless of its use. At onetime an exemption for the sugar used in softdrink production was considered becausemost vitamin A is lost during processing (9);however, in light of the uncertainty that un-fortified sugar would be effectively con-trolled and to prevent it from reaching con-sumers, it was decided that it would bepreferable to assume the additional cost(30%) rather than endanger the quality of theentire program. To date, all food productsprepared with fortified sugar contain vita-min A, including cookies, baked goods,candy, desserts, and other similar products,as earlier mentioned. More than 80% of thevitamin A in sugar is conserved in theseproducts (10).

THE EVOLUTION OF MONITORING(QUALITY CONTROL, INSPECTION,

AND SURVEILLANCE)

As part of the process of sugar fortifica-tion, in 1975 INCAP investigators (11) de-signed an analytical method based on theCarr-Price reaction (12), which produces atemporary blue compound when the reagentreacts with retinol. The advantage of thismethod is that the amount of retinol presentin sugar can be assessed visually, withoutneed for any special equipment, by compar-ing the intensity of the color to a scale pre-pared from copper sulfate solutions of dif-ferent concentrations. The procedure wasreviewed in the 1990s to improve its analyti-cal resolution, so that it could be used effec-tively as a semiquantitative method in sugarrefineries (13). It was established that the de-termination should be performed with a so-

lution prepared with at least 10 g to 20 g ofsugar, based on the fact that only one grain ofsugar in each 1,000 bears vitamin A. In addi-tion, a simpler alternative method was de-veloped for rapidly determining the pres-ence or absence of the vitamin around a fixedcutoff point. Levels of 3.5 mg/kg and 5.0mg/kg were selected for use in screeningtests in the surveillance activities carried outin homes and at points of sale, respectively.This cutoff point (3.5 mg/kg) was selectedfor homes because it ensures the supply of atleast 200 µg of vitamin A with the usualsugar consumption of Guatemalans, whichrepresents 33% to 50% of the recommendednutritional intake of this nutrient. The cost ofthe semiquantitative method is US$ 1.00 persample, and the cost of screening is US$ 0.50per sample.5 The greatest advantage of thismethod is that a single person can processnearly 200 samples a day, in contrast with 20to 30 daily samples with the semiquantita-tive method.

To support quantitative retinol measure-ments in sugar, INCAP designed a spec-trophotometric method based on retinol ex-traction in hexane and its measurement bymeans of its absorbance at 325 nm (13). Thequantification limit of this method is 1.5mg/kg, and the cost is US$ 3.00 per sample.The minimum amount of sugar to dissolve is10 g for refined sugars and 20 g for directwhite or sulfated sugars. However, to guar-antee the reproducibility of results, the cur-rent practice is to dissolve 100 g, regardlessof the sugar type.

At the same time that analytical chemicalassays were developed, periodic samplingpractices and reports were introduced fordifferent stages of monitoring in the pro-gram. Monitoring includes quality control


5Calzia R, Martínez C, Domínguez P, Dary O. Qualita-tive method to determine vitamin A in sugar and otherfoods for fast screening in monitoring programs. Ab-stract W35. In: IVACG Secretariat. Report of the XXI Inter-national Vitamin A Consultative Group Meeting. Improvingthe Vitamin A Status of Populations. Washington, DC:IVACG; 2003:76.

and quality assurance by the refineries (ex-ternal monitoring). Then, officers of the Min-istry of Public Health and Social Welfare’sDepartment of Food Regulation and Protec-tion carry out inspection and auditing prac-tices in production centers and customs forimportation (external monitoring) and incenters of distribution and sale (commercialmonitoring). The actions of the Governmentconstitute regulatory monitoring and havelegal connotations. The system is completedby sampling in households to establish theutilization and quality of the table productused by consumers (home monitoring).6

Every year, INCAP laboratory profes-sionals have collaborated with ASAZGUA toprovide training and continuing educationcourses for those responsible for quality con-trol departments in the refineries of Guate-mala. In 2002, ASAZGUA published a de-tailed manual on quality control of the sugarfortification program.7 In short, the systemconsists of daily quantitative estimates of vi-tamin A content in the sugar premix. Regard-less of production volume, refineries test thevitamin A content of the fortified sugar beingproduced every one to four hours—andmore often if homogeneity is unsatisfactory.The semiquantitative colorimetric method isused, although some refineries have intro-duced the quantitative spectrophotometricmethod. Furthermore, each refinery preparesa daily composite sample that is sent to a ref-erence laboratory. Vitamin A content is deter-mined in the laboratory using the spec-trophotometric method. At the time offortification, the goal is to keep vitamin Acontent above 10 mg/kg. All the results arerecorded at each refinery and, until 2003, acopy of the results was sent to the manager

of the ASAZGUA fortification program, whoproduced periodic reports on the results ofall the country’s refineries. Currently, controlof the program is the responsibility of theMáquinas Exactas company, which is part ofthe sugar consortium. As an external control,sugar samples are sent to INCAP to corrobo-rate the results of the internal quality audits.

During the sugar harvest, officers of theDepartment of Food Regulation and Pro-tection have visited refineries to observecompliance with the process and to obtainsamples to corroborate vitamin A content(external monitoring). Less systematically,samples have also been obtained at points ofsale (commercial monitoring). These actionsintensified after 2000. The National Labora-tory of Health analyzes the samples using aspectrophotometric method.

Since 1995, UNICEF and INCAP haveurged the Ministry of Education to partici-pate in the home monitoring of food fortifi-cation programs. The system is known as Mi-cronutrient Sentinel Schools and consists ofobtaining 20 sugar (and salt) samples fromthe same number of students in 420 ruralpublic schools throughout the country se-lected randomly from an official list. In thefirst year, one sample out of every four wasanalyzed—to lower costs and analysistime—but from 1996 to 2000, two compositesamples were prepared by combining 10 in-dividual samples per school, under the as-sumption that all the sugar of a communitycomes from the same source. Starting in2001, the system was perfected. All samplesbegan to be screened using a simple cutoffpoint method of 3.5 mg/kg. Then two com-posite samples per school are prepared withthe individual samples that satisfy the cutoffpoint, and their vitamin A content is deter-mined quantitatively using the spectropho-tometric method.

The INCAP Laboratory of Nutritional Bio-chemistry has carried out this task. Screeningis used to assess program coverage; that is,the proportion of samples with a vitamin Acontent above the cutoff point, while the


6Dary O, Martínez C, Alfaro C, Chinchilla D, LacayoM. Quality control (QC)/quality assurance (QA) andmonitoring system of the sugar fortification program inCentral America. Abstract W60. In: IVACG Secretariat.Report of the XXI International Vitamin A ConsultativeGroup Meeting. Improving the Vitamin A Status of Popula-tions. Geneva: IVACG; 2003:83.

7ASAZGUA. Protocolo del Programa de Fortificacióndel Azúcar con Vitamina A.

quantitative data are used to establish the av-erage vitamin A content of adequately forti-fied samples.8 UNICEF published two re-ports with the results of this program in 1995and 1999. Starting in 2000, the results of thisactivity have been included in the annual re-ports on food fortification programs pub-lished by the National Commission on theFortification, Enrichment, and Comparisonof Foods (CONAFOR), INCAP, and UNICEF.El Salvador, Honduras, and Nicaragua havealso produced these reports, in which thename of the public health ministry appearsinstead of CONAFOR. This was not possiblein Guatemala due to the conflict between the Government and national food produc-ers, especially sugar refiners, which is de-scribed in the corresponding section belowon the various economic and political set-backs experienced by the sugar fortificationprogram.

Table 1 presents a summary of the avail-able results of home monitoring. The com-plete system, including the sampling andanalysis of sugar, salt (for iodine), and bread(for iron and vitamin B complex) samples forevery five schools, and the production of thecorresponding report, costs approximatelyUS$ 25,000 a year. This is financed byUNICEF and by funds from projects grantedto INCAP by USAID, and by the Micronutri-ent Initiative sponsored by the Governmentof Canada.

Between 2000 and 2003, CONAFOR de-cided to implement a surveillance system atpoints of sale in tandem with official inspec-tions by the Ministry of Public Health andSocial Welfare, in light of fears that thismight be insufficient to control the quality ofimported unfortified products, which by lawmust be fortified before sale. The system,

called a “social audit,” was the responsibilityof the Consumers League and was also fi-nanced by UNICEF. In Table 2, the results ofgovernment inspection are compared withthose obtained by the social audit. It is inter-esting to observe that the results coincide, ex-cept for the governmental data of 2002,which were much lower than the results ob-tained by the social audit and home monitor-ing the same year. This may be because sam-pling carried out by the Ministry of PublicHealth and Social Welfare focused that yearon brands that were noncompliant with thestandard.

The complete monitoring system estab-lished in Guatemala made it possible to de-termine that sugar at the time of fortificationin the refinery contains an average of 12 mgof vitamin A per kg; upon reaching the pointof sale, the content is 10 mg/kg, and on thetable of consumers, it is 7.5 mg/kg. Thetechnological process was designed so thatsugar would contain 15 mg of vitamin A perkg, without considering any loss. This meansthat 50% of the vitamin A added in the re-fineries reaches the consumer, a result thatcoincides with the conclusions obtained instability experiments carried out by INCAP.The gradual loss of vitamin A during storageis normal and occurs with any other food for-tified with this nutrient. The results are ac-ceptable, considering a sugar shelf life of oneyear, which is approximately when homemonitoring is performed.

THE BIOLOGICAL EFFECTS OF THE PROGRAM

Studies by Arroyave and colleagues (4, 5)clearly demonstrated the biological impact ofthe consumption of sugar fortified with vita-min A when the program was launched inthe 1970s. Other studies of food fortificationindicate that the vitamin A used in fortifica-tion is well absorbed, regardless of the foodmatrix (14). As a result, to predict effects onhealth, it is enough to measure the additional


8Domínguez P, Martínez C, Molina R, Dary O. Evalu-ation of a surveillance system for the program of sugarfortification with vitamin A at the household level. Ab-stract W59. In: IVACG Secretariat. Report of the XXI Inter-national Vitamin A Consultative Group Meeting. Improvingthe Vitamin A Status of Populations. Washington, DC:IVACG; 2003:83.

vitamin A intake received this way to esti-mate the benefits of fortification.

The results of home monitoring (Table 1)and the data on usual sugar consumption inGuatemala—without taking into accountsugar from processed food products madewith fortified sugar—of 60 g/day to 120g/day in adults and 30 g/day to 60 g/dayin children suggest that Guatemalans receivebetween 60% and 150% of the recommendedvitamin A intake. This means that sugar com-

plements the diet with regard to the daily vi-tamin A requirements. Sugar is providingmore vitamin A than all other foods com-bined (15).

The Guatemala National MicronutrientSurvey of 1995 (8) revealed that only 15.8%of preschool children (1- to 5-year-olds) hadlow plasma retinol levels (< 0.7 µmol/L or< 20 µg/dL), meaning that vitamin A defi-ciency was under control. The InternationalVitamin A Consultative Group (IVACG) has


TABLE 1. Evolution of the coverage and quality of the sugar fortification program inGuatemala at the household level.a

Percentage ofindividual Percentage ofsamples participating Coverage Quality

examined schools (% reference [Vit. A]Year (n = 8,400) (n = 420) criterionb) (mg/kg)

> 5.0 mg/kg1995 85 100 51 6.61996 — 42 79 7.01997 — 72 75 6.91998 — 65 76 6.91999 — 95 80 7.92000 — 100 79 7.5

> 3.5 mg/kg2001 64 100 77 9.32002 23 43 68 7.42003 36 75 85 9.5

aCoverage means the percentage of samples that meet the specified minimum criterion, and quality refers to averagevitamin A content in those samples.

bThe criteria used were > 5 mg/kg and > 3.5 mg/kg. The criterion for coverage was changed from > 5 mg/kg of vi-tamin A to > 3.5 mg/kg because, starting in 2001, a method of screening individual samples began to be used, whereasin previous years the criterion was applied for composite samples formed by the combination of 10 individual samples.When that system was used, from 97% to 99% of the composite samples contained detectable levels of vitamin A (> 1.5mg/kg).

Source: CONAFOR/INCAP/UNICEF; Informes Anuales de la Situación de los Alimentos Fortificados, 2000, 2001,2002, and 2003.

TABLE 2. Comparison of the quality of fortified sugar in refineries and points of sale.Government inspectiona Social auditb

> 5 mg/kg [Vit. A] > 5 mg/kg [Vit. A]Year n (%) (mg/kg) n (%) (mg/kg)

2000 122 75 9.8 — — —2001 112 82 11.1 264 82 9.32002 430 42 5.9 102 84 10.92003 311 81 13.3 — — —

aData of samples collected in refineries and points of sale by personnel of the Ministry of Public Health and SocialWelfare’s Department of Food Regulation and Protection.

bData of samples collected in retail sale sites in different geographical departments of the country by volunteers of theConsumers League and analyzed by INCAP.

Source: CONAFOR/INCAP/UNICEF; Informes Anuales de la Situación de los Alimentos Fortificados, 2000, 2001,2002, and 2003.

suggested that a frequency of subnormal vi-tamin A levels in excess of 15% indicates thatthe nutritional status of this vitamin is inad-equate in the population (16). Guatemala stillappears to be in that situation. However,data from the survey cited were not adjustedfor infections and inflammations, which re-duce the protein that transports retinol (17)and, as a result, plasma retinol. It is to be ex-pected, then, that the nutritional status ofGuatemalan preschool children may bemuch better than suggested by the 1995 sur-vey. On the other hand, only children underage 3 had frequencies of low plasma retinollevels of more than 15% (Table 3). Further-more, the quality of sugar fortification is bet-ter now than in 1995 (Table 1). Perhaps onlychildren under the age of 24 months who arenot breast-fed by their mothers are in dangerof receiving insufficient vitamin A. For thisreason, Guatemala maintains a program ofpreventive supplementation with high-dosevitamin A every six months for children ages6 to 35 months old.

An indirect verification of the positive ef-fect of sugar fortification is the almost com-plete elimination of xerophthalmia (blind-ness caused by vitamin A deficiency) in thecountry. In recent years, very few cases havebeen found, and these cases have been asso-ciated with acute protein-energy malnutri-tion conditions that have affected some local-ities of the country. Table 4 shows theincidence of ocular perforation in childrenwho suffer from vitamin A deficiency ac-cording to the hospital registries of the Na-

tional Committee for the Defense of theBlind and Deaf-mutes of Guatemala in thetwo most populous cities of the country(Guatemala City and Quetzaltenango). Itshould be pointed out that ocular disordersdue to vitamin A deficiency have disap-peared almost entirely since the high-dosevitamin A supplementation campaign of1987 and the reintroduction of sugar fortifi-cation in 1988.

FUTURE TOPICS OF INTEREST INPUBLIC HEALTH

In the 1970s, the idea of adding vitamin Ato sugar was conceived based on the suppo-sition that consumption of this productwould remain unchanged; publicity basedon the condition of fortification was prohib-ited. However, in the 1990s it was recognizedthat it was necessary that the consumer haveinformation on the importance of sugar as avitamin A vehicle in order to justify and de-fend the program’s existence. This objectivewas achieved, and the general population


TABLE 3. Prevalence of low levels of plasmaretinol in boys and girls of Guatemala in 1995(< 20 µg/dL or < 0.7 µmol/L).Age Low levels of plasma retinol(months) (%)

12–23 19.924–35 17.736–47 13.148–59 11.9

Source: Guatemala, Ministerio de Salud Pública y AsistenciaSocial. Encuesta nacional de micronutrientes, 1995. Guatemala:Ministerio de Salud Pública y Asistencia Social; 1996.

TABLE 4. Incidence of ulcerations and ocularperforation in Guatemala associated with vitamin A deficiency.

Cases

Children ChildrenYear < 4 years 4–10 years Total

1982 6 3 91985 3 2 51986 4 2 61987a 1 0 11988b 1 0 11989 1 0 11990 2 0 21991 1 0 11994 1 0 11997 0 0 0

aA national campaign to distribute vitamin A capsules was car-ried out in 1987.

bThe sugar fortification program with vitamin A resumed in1988.

Source: INCAP, Laboratory of Nutritional Biochemistry, unpub-lished data obtained from the hospital registries of the NationalCommittee for the Defense of the Blind and Deaf-mutes of Guate-mala in Guatemala City and Quetzaltenango.

now recognizes that sugar should containthis nutrient. In the last 30 years, sugar con-sumption—both sugar consumed directlyand sugar added to industrially processedfood—has increased, and it is now more than100 g/day per person. This behavior doesnot coincide with recommendations of theWorld Health Organization (18) that the con-sumption of simple sugars be restricted to10% of daily calorie intake, which is equiva-lent to approximately 45 to 70 g/day ofsugar. Fortification has probably had little in-fluence on the increase in sugar consumptionin Guatemala, but some entrepreneurs havebegun to exploit the interest of the popula-tion in micronutrients and at their owninitiative have launched sugar that also con-tains iron on the market. To date, informa-tion is lacking on the technical quality andtrue biological value of iron fortification, aswell as its influence on the promotion ofsugar consumption. Excess sugar consump-tion, potential excess vitamin A intake, andsugar fortification with other micronutrientsare new fields of work in the public healtharea.

THE POLITICAL AND ECONOMICCRISES OF THE PROGRAM

The sugar fortification program of Gua-temala enjoys national and internationalrecognition. Guillermo Arroyave has beenawarded the Order of the Quetzal, the mostimportant medal of Guatemala, mainly forconceiving and promoting this program. InJanuary 1998, he became the distinguishedrecipient of a Prince Mahidol Award con-ferred by the King of Thailand in recognitionof his universally important contributions tothe public health of humankind. In addition,in 1996 UNICEF granted public recognitionto the Government of Guatemala and tosugar producers for achieving universal for-tification of this product in the country.

However, despite the importance andprestige of the program and the positive ef-

fects that it has demonstrated, the first Cabi-net Resolution of January 1998 (Governmen-tal Agreement 01-98) repealed the resolutionfor compulsory sugar fortification (Govern-mental Agreement 497-93). The measure wasdesigned to favor sugar imports in responseto a 10% increase in the price of the productdecided by producers in December 1997,which increased the price from US$ 0.56/kgto US$ 0.60/kg, equivalent to US$ 1.00 perperson a year, assuming a direct domesticconsumption of 25 kg/year/person. The av-alanche of protests from both Guatemalansand the international arena captured thefront pages of all the country’s newspapersand received broad coverage in other com-munications media. The fact that the pro-gram was backed by a Congressional decreeissued in 1992 and the situation declared tobe a national emergency caused other Stateagencies to intervene. Furthermore, the Lawof Sugar Fortification of 1974, also passed byCongress, remained in force.

In view of the unanimous social opposition,the Government issued a new regulation on 13January 1998 (Governmental Agreement 15-98)that restored mandatory sugar fortification.This regulation left open the possibility of im-porting unfortified sugar, but required its for-tification with vitamin A before its distributionand sale. At the same time, producers agreedto turn back the price of sugar to the price ineffect in December 1997. Given the interna-tional importance of the program for publichealth, the journal Sight and Life published a re-view by Solomons and Bulux (19) on the eventsin Guatemala.

Although the opportunity to import sugarinto the country was opened, no companytook advantage of it. Guatemala is the third-largest sugar exporter of Latin America, afterBrazil and Cuba, producing 1.8 million met-ric tons of sugar per year, of which 1.3 mil-lion (72%) tons are exported and 0.5 million(28%) tons are allocated to supply the coun-try’s internal demand. Sugar is one of thecountry’s principal sources of foreign ex-change, in 2004 surpassing coffee in impor-


tance.9 In 1998, sugar production in Guate-mala was equivalent to the combined totalproduction of the rest of the Central Ameri-can countries. Furthermore, the local price ofthis product was the lowest in the region,with the exception of Belize, which subsi-dizes sugar production.

In December 1999, history repeated itself:producers raised the price of sugar from US$0.48/kg to US$ 0.54/kg (prices were lowerthan in 1998 due to the devaluation of na-tional currency in relation to the U.S. dollar),and the Government repealed Agreement 15-98 and allowed the importation and sale of10,000 metric tons (approximately 25% ofmonthly demand) of unfortified sugar for 30days, the period in which the equipmentneeded for fortification was to be installed.On 15 January 2000 there was to be a changein government authorities, so the outgoingGovernment issued another regulation forsugar fortification on 7 January 2000 (Gov-ernmental Agreement 021-2000), which wassimilar to that of January 1998 but mentionedthe exemption from fortification of the 10,000metric tons which had been authorized. Thetechnical specifications of this regulationhave been in force until the time of this writ-ing in 2005.

With the new Government, the conflict in-tensified and open confrontation with sugarproducers began. A new Government Agree-ment (121-2000) authorized the tax-free im-portation of 218,922 metric tons of sugar(44% of annual national demand), of which72,974 did not have to be fortified because itwas destined for industrial use. The Govern-ment backed these measures arguing thatGuatemalans were paying five times morefor sugar, referring to the price of raw sugaron the New York Stock Exchange (US$0.11/kg). Producers claimed that the price ofwhite sugar was higher than that of rawsugar on the international market, whichdoes not include the expense of transpor-

tation, storage, packaging, and marketing.They also publicized rates for the importa-tion of sugar from other countries (30%–40%) and sugar prices, which highlightedthe fact that, on the average, prices were 17%lower in Guatemala than in any of the otherCentral American countries and Mexico,with the exception of Nicaragua.10 On thisoccasion, there was less civil protest in de-fense of the program, and the crisis focusedinstead on the possible harm that the deci-sion would inflict on the national economy.After an intense campaign in the communi-cations media and public manifestations bythe sugar sector and associated industries,the Government and sugar producersagreed in April that the sugar price wouldreturn to the levels existing in previousyears. The Government would authorize theimportation of only 5,000 metric tons peryear of fortified sugar, tax-free, an amountthat could increase depending on need. Fur-thermore, fortified sugar could be importedfreely with a 20% tax.11 Agreement 121-2000was repealed, and Agreement 151-2000 wasissued.

In July 2000, the first lot (5,000 metric tons)of sugar from Cuba was admitted to thecountry12 (additional lots from Brazil wouldenter later). This was unfortified sugar be-cause, according to the importing companyand the Government, it was destined for in-dustrial use. Subsequently, it was revealedthat it would be distributed on the marketfor direct consumption, after fortification inthe customs warehouse.13 This set off an ad-vertising and legal battle between nationalproducers and the importing company. Theproducers claimed that Agreement 151-2000applied to the importation of fortified sugar,not unfortified sugar. In turn, importers and


9Prensa Libre 20 July 2004, Economics section. Avail-able at: www.prensalibre.com

10El Periódico 28 March 2000:25; Prensa Libre 5 April2000:30.

11Prensa Libre 11 April 2000:3, National section; SigloVeintiuno 11 April 2000:3.

12Prensa Libre 15 July 2000:17, Economics section.13Siglo Veintiuno 9 August 2000:35; Prensa Libre 10 Au-

gust 2000:41.

the Ministry of Public Health and Social Wel-fare publicly accused national producers ofviolating the fortification requirement,14 bas-ing their complaint on data that emergedfrom the Ministry’s inspection activities,which coincided with the official results pre-sented in Table 2 for that year. In order toavoid damaging public opinion of the pro-gram, which was operating satisfactorily,CONAFOR had to clarify publicly this mis-leading and malicious statement.15 Afterweeks of disputes, imported sugar began tobe marketed in the country. Its price was US$ 0.006/kg, lower than the domesticproduct, meaning a yearly saving of US$0.15 per person for those who purchased thissugar.

In August of the following year (2001),Agreement 151-2000 was modified to allowthe legal tax-free importation of 5,000 metrictons of unfortified sugar (GovernmentAgreement 350-2001). National producersagain reacted, threatening to stop fortifica-tion since it had not been guaranteed thatthe imported sugar would be fortified.16 Inturn, CONAFOR, in light of the uncertaintyof the situation, created a social auditingsystem to monitor sugar quality in the Gua-temalan market. Monitoring activities in2001–2002 indicated that the majority ofsugar samples of national brands were forti-fied and that only one brand of refined sugarproduced nationally and one importedproduct were being distributed without vi-tamin A. The results of the social audit weremade public in 2002, citing all the brandnames analyzed. The Government reactedby confiscating refined sugar of the brandidentified and sold in supermarkets of Gua-temala City, but it did not take any actionagainst the imported product. Furthermore,several national refineries were denounced

with government claims of noncompliancewith fortification.

Tension continued, although lessened,until December 2003, when, after the presi-dential elections, producers raised the priceof sugar from US$ 0.48/kg to US$ 0.53/kg.The Government repealed Agreement 350-2001 and issued Agreement 1-2004, which al-lowed the tax-free importation of 100,000metric tons of unfortified sugar.17 Producersasked the Court of Constitutionality to de-clare the agreement unconstitutional. TheCourt resolved in their favor.18 When thenew Government took power, GovernmentAgreement 1-2004 remained definitivelyvoid, and it was agreed that the price ofsugar would be left at a price between theprevious and new value (US$ 0.51/kg).19 Itis interesting to note that in September of thesame year, the Ministry of Public Health andSocial Welfare warned the populationthrough the press that sugar imported fromBrazil was being marketed without previousauthorization by health authorities as re-quired by Guatemalan law.20

This protracted period of crisis affected theprogram. Although it was maintained, theprogram’s integrity deteriorated with regardto home monitoring, because samples wereobtained from only 43% of schools in 2002(Table 1), lacking samples even from metro-politan schools. In 2003, the situation beganto improve, but performance was still inferiorto that of 2001 and previous years. Social au-dits ceased to be made in 2003 due to lack offinancing. Furthermore, the public’s continu-ous exposure to messages about vitamin A insugar created the impression that sugar forti-fication was an invention of national produc-ers devised to protect their market and in-crease sales. The present opinion of thepopulace about the program is unknown.


14Siglo Veintiuno 1 September 2000:40; Prensa Libre 1September 2000, Economics section.

15Prensa Libre 11 September 2000:37.16Prensa Libre 10 September 2001:19, Economics

section.

17Prensa Libre 3, 7, and 8 January 2004; Economicssection.

18Prensa Libre 13 January 2004, Economics section.19Prensa Libre 11 February 2004, Economics section. 20Prensa Libre 30 September 2004.

THE ROLE AND IMPORTANCE OF CONAFOR

The Law of Food Fortification of Guate-mala of 1992 created the National Commis-sion on the Fortification, Enrichment, andComparison of Foods (CONAFOR), an in-terinstitutional and intersectoral entity re-sponsible for coordinating and supervisingfood fortification programs important forpublic health. CONAFOR consists of repre-sentatives of the Ministries of Public Healthand Social Welfare; Agriculture, Livestock,and Food; Economy; and Government; aswell as trade and food associations affectedby the law (sugar, salt, and wheat flour) andthe Consumers League. This Commission re-ceives technical advice from the NationalUniversity, INCAP, the Pan American HealthOrganization, and UNICEF. All membersserve ad honorem, without economic incen-tive or remuneration for attending work ses-sions. CONAFOR has met systematicallysince its creation with almost monthly perio-dicity. Although the law that established theCommission did not specify a regulation forthe distribution of positions, its membersdesignated as president one of the represen-tatives from the private sector (associationsof sugar, salt, and wheat flour producers), aposition which rotates every two years,while the Secretariat was assigned perma-nently to the Ministry of Public Health andSocial Welfare.

Even in the midst of the conflicts that oc-curred between 1998 and 2004, CONAFORwas able to facilitate ongoing communica-tion and cooperation among the technicalpersonnel in the public and private sectorsand with the country’s international organi-zation partners, thus proving its ability toserve as a valid and effective forum for dis-cussing and resolving differences. Generallyspeaking, an atmosphere of cordiality reignsamong members, even if at times it is dis-turbed by the pressures brought to bear onthe Department of Food Regulation and Pro-tection to increase its efforts to ensure that all

food brands on the market satisfy sugar, salt,and wheat flour fortification requirements.

CONAFOR has carried out promotionaland educational activities on topics related tofood fortification and targeted these to a va-riety of groups, including civil servants, foodproducers, and consumers. CONAFOR’swork has made it possible to formulatewheat flour to include folic acid and to re-place reduced elementary iron with ferrousfumarate. CONAFOR has also played an in-strumental role in the preparation of a regu-lation requesting the addition of fluoride andiodine to salt for human consumption and isinvolved in efforts to achieve the fortificationof cornmeal flour. Finally, it is important tonote that another of CONAFOR’s core func-tions is the preparation of proposals aimed atsecuring international financing to reinforcethe monitoring, surveillance, evaluation, andeducational activities of Guatemala’s foodfortification programs.

The conflicts between the Governmentand the national private sector have at timesthreatened the work and continuity ofCONAFOR. At the most critical moments,representatives of the public sector havewithdrawn, but they have subsequently re-turned at the first sign of lessening tension.There were times, however, when represen-tatives of the Ministry of Public Health andSocial Welfare expressed a wish that Con-gress modify the Law of Food Fortification toconvert CONAFOR into a simple advisorybody because they considered that programsupervisory functions should be the solecompetence of the Government. CONAFORhas also been attacked by private sector rep-resentatives who accuse it of being a tool fornational producers of sugar, wheat flour,and salt to use for their own benefit. How-ever, it can be claimed that the continuousand persevering work of CONAFOR since its creation has sustained interest in food for-tification programs and that its participa-tion has been crucial during times of crisiswhich threatened the very existence of theseprograms.


DISCUSSION AND CONCLUSIONS

Between 1987 and 2005, the sugar fortifi-cation program in Guatemala has improvedprogressively. Its nature and characteristicsare now better understood, so that the factorsthat condition effectiveness can be controlledbetter. Water-dispersible vitamin A micro-capsules now contain plant ingredients in-stead of animal gelatins, favoring the intro-duction of this process in societies that donot consume animal products. The techno-logical development of the sugar industrydemanded the invention of automatic feed-ers and special mixers that not only havehelped to improve automation and the ho-mogeneity of the process in refineries, butalso have made it possible to fortify sugar inpackaging centers. This is important becauseit enables the fortification of imported orstored unfortified sugar. It has been deter-mined that the variation in the process is 10%to 30% and is greater when fortification iscarried out in sugar refineries. The stabilityof vitamin A in sugar is similar to that ofother fortified foods. In the case of Guate-mala, recovery is 80% in refineries, 67% atpoints of distribution and sale, and 50% inhomes a year after sugar has been fortified.Taking all of these factors into account, themaximum cost of fortification is US$ 0.009/kg to achieve a minimum vitamin A contentof 3.5 mg/kg and an average vitamin A con-tent of 7.5 mg/kg in the sugar that reachesthe tables of consumers.

The case of sugar fortification in Guate-mala illustrates the importance of specifyingthe nature of a program before issuing stan-dards and regulations. Legislative instru-ments often demand specifications that areimpossible to attain due to the technicalcharacteristics of the processes. This incom-patibility creates conflicts when food regula-tion authorities attempt to confirm compli-ance with specifications based on purelytheoretical standards.

It has been concluded that it is better tospecify a minimum level of fortification in-

stead of a margin of variation. The level iscalculated after considering the variation inthe process and nutrient loss during storage.In Guatemala, this level was set at 5.0mg/kg, a value that ensures an average vita-min A content of 7.5 mg/kg or more, withwhich the Guatemalan population receives60% to 150% of the daily nutritional require-ments of vitamin A in sugar.

Vitamin A is one of the nutrients that hasa maximum tolerable intake value (20, 21),which is 3,000 µg a day for adults (for otherage groups, maximum tolerable intake islower). To protect against a higher consump-tion than that, a maximum tolerable level offortification should be established. This leveldepends on consumption and will decreaseas consumption of the food vehicle increases.In the case of Guatemala, the maximum tol-erable fortification level recommended is 25mg/kg. The ideal fortification practice is thatfood should contain the nutrient of interestat a concentration higher than, but as close aspossible to, the minimum level of fortifica-tion. The maximum tolerable level of fortifi-cation is important to guarantee that mi-cronutrient content be as uniform as possibleand always within safe levels.

The monitoring system (quality control,inspection, and surveillance) of the sugarfortification program in Guatemala illus-trates that chemical and analytical support isessential and does not require the use of so-phisticated tests or expensive equipment.Analytical tests should be selected in accor-dance with their purpose and the urgencywith which the results must be known. Forexample, the analytical resolution can be re-duced (as in the semiquantitative methodused in refineries) to obtain rapid results, butalways seeking a method with a satisfactoryaccuracy within the range of concentrationsused for decision-making. On the otherhand, discriminatory tests with a fixed cutoffpoint are useful for estimating coverage,while quantitative methods help to obtain abetter idea of the amount of nutrient beingsupplied to the population. Knowing the


nutrient content of the fortified food is usefulfor estimating intake. An important aspect ofmonitoring is the presentation and dissemi-nation of results. Documentation of the pro-gram and its processes in Guatemala hasmade it possible to narrate their history andthus to illustrate the program’s evolutionand discover when information is modifiedor misinterpreted for interests other thantechnical interests. The availability of this in-formation has made it possible to defend theprogram when its quality has been under at-tack. It could even be speculated that hadthis information not been available, the pro-gram could have ceased to exist. The weakpoint of monitoring fortified sugar in Guate-mala is that it has depended financially uponinternational cooperation entities. While itscost is not excessive, the governments of de-veloping countries usually do not reservefunds for this purpose.

Another weakness of the program is theabsence of a system of epidemiological andnutritional surveillance that would make itpossible to assess on a fairly regular basis thequality of the diet and nutritional status ofthe population. The most recent informationis from 1995, when it was determined that vi-tamin A deficiency was under control. How-ever, it would have been useful to assess thefood and nutrition situation in subsequentyears, in addition to identifying potentiallyexcessive levels of intake. This information isfundamental in view of the latent threat thatthe program will be interrupted. If this in-deed were to happen, the most substantialargument for urging its restoration would beto discover a resurgence of vitamin A defi-ciency. The lack of surveillance systems iscommon in developing countries and hascontributed to the adoption of many deci-sions relevant to public nutrition on the basisof assumptions, ideologies, and good inten-tions, rather than scientific tests and sensibledeductions.

The role of INCAP in the Guatemalan pro-gram for sugar fortification has been vitalfrom its inception. The process originated

thanks to research on nutritional epidemiol-ogy and on food technology conducted inthat institution. The credibility, ability to con-vince, and prestige of INCAP favored thepromotion, launching, and defense of theprogram. The experience acquired in the1988–2005 period illustrates the importanceof technical and scientific bodies. Food fortifi-cation programs are in continuous evolution,meaning that they require ongoing improve-ment of their technical, scientific, and regu-latory aspects, especially monitoring andbiological evaluation. No advance can beconceived and attained without independentcenters for research and development. Fur-thermore, it may be impossible to sustainachievements without them. Herein lies theimportance of ensuring that the technical andscientific services of centers like INCAP aresustainable and even strengthened.

The combination of excessive sugar con-sumption and high vitamin A levels impliesthe risk of surpassing the tolerable maxi-mum intake value. If it is accepted that thepermissible maximum fortification level is 25mg/kg, then it would suffice for adults toconsume 120 g of sugar a day to attain themaximum tolerable intake of 3,000 µg of vi-tamin A (21). This is highly probable in Gua-temala, where the combination of high in-take of sugar containing high vitamin Alevels has already been reported.21 The previ-ous analysis was made without includingother processed foods in the diet that alsocontain vitamin A in the form of retinol, thepresence of which is increasing on the mar-ket. This situation indicates a pressing needto issue regulations to adjust the content ofvitamin A in sugar to current consumptionprofiles, as well as to restrict the addition ofthis nutrient to any other processed food.

Sugar is an ideal vehicle for fortification inmany countries like Guatemala because thepopulace consumes it regularly in sufficientquantities and because it is produced in a rel-atively few number of centers with accept-


21Noel W. Solomons, personal communication.

able levels of industrial development. Thissituation is attractive in the sense that itopens the door to the possibility of addingother nutrients to sugar. The idea, while agood one, nonetheless requires technologicaldevelopment, especially to avoid the seg-regation of nutrients from sugar crystals(solids of different sizes) and to prolong thenutrients’ stability—in the case of vitamins—during the shelf life of the processed sugar.

For example, there is an initiative to addiron to sugar, but it still has to be shown thatthe nutrient remains adhered to the sugargrains, that the presence of iron is compatiblewith sugar uses, and that the amount of ironadded has significant biological effects. Untilconcrete proof of these requirements be-comes available, sugar fortification withiron—or with any other nutrient—will re-main little more than a sales strategy devisedby producers and marketers for commercialimage enhancement. In any event, as sugar isa food whose consumption should be limited(18), any type of sugar fortification should bedone following regulations and standards is-sued by the public health authorities of theindividual country in question.

Guatemala became an experimental sitefor identifying the forces influencing foodfortification programs for widespread con-sumption, which, as has been shown in thischapter, at times transcend the interests ofnutrition and public health. Fortification in-volves costs that, although minimal, canoriginate large financial losses when extrap-olated to food consumption volumes (themarket share of a product may decline due toa difference of a few cents in price) or largegains (due to false statements that a productis fortified or to restrictions in competition).In this play of economic relations, govern-ments may act on behalf of specific interests,and food fortification programs can becomeobstacles to the flexibility authorities seek tofacilitate their decisions. Fortification is not abarrier to commercial competition if the rulesand the criteria for their compliance are clearand applicable to everyone involved. How-

ever, for this purpose governments musthave systems of food inspection and protec-tion that are reliable, constant, and effective.Unfortunately, in many developing countriesthis requirement is rarely met due either tothe lack of resources or practices that are vul-nerable to corruption. Under these circum-stances, the participation of consumers in thedefense of their rights would appear to be anappropriate solution. For this reason, thepromotion of social audits carried out bynongovernmental consumer protection or-ganizations and bodies with relative inde-pendence for supervising the programs, suchas CONAFOR, would likewise appear to befeasible control measures. While the work ofthese bodies can create friction with govern-mental food regulation authorities and attimes with individual commercial producers,this is normal in any human society. What isimportant is to guarantee that these publichealth programs, which by definition in-volve the participation of economic produc-tion structures, can maintain their qualityand sustainability in benefit of the generalpopulation whom they serve.

The vicissitudes experienced by the sugarfortification program in Guatemala duringthe 1998–2004 period highlight the fact thatpartnerships between the public and privatesectors are more goals than realities. Rela-tions are constantly shifting and require con-stant upkeep because the particular individ-uals involved change from moment tomoment and particularly so with changes ingovernment. The sugar fortification programimplemented between 1975 and 1977 arose inresponse to pressure from the public healthsector, but lacked unanimous support fromthe private production sector, which made iteasy to find reasons for discontinuing it.Health interests also motivated its reinitia-tion in 1988, but on this occasion better col-laboration and mutual respect were beingdeveloped gradually, especially between thetechnical personnel of both sectors. Once thesugar fortification program was constituted,it extended to spheres other than health, but


lost the attention of the health sector, espe-cially when the latter’s weakness in enforc-ing respect for the regulations became evi-dent. In Guatemala, the situation wasaggravated by the fact that fortification pro-grams based on food products of major eco-nomic and political interest relegated publichealth objectives to a lower level of visibility.This highlights the lack of political supportand recognition of the importance of the for-tification programs displayed during this pe-riod and illustrates the need for a sustaineddefense of the public health benefits to be se-cured through the fortification program, aswell as for permanent transparency and dis-semination of the results of program moni-toring and evaluation.

The creation of CONAFOR by a law ofCongress as an independent body for the co-ordination and supervision of food fortifica-tion programs turned out to be a successfulstrategy because it increased the commit-ment and motivation of its members in rela-tion to these programs. One of the limitationsmay have been the weak leadership of theMinistry of Public Health and Social Welfaresince its representation was not delegated tohigh-level officials when the importance ofCONAFOR required it. This drawback, how-ever, can be easily resolved through the cre-ation of a political commitment to stimulatethe development of partnerships with theprivate sector. In any case, the importance ofCONAFOR as an independent body wasconfirmed, and its existence would be justi-fied by the mere fact that it was persistent inpromoting food fortification programs acrossthe board to Government workers, the busi-ness community, and consumers themselves.

In conclusion, food fortification programsare complex, require the participation ofmany institutions and sectors, and are vul-nerable to economic interests and powerstruggles, but if they are structured ade-quately, they can produce major benefits at avery low cost to society as a whole. The eval-uation, documentation, and continuous dis-semination of the quality and achievements

of these programs seem to be the key to con-vincing all those involved of their impor-tance in ensuring the well-being of society. Itcould be advantageous if international de-velopment agencies were to consider pro-moting social audits, home monitoring, andfood and nutrition evaluations associatedwith these programs on an ongoing and per-manent basis, since the benefits far outweighthe investment required.

REFERENCES

1. Dary O. Avances en el proceso de fortificación deazúcar con vitamina A en Centroamérica. Bol OficinaSanit Panam 1994;117(6):529–537.

2. Mora JO, Dary O, Chinchilla D, Arroyave G. VitaminA Sugar Fortification in Central America. Experienceand Lessons Learned. Arlington, Virginia: MOST, TheUSAID Micronutrient Program; 2000.

3. Institute of Nutrition of Central America andPanama, US Interdepartmental Committee of Nutri-tion for the National Defense. Nutritional Evaluationof the Population of Central America and Panama: Re-gional Summary, 1965–1967. Washington, DC: USDepartment of Health, Education and Welfare; 1972.(DHEW Publication HSM 72–8120).

4. Arroyave G, Aguilar JR, Flores M, Guzmán MA.Evaluation of Sugar Fortification with Vitamin A at theNational Level. Washington, DC: Pan AmericanHealth Organization; 1979. (Scientific Publication384).

5. Arroyave G, Mejía LA, Aguilar JR. The effect of vi-tamin A fortification of sugar on the serum vitaminA levels of preschool Guatemalan children: a longi-tudinal evaluation. Am J Clin Nutr 1981;34(1):41–49.

6. Dary O, Arroyave G. Part 2: Technical and opera-tional guidelines for preparing vitamin A premixand fortified sugar. In: Dary O, Arroyave G. Manualfor Sugar Fortification with Vitamin A. Arlington, Vir-ginia: USAID Opportunities for Micronutrient In-terventions Project (OMNI); 1996:21–26.

7. Peláez I. Determinación del grado de eficiencia de laactual dosificación de vitamina A en el azúcar deGuatemala y alternativas para su mejoramiento[thesis]. Guatemala: Universidad de San Carlos, Es-cuela de Ingeniería Química; 1995.

8. Guatemala, Ministerio de Salud Pública y Asisten-cia Social. Encuesta nacional de micronutrientes, 1995.Guatemala: Ministerio de Salud Pública y Asisten-cia Social; 1996.

9. Dary O, Guamuch M, Nestel P. Recovery of retinolin soft-drink beverages made with fortified unre-fined and refined sugar: implications for nationalfortification programs. J Food Compost Anal 1998;11:212–220.


10. Dary O. Sugar fortification with vitamin A: a Cen-tral American contribution to the developing world.In: The Micronutrient Initiative. Food Fortification toEnd Micronutrient Malnutrition. State of the Art Sym-posium Report August 2, 1997. Ottawa: The Micronu-trient Initiative; 1998:95–98.

11. Arroyave G, Pineda O, Funes C de. Enriquecimientode azúcar con vitamina A. Método rápido para lafácil inspección del proceso. Arch Latinoamer Nutr1974;24:155–159.

12. Bayfield RF, Cole ER. Colorimetric determination ofvitamin A with trichloroacetic acid. In: McCormickDB, Wright LD, eds. Methods in Enzymology. Vol. 67,Part F: Vitamins and coenzymes. New York: Aca-demic Press; 1980:189–195.

13. Dary O, Arroyave G, Flores H, Campos FACS, LinsMHCB. Part 3: Analytical methods for the controland evaluation of sugar fortification with vitaminA. In: Dary O, Arroyave G. Manual for Sugar Fortifi-cation with Vitamin A. Arlington, Virginia: USAIDOpportunities for Micronutrient Interventions Proj-ect (OMNI); 1996:11–19.

14. Dary O, Mora JO. Food fortification to reduce vita-min A deficiency: International Vitamin A Consul-tative Group recommendations. J Nutr 2002;132(Suppl 9):2927S–2933S.

15. Krause V, Delisle H, Solomons NW. Fortified foodscontribute one half of recommended vitamin A in-

take in poor urban Guatemalan toddlers. J Nutr1998;128(5):860–864.

16. Sommer A, Davidson FR. Assessment and control ofvitamin A deficiency: the Annecy Accords. J Nutr2002;132(Suppl 9):2845S–2850S.

17. Thurnham DI, McCabe GP, Northrop-Clewes CA,Nestel P. Effects of subclinical infection on plasmaretinol concentrations and assessment of prevalenceof vitamin A deficiency: meta-analysis. Lancet2003;362(9401):2052–2058.

18. World Health Organization. Diet, Nutrition and thePrevention of Chronic Diseases. Report of a JointWHO/FAO Expert Consultation. Geneva: WHO;2003:56–58. (Technical Report Series 916).

19. Solomons NW, Bulux J. Vitamin A fortification sur-vives a scare in Guatemala. Sight and Life Newsletter1998;2:26–30.

20. Institute of Medicine, Food and Nutrition Board.Dietary Reference Intakes for Vitamin A, Vitamin K,Arsenic, Boron, Chromium, Copper, Iodine, Iron, Man-ganese, Molybdenum, Nickel, Silicon, Vanadium, andZinc. Washington, DC: National Academy Press;2001.

21. Food and Agriculture Organization of the UnitedNations, World Health Organization. Human Vita-min and Mineral Requirements. Report of a JointFAO/WHO Expert Consultation. Bangkok, Thailand.Rome: FAO; 2002.


INTRODUCTION

The existence of subclinical vitamin A de-ficiency (VAD) in Central America was firstdocumented in the mid-1960s (1). The factthat clinical signs were infrequent may haveaccounted for the relatively low priority thenassigned to control VAD, which for a longtime was seen mainly as an eye-related prob-lem (2, 3). Some mass distribution of vitaminA capsules occurred in 1973–1974 in El Sal-vador (4) and in 1988 in El Salvador andGuatemala. By the mid-1970s, the Institute ofNutrition of Central America and Panama(INCAP) of the Pan American Health Orga-nization (PAHO) had developed the technol-ogy for and demonstrated the impact of for-tifying sugar with vitamin A as a means toreduce VAD (5, 6). Fortification was regardedas a more sustainable and far-reaching ap-proach than pharmaceutical supplementa-tion. Thus, sugar fortification was rapidly in-troduced in Costa Rica, Guatemala, andHonduras in 1977 by means of mandatorylegislation. These programs, however, lastedonly a few years. A long period with little orno action followed (7) except for resumptionof sugar fortification in Guatemala and Hon-duras in the late 1980s.

By the early 1980s, it had become clearthat even subclinical VAD was associated

with significantly greater risk of child mor-bidity and mortality from infectious diseases(8, 9). This was subsequently confirmed byresults of field trials demonstrating the child-mortality-reducing impact of improved vita-min A status through either supplementationor food fortification (10). With the realizationof the association between VAD, immunity,morbidity, and mortality in children, VADgained recognition as an important threat tochild health and survival. Since then, VADhas been assigned high priority as part of thehealth and nutrition plans in a number ofcountries where VAD is a serious publichealth issue, and periodic high-dose vitaminA supplementation has been promoted as alow-cost, highly effective means of rapidlyimproving vitamin A status, health, and sur-vival of children; indeed, it has been por-trayed as one of the most cost-effective childsurvival strategies available to public healthplanners and programmers (11–13).

VIRTUAL CONTROL OF VITAMIN ADEFICIENCY IN NICARAGUA

José O. Mora,1 Gloria E. Navas,2 Josefina Bonilla,3and Ivette Sandino4

61

1Senior Technical Advisor, USAID/MOST Program,Arlington, Virginia, U.S.A.

2Nicaragua Country Coordinator, INCAP, Managua;former Director of Department of Nutrition, Ministry ofHealth of Nicaragua.

3Executive Director, NicaSalud NGO Network, Man-agua; former Nicaragua local resident advisor, USAID/MOST Program and USAID/OMNI (Opportunities forMicronutrient Interventions) Project.

4Primary Health Care and Nutrition Advisor,UNICEF/Nicaragua.

Following the recommendations of theWorld Health Organization (WHO), supple-ment distribution was later integrated intoNational Immunization Days (NIDs) in sev-eral countries (14). Despite ongoing VADcontrol programs, including high-potencysupplementation in 85 countries, today VADaffects an estimated 127 million preschoolchildren (15) and is sufficiently severe to re-sult in death or blindness in over a millionchildren annually (16). It is generally recom-mended that, in addition to supplementa-tion, a food-based approach, including forti-fication and dietary diversification, shouldbecome part of an integrated strategy to ef-fectively address VAD and its health and sur-vival implications (17, 18).

When in 1993 the Nicaraguan Ministry ofHealth (MOH) confirmed VAD as a nation-wide public health problem, advocacy effortsbenefited from the results of child mortalitytrials and meta-analysis (10), and mass sup-plementation was thus the immediate emer-gency response. In 1995, a National Micronu-trient Plan (NMP) was formulated, whichincluded a well-defined VAD control compo-nent that has been successfully implementedover the past 10 years.

The purpose of this chapter is to describethe Nicaraguan experience in VAD controlover the last decade and to highlight some ofthe principal lessons learned. Countries thatare still affected by VAD may find theNicaraguan experience useful in addressingtheir own situations.

BACKGROUND

Nicaragua is the second-poorest countryin the Latin America and Caribbean regionafter Haiti. In the twentieth century, thecountry passed from a long period of family-led dictatorship ending in the late 1970s to adecade of social and political turmoil fol-lowed by a transition to democratic stabilityin the 1990s. GNP per capita, which drasti-cally declined in the 1980s, more recently has

modestly recovered. Most of Nicaragua’spopulation of 5.5 million (2003 estimate) oc-cupies the Pacific Ocean coastal half of thecountry, which lies midway along the Cen-tral American chain; nearly 60% of the coun-try’s residents live in urban areas. Aboutone-third of the adult population is illiterate.

Infant and under-5 mortality have signifi-cantly declined from 140 and 209 per 1,000live births, respectively, in 1960, to 31 and 40per 1,000 in 2001. Coverage rates for immu-nizations have consistently reached > 90%,and the use of oral rehydration therapy fordiarrhea amounted to 82% in 2001. Underthe ongoing MOH decentralization process,the health sector in Nicaragua encompasses17 districts, or Integrated Local Health Sys-tems (Sistemas Locales de Atención Integral enSalud, or SILAIS), which enjoy high manage-ment and partial budgetary autonomy. MOHcentral units provide policy and technicalguidance, training, and supervision to thedistricts. Nicaragua has a long tradition ofcommunity participation in health and nutri-tion initiatives.

In the mid-1960s, INCAP promoted andsupported national nutrition surveys in mostCentral American countries, with the cooper-ation and assistance of the Nutrition Pro-gram of the United States Public Health Ser-vice (1). Several nutritional deficiencies werefound to be widespread in the region. In Nic-aragua, 600 families from 30 localities werecovered, excluding the Atlantic Region. Theregular diet of 68% of the families country-wide (75% in the rural area) met less than50% of their vitamin A needs (5). Clinicalsigns of VAD were not found, but about 20%of the children under 5 years were subclini-cally deficient (serum retinol < 20 µg/dL).However, no specific action to control VADwas initiated as a result of the nutrition sur-vey. By then, VAD was mostly considered asan eye problem, and ocular clinical signswere uncommon in most countries of the re-gion (19). Except for establishment of salt io-dination in 1978, few program and policyconsiderations regarding micronutrient defi-

62 Virtual Control of Vitamin A Deficiency in Nicaragua

ciencies were implemented in Nicaragua be-fore the 1990s.

In 1993, twenty-eight years after the nutri-tion survey, in response to advocacy effortsby the United States Agency for InternationalDevelopment (USAID) and INCAP/PAHO,the First National Micronutrient Survey toassess the status of vitamin A deficiency andanemia was conducted by the MOH with as-sistance from the USAID’s VITAL (Vitamin Afor Health Field Support) Project (20). Thesurvey covered a national sample of 1,791families with children 1 to 4 years of age.Blood specimens were collected and ana-lyzed at INCAP laboratories in Guatemalausing a spectrophotometry method. A 24-hour recall dietary intake assessment wascarried out in 900 families. Persistent VADwas confirmed as a problem of public healthsignificance: 31.3% of the children had sub-clinical VAD (plasma retinol < 20 µg/dL),with no differences by region, and 7.9%showed severe deficiency (plasma retinol < 10 µg/dL). About 59% of the children 12 to59 months of age and 71% of the familiesconsumed less than 50% of the recom-mended amounts of vitamin A per day.5 Bythen, among the 10 Latin American countrieswith national data, Nicaragua had thesecond-highest prevalence of VAD after ElSalvador (19). Nevertheless, clinical signs ofVAD were not found.

When the results of the 1993 survey werereported, there was growing evidence andinternational recognition of VAD as a seriousthreat to child survival. Meta-analyses offield trials demonstrating a significant im-pact of improved vitamin A status on childmortality had been widely publicized. As aresult, advocacy for VAD as a problem de-serving priority attention became moreclosely linked to the ongoing child survivalmovement.

It was in this scenario that the NicaraguanMOH Nutrition Department developed and

put in operation a three-year micronutrientadvocacy and action plan (1993–1996), whichincluded an aggressive sensitization cam-paign to create awareness of existing mi-cronutrient deficiency problems and theirimplications. During this period, it wasthought that no sustained commitment toaddress micronutrient deficiencies could beelicited without aggressive awareness andsensitization efforts. The campaign targetedMOH technical personnel, politicians, aca-demic institutions, health professionals, thefood industry, NGOs, community groups,media networks, and the general population.The purpose was to generate political com-mitment to address VAD and other micronu-trient deficiencies. Central messages on vita-min A stressed that “VAD is a seriousproblem contributing to child deaths frominfectious diseases and reducing child sur-vival”; “one of every three Nicaraguan chil-dren is affected by VAD”; “VAD worsens theseverity and duration of infectious diseasesin children”; “the problem requires priorityaction”; and “vitamin A supplements andfortified foods are effective in controllingVAD.”

The survey results were widely dissemi-nated. Presentations were scheduled forMOH technical staff at the central and dis-trict (SILAIS) levels, food industry represen-tatives, and academicians; press releaseswere repeatedly issued; brief technical docu-ments on the three key micronutrient defi-ciencies were prepared and widely distrib-uted; and frequent meetings were held withhigh-level officials from the MOH and otherministries. An assessment of the policy andprogram environment was conducted, aswell as an inventory of the technical and in-stitutional resources available that could betapped to address the problem. Politicalcommitment was generated at the highestlevels of government.

As part of the three-year plan, the MOHdecided that vitamin A supplementation beinitiated immediately as an emergency mea-sure to ameliorate VAD while universal forti-

Mora, Navas, Bonilla, and Sandino 63

5This estimate was based on a β-carotene-vitamin Aconversion factor of 6:1.

fication of a food staple could be established.A stand-alone vertical supplementation pro-gram for distribution of only vitamin A wasnot considered warranted. The challengewas to secure high coverage of children 6 to59 months. Despite some initial concernsabout the sustainability of a campaign-typeapproach, the MOH decided that incorpora-tion of vitamin A supplementation into thewell-established and highly successful Na-tional Immunization Campaigns (NICs), orJornadas Nacionales de Vacunación, offered thebest programmatic option. Therefore, twice-a-year expanded National Health Cam-paigns (NHCs), or Jornadas Nacionales deSalud, spearheaded by immunizations, sub-stituted for the NICs beginning in May 1994.At this time, concerns from the medical com-munity regarding potential toxicity andlong-term undesirable effects of high-dosevitamin A supplements were successfullyaddressed through technical meetings for the distribution and discussion of pertinentliterature.

In order to secure high coverage, the scopeof the NICs was expanded into an integratedpackage of preventive maternal and childprimary health care services to be imple-mented twice yearly. In addition to distri-bution of vitamin A and iron/folate sup-plements, the package included routineimmunizations, anti-helminthes medica-tions, health education, oral rehydrationsalts, contraceptives, chloride for water treat-ment, and anti-louse medications. This re-quired establishing a semi-annual cycle ofdistrict-level activities to improve facilityusage for preventive services, as well as com-munity outreach using school buildings andthe households of community leaders and/or community health volunteers (brigadistas)as delivery posts. Universal vitamin A sup-plementation for children 6 months to 10years through NHCs was then establishedand later (1997) retargeted to children 6 to 59months.

In 1994, the high priority assigned by thecentral government to preventing and con-

trolling micronutrient deficiencies material-ized in the creation of the National Micronu-trient Commission (NMC), presided over bythe MOH Vice Minister, to develop and coor-dinate the implementation of a five-year na-tional micronutrient plan. The NMC is com-posed of more than 20 member institutionsfrom the public, nonprofit, and private sec-tors, including the Ministries of Health; Edu-cation, Culture, and Sports; and Develop-ment, Industry, and Commerce, as well asinternational cooperation agencies (USAID,UNICEF, INCAP/PAHO), the Consumer’sLeague, and the food industry (salt, sugar,and wheat flour producers).

THE NATIONAL MICRONUTRIENTPLAN 1996–2000

A Task Force was designed by the NMC in1994 to prepare a five-year National Mi-cronutrient Plan to be implemented in 1996.The plan was completed in 1995 with assis-tance from USAID’s Opportunities for Mi-cronutrient Interventions Project (USAID/OMNI), UNICEF, and INCAP/PAHO, andin consultation with academic groups, thefood industry, MOH technical personnel,and high-level decision-makers. Involve-ment of these individuals in periodic meet-ings and discussions throughout the processproved to be very useful and allowed for ad-ditional advocacy and reinforcement of polit-ical commitment. The NMP adopted an inte-grated strategy to primarily address vitaminA and iodine deficiencies as well as nutri-tional anemia, with vitamin A and anemiacontrol programs becoming more systemati-cally integrated.

The NMP became a blueprint to put intooperation, as circumstances permitted, a se-ries of specific micronutrient activities. Theseincluded: (1) vitamin A and iron/folate sup-plementation to children and pregnantand/or postpartum women, for immediateimplementation; (2) fortification of food sta-ples with vitamin A or iron and B-complex


vitamins, in addition to ongoing salt iodina-tion; (3) information, education, and commu-nications (IEC) to enhance awareness andpromote demand for supplements and in-creased consumption of micronutrient-richfoods; (4) other public health measures suchas periodic deworming of preschool- andschool-age children; (5) training of healthservice personnel, health professional fac-ulty, and students and community volun-teers; (6) development of program monitor-ing and evaluation (M&E) and surveillancesystems; and (7) operations research.

Instead of being launched simultaneously,NMP interventions were sequentially intro-duced; e.g., supplementation and deworm-ing in 1994, food fortification in 1997 and2000, and IEC in 1999. In a related effort in1997–1998, with USAID/OMNI assistance,nutrition and micronutrient contents weredeveloped and incorporated into the under-graduate curriculum of health professionalschools (medicine, nursing, nutrition) withteaching manuals and prototype materialsprepared in conjunction with INCAP. In1998, USAID commissioned a mid-term ex-ternal assessment and portfolio review of theNMP and micronutrient policies, programs,and opportunities for continued assistance.This exercise was extremely useful to iden-tify strengths and weaknesses in NMP im-plementation, with emphasis on the VADcontrol program, and to evaluate the extentto which NMP goals were being reached, inorder to set program priorities and define is-sues in need of immediate attention.

THE VITAMIN A DEFICIENCYCONTROL PROGRAM

VAD was approached through an inte-grated strategy encompassing mass supple-mentation of children and postpartumwomen, fortification of sugar, IEC, periodicdeworming, training, and program M&E.Program interventions were phased in grad-ually, with supplementation and deworming

introduced in 1994, and sugar fortification,training, and IEC in 1999–2000. While de-worming was expected to contribute to con-trol both VAD and anemia, training and IECwere conceived as comprehensive supportsystems cutting across specific programs,thus adopting an integrated approach toVAD and anemia control (Figure 1). Programmonitoring and evaluation were progres-sively built up to the establishment of an in-tegrated nutrition M&E system in 2002.

Supplementation

The policy decision on vitamin A supple-mentation was made and began to be imple-mented early in 1994; thus, ahead of overallNMP development. In 1995, vitamin A sup-plements were officially included in theMOH list of essential medicines. Technicalguidelines were developed for supplementa-tion targeted to children and postpartumwomen, following WHO recommendations.Since the beginning, vitamin A supplementa-tion became an integral component of theNHCs. Local health units are ultimately re-sponsible for distribution of vitamin A andother supplements. Coordination of the im-plementation of NHCs is a responsibility ofthe districts. MOH central units are responsi-ble for setting the stage for, coordinating, andsupporting the NHCs’ implementation twiceper year (usually May and October) by se-curing sufficient supplies and providingtraining as needed to the districts and these,in turn, to the local health services.

District and local coordination commit-tees arrange for participation of the differentpartners, identify service delivery posts (e.g.,local health units, schools, the houses ofcommunity leaders and brigadistas), and co-ordinate district and local planning and im-plementation. Media communications sup-port is also provided to districts in order toraise awareness and mobilize communities,and to enlist the long-established large cadreof brigadistas in support of the NHCs. Dur-ing the NHCs, communities (particularly


women and children) are massively mobi-lized by engaging the media, municipal au-thorities, the church, and other communitygroups, with very active participation by pri-mary school teachers, secondary school anduniversity health sciences students, commu-nity volunteers, traditional birth attendants,the military, and NGOs. The need to take ad-vantage of the variety of primary health careservices provided at local health facilitiesand distribution sites is highly emphasized.

Each NHC may last one week in urbanareas and as many as four weeks in rural iso-lated areas, where activities of this type arepractically the local population’s only con-tact with the public health system. Vitamin Asupplementation is only one—albeit a veryimportant one—of all the services provided.It is now targeted to children 6 to 59 monthsand postpartum women. While most immu-nization coverage is achieved in the firstround of the year, the second round providesan opportunity for booster doses and forreaching children not covered in the first

round with the full set of primary health careservices; both rounds are used successfullyfor vitamin A distribution. Each campaign is carefully planned jointly by the centralMOH and the districts, and largely fundedby international donors in addition to regu-lar MOH budgetary allocations. In order to achieve the optimal coverage possiblethrough the NHCs, the districts are encour-aged to tap other opportunities for contactswith mothers and children to ensure addi-tional supplement delivery through routinehealth services; however, coverage throughroutine health services has been low (< 1%).

A supervision and monitoring system hasbeen established which, in addition to oversee-ing implementation, periodically providesinformation on population coverage achievedby each district through both NHCs and ad-ditional routine distribution. Supplement de-livery is registered on each child’s health cardand recorded on immunization tally sheets thatare compiled monthly at health units and sub-mitted to the districts (SILAIS). These, in turn,


INCREASEDINTAKE ANDABSORPTION

OF IRON/FOLATE

MANDATORYFORTIFICATION

OF WHEAT FLOUR

DEWORMING

REDUCEDANEMIARATES

VITAMIN ASUPPLEMENTATION

MANDATORYFORTIFICATION

OF SUGAR

BEHAVIORALCHANGE

COMMUNICATIONS

IRON/FOLATESUPPLEMENTATION

INCREASEDINTAKE ANDABSORPTIONOF VITAMIN A

IMPROVEDVITAMIN A

STATUS

FIGURE 1. Integrated approach to VAD and anemia control in Nicaragua.

send the information to the MOH central unitsof the Expanded Program of Immunizations(EPI) and the Department of Statistics whereit is entered in a computer database andprocessed to estimate both immunizations andvitamin A coverage. Semi-annual reportswith coverage rates by age group and districtare released and discussed at the central anddistrict levels in post-campaign evaluationmeetings where the coverage ranking of dis-tricts is examined and options for future im-provement are discussed. Public and profes-sional recognition encourages health staff toachieve high rates of coverage. No adverse ef-fects of supplementation have been reported.

Guidelines were developed for supple-mentation activities to be implemented bythe health units and health care personnel,including community health volunteers(brigadistas). Parallel efforts have been madeto improve procurement, distribution, andlogistics of micronutrient supplements, al-though a specific management logistics sys-tem has not yet been established. In practice,however, this has become a more importantconstraint for iron/folate than for vitamin Asupplementation through NHCs. Annualbudgetary allocations for procurement ofmost vitamin A supplements were made upto 1997. Since then, large-scale donationshave been made by the Government ofCanada through the Micronutrient Initiative(MI); the Governments of Japan, Spain, andSweden; PAHO/WHO; UNICEF; the Wis-consin Lion’s Club; and Friends of the Amer-icas. The districts prepare periodic requestsbased on estimated needs. Timely supply ofdonated supplements and distribution to de-livery points together with other supplieshave been secured for NHCs but not for rou-tine health services; indeed, a managementlogistics system for micronutrient supple-ments in health services beyond those of-fered by the NHCs remains a critical need.

In the late 1990s, PAHO provided techni-cal cooperation to strengthen the supplemen-tation monitoring system by incorporatingsupplement delivery in the child immuniza-

tion and maternal health cards and tallysheets, as well as integrating child supple-mentation with polio vaccine and postpar-tum supplementation with BCG. In 2001,PAHO documented achievements in 10 LatinAmerican countries where vitamin A supple-mentation had been incorporated into im-munization activities (21). Despite someprogress, only five countries had country-wide programs, and a number of program-matic constraints precluded achievement ofconsistently high coverage among children.Nicaragua was an outstanding example.However, beginning in 2003 only one NHCper year has been implemented.

Sugar Fortification

Policy dialogue and negotiations aimed atestablishing mandatory fortification of sugarwith vitamin A began in 1994. Sugar was re-garded as a suitable vehicle based on pro-duction and consumption data: it was cen-trally produced in only seven privatelyowned plants, it was consumed regularly by more than 95% of all Nicaraguan fami-lies, and the domestic supply per personamounted to about 30 kg per year, or 80grams per day. The small number of produc-tion plants and the absence of importedsugar would make government control offortification less complex. The negotiationprocess was brokered jointly by USAID/OMNI, INCAP/PAHO, and UNICEF.Through participation of industry represen-tatives in earlier awareness-raising events,channels of communications had beenopened with the purpose of developing apublic-private sector partnership. Sugar pro-ducers were made aware of VAD and theneed for and benefits of sugar fortificationfor the population; however, they were cau-tious about making a firm commitment.

Despite industry awareness and the Nica-raguan Government’s interest in this initiative,the establishment of a partnership was a cum-bersome and time-consuming process. Gettinga formal commitment by the industry was dif-


ficult since sugar refineries were still in theprocess of recovering from a long period ofinstability after nationalization by the govern-ment in the 1980s. The report of an indepen-dent technical and economic feasibility as-sessment commissioned by the NationalCommittee of Sugar Producers (NCSP) in 1995was positive, but some unresolved issues per-sisted. Major concerns for the industry were thecost of fortification, as well as the need for for-eign currency and considerations related to thefeasibility of transferring the cost of fortifica-tion to the consumer. The existing political andeconomic climate in a period of difficult polit-ical transition to democracy and slow economicrecovery would make price increases a polit-ically sensitive issue. An additional concernwas the uncertainty regarding ownership of thesugar mills, which had been confiscated by theprevious government, and the legal processsurrounding devolution by the new govern-ment to the original owners had not yet beencompleted.

Throughout the initial negotiations process,which lasted four years, both the governmentand external cooperating agencies adopted apositive but cautiously optimistic attitude, care-fully handling advocacy efforts as the circum-stances dictated. At a point when the processseemed to be losing ground, fortifying veg-etable oil was explored as a contingency op-tion. Market, purchase, usage, storage, and con-sumption patterns for edible oil were assessedwith promising results, but a market and eco-nomic analysis of the domestic oil industry re-vealed serious problems affecting the economicfeasibility of fortification, and the idea was ul-timately abandoned. During the entire process,a highly motivated and forceful NCSP execu-tive secretary, the late Noel Chamorro, cham-pioned the cause of vitamin A and emphasizedthe social responsibility of the industry to col-laborate with the government in fosteringeffective solutions to public health problems by reconciling industry and public healthinterests.

Negotiations with the sugar industry mate-rialized in October 1998 when the NCSP exec-

utive director advised the government of theindustry’s readiness to go ahead with fortifi-cation and requested assistance in findingsources of financial support to cover the costof fortificant supplies for the first year, esti-mated at US$ 1.4 million. The largest sugar re-finery in the country (San Antonio) was se-lected as the site for building the premixpreparation plant. The industry request forgovernment assistance in securing financialsupport (a low interest loan) was positivelyconsidered. A soft loan with a 10-year grace pe-riod was obtained from the Nordic Multilat-eral Development Fund (NMDF) and trans-ferred to the industry. The MOH Office ofInternational Relations acted efficiently inaccelerating the lending process. A draftagreement was then prepared by which agovernment-industry partnership was for-mally established with the purpose of initiat-ing sugar fortification in the 1999–2000 harvest.The agreement was officially signed in a spe-cial ceremony in February 1999 with the Pres-ident of Nicaragua acting as an official witness.

Specific responsibilities for the govern-ment and the industry were defined in theagreement regarding legal regulations; gov-ernment assistance in searching for financialsupport; free importation of fortificationequipment and supplies; an eventual in-crease in the price of sugar to create a revolv-ing fund to secure sustainability of the forti-fication program; an informational campaignto the consumer; training to establish indus-try quality control, government monitoring,and surveillance systems for fortified sugar;and joint development and implementationof a work plan with concrete steps to initiatefortification. Sugar producers pledged tocover the initial investment in equipmentand local facilities.

A 12-month work plan was prepared andimplemented jointly by the government and the sugar industry, with assistance fromUSAID’s Micronutrient Operations, Strategies,and Technology Program (USAID/MOST),UNICEF, and INCAP/PAHO. The plan in-cluded six specific actions aimed at the estab-


lishment of universal sugar fortification by the1999–2000 harvest: (1) securing start-up finan-cial assistance, (2) setting technical regulationsand standards, (3) training industry personnel,(4) installation of the premix production plantand mixing equipment, (5) a pilot test and adap-tation of the fortification technology, (6) estab-lishment of industry quality control and gov-ernment monitoring systems, and (7) designand implementation of an informational cam-paign to the consumer. Training and technicalassistance needs were also defined and re-sources allocated by cooperating agencies. Drafttechnical specifications and regulations forsugar fortification were prepared to be dis-cussed with the industry. The draft was basedon regional standard regulations developed bythe USAID/OMNI-INCAP Central AmericaMicronutrient Initiative early in 1998.

The World Bank acted as a fiduciary agentmanaging the NMDF loan for procurement ofthe vitamin A fortificant (retinol palmitate) tobe shipped to the NCSP. However, since theinitial disbursement of NMDF funds tooklonger than expected, the government andUSAID contacted the Micronutrient Initiativeof Canada for a donation to cover the cost ofimporting the fortificant for the first threemonths of implementation. The MI donatedUS$ 350,000 to cover this initial fortificantsupply until the NMDF loan became effec-tive. The sugar industry covered all costs as-sociated with the building and equipping ofthe preparation plant and with procurementof the mixing equipment (dosifiers) for thesugar plants, for a total of about US$ 250,000.UNICEF donated the imported vitamin A for-tificant that was used for the testing andadaptation of the fortification technology.

INCAP and USAID/MOST providedtechnical assistance and training on qualityassurance and control (QA/QC) and moni-toring systems for fortified sugar that hadbeen developed and tested in neighboringHonduras. Since the late 1990s the MOHFood Control Division had operated a regu-latory monitoring system for fortified foods(salt, wheat flour) through periodic inspec-

tions of production plants and retail outlets,to which sugar monitoring was added in2000. Production of fortified sugar began inNovember 1999 with the annual sugar har-vest of 1999–2000. The balance of unfortifiedsugar from the previous harvest continued tobe marketed until early 2000, when the forti-fied product began to reach consumers.

By 2004 sugar fortification was a well-established program. By the end of this sameyear, total sugar production amounted toabout 450,000 metric tons per year, of which60% is exported unfortified, and 40%, or180,000 metric tons, is fortified for domesticconsumption as table sugar or added to com-mercial products (soft drinks, candies, bak-ery items, etc.). Estimated domestic per cap-ita supply is 31.7 kg per year, or 87 g per day,of which about 65 g is consumed as tablesugar.

Information, Education, andCommunications (IEC)

Dietary diversification was contemplatedin the NMP as a long-term approach toaddress VAD primarily through a well-designed information, education, and com-munications (IEC) strategy. The objective ofthe strategy was to increase vitamin A intakefrom natural sources by means of promotingchanges in the regular diet of women andchildren, in addition to encouraging supple-ment demand and acceptance. A formativeresearch plan was implemented in 1997 tobetter understand the general population’sknowledge, attitudes, and practices regard-ing feeding and supplementation of infants,children, and pregnant women. The planalso encompassed research on anemia andiron supplementation, and on the feedingpractices of pregnant and lactating womenand children less than 3 years of age. Meth-ods used were in-depth interviews, focusgroup discussions, and trials of improvedpractices with women of childbearing age(pregnant, lactating, and others), fathers,grandparents, health care personnel, and


volunteer community health workers. Tech-nical assistance from USAID/OMNI wasprovided through the Manoff Group.

Based on the results of formative research,an IEC strategy was developed in 1998 and dis-cussed in a workshop attended by a multidis-ciplinary group which included public healthauthorities, academicians, personnel from theMinistry of Social Action,6 and representativesof external cooperation agencies. The plan en-compassed mass media and person-to-personeducation through the health services. Mes-sages were designed and tested, and commu-nication materials produced, tested, and repro-duced for field use. Materials emphasized theimportance and sources of vitamin A and iron,and the need for children to take vitamin A andiron supplements and to consume foodsources of vitamin A and iron, including for-tified foods. A baseline knowledge, attitudes,and practices survey was conducted in 1998 ina nationally representative sample of house-holds, although further assessments have notbeen made. Unfortunately, the two communi-cation components could not be implementedconcomitantly due to budgetary constraints;the mass media campaign was launchedearly in 1999 by the Ministry of Social Actionwith funding from the USAID/PL-480 Title IIProgram, whereas training of health care per-sonnel in the person-to-person educationcomponent was gradually carried out and ex-tended throughout 1999 and 2000, withUSAID support.

The IEC plan was revised in mid-2000,with the purpose of strengthening its effec-tiveness in inducing behavioral change. Therevised plan provides a more integratedframework and approach to behavioralchange communications, identifies specificbehaviors to be changed, and takes into ac-count environmental and other factors affect-ing these behaviors, as well as proposes con-crete educational messages and propermeans to deliver them, with special attention

to expected behavioral results. It also setsspecific objectives for raising awareness andadvocacy; the supply, quality, delivery, andutilization of services; and the knowledge, at-titudes, and practices of the target popula-tion. Finally, it describes the different acti-vities to be implemented in coordination,training, service delivery, community in-volvement, mass media support, and indi-vidual counseling, as well as monitoring andevaluation. Educational messages on vitaminA focus on the importance and benefits of vi-tamin A; supplements for children and post-partum women; enhancers of vitamin A ab-sorption; supplement distribution throughNHCs and routine health services; recordingof supplement delivery in the child healthcard; foods naturally rich in vitamin A (breastmilk, yellow squash, mango, papaya, yellowplantain); and recipes for preparation. As ofthis writing, implementation of the IEC planhas not yet been evaluated.

A mass media informational campaignthrough radio and television, supported byUSAID/MOST and UNICEF, was imple-mented early in 2000 concomitantly with thelaunching of sugar fortification. This cam-paign emphasized the need to increase con-sumption of natural sources of nutrients inaddition to commercially fortified foods, andinformed the public that fortification ofsugar was now mandatory and universal.The campaign introduced a special cartooncharacter named Dulcito (“little sweet”) andemphasized that fortified sugar should bepreferred but that excess intake would not behealthy. The importance for the child (andfor the mother immediately after delivery) toget high-dose vitamin A supplements wasstressed, together with guidance as to whereto obtain them and the opportunity providedby the NHCs. No evaluation has yet beenmade of this campaign.

Other Public Health Measures

These included interventions that arelikely to directly or indirectly improve vita-


6This Ministry closed in 2002.

min A and anemia status; e.g., periodic ad-ministration of anthelminthic medicationsfor preschool and school-age children (alben-dazole or mebendazole in single doses of 400mg and 500 mg, respectively), and parallelactions to address iron deficiency anemia(iron/folate supplementation to pregnantwomen and children under 5 years, and for-tification of wheat flour with iron and B vita-mins). Since establishment of the NHCs, dis-tribution of albendazole or mebendazole forchildren 2–5 years of age and for those at-tending elementary school has become partof the biannual standard package of services.In the early 1990s the overall prevalence ofintestinal parasites in preschool children hadreached around 60%. Beginning in 1997 de-worming has been restricted to children24–59 months of age.

Training

Atraining plan was prepared for the person-to-person component of the IEC plan. As men-tioned earlier, in the late 1990s, special effortshad been made to integrate general nutritionand specific micronutrient contents into the reg-ular undergraduate curriculum of health pro-fessionals (medical, nursing, and nutritionschools). This generated a great deal of aware-ness and interest in micronutrients among newhealth professionals who are now more moti-vated and willing to collaborate in the imple-mentation of nutrition programs, provideinput to the NMC, and, eventually, increasetheir involvement in research projects and otherfield activities.

Beginning in 1999, public health staff(physicians, nutritionists, nurses, and auxil-iary nurses), as well as university health pro-fessional faculty and students, were compre-hensively trained in micronutrients through50 two-day training workshops in the 17health (SILAIS) districts. A training curricu-lum and manual were prepared. Technicalguidelines were developed; e.g., on supple-mentation and on the use of the differentcommunication materials. Training methods

that were used included slide presentations,practical exercises, group dynamics sessions,social dramas, and plenary discussions.Training sessions were systematically evalu-ated through pre- and post-tests. In 1999–2000, a total of 1,492 health care workerswere trained in all aspects of micronutrientdeficiency control (vitamin A, iron/anemia,and iodine), with emphasis on supplemen-tation, food fortification, and behavioralchange communications; e.g., the use of edu-cational messages and materials. USAID/MOST and UNICEF supported training.Field staff from NGOs and private voluntaryorganizations were also trained. Addition-ally, refresher training has been providedyearly to newly graduating physicians en-rolled in the one-year program of compul-sory social service in rural areas.

Program Monitoring and Evaluation(M&E)

Monitoring of the supplementation pro-gram has been integrated within the existinginformation system for EPI. Training activi-ties emphasized the need for service deliverypersonnel to register vitamin A supplemen-tation on the child’s health card, which wasmodified for that purpose, as well as on theforms and tally sheets used for immuniza-tions, which were revised to create a spacefor vitamin A. The flow of information goesfrom the local units to the districts and to thecentral MOH Department of Statistics whereit is processed twice per year. The Depart-ment prepares a report with supplementa-tion and immunization coverage after eachNHC. The report is distributed to the dis-tricts and used by the central coordinationteam as a basis for twice-a-year evaluationworkshops.

Critical to the success of the sugar fortifi-cation program has been the establishmentof an effective QA/QC system by the indus-try, with periodic sampling and laboratoryanalysis by the sugar refineries, and a simplebut workable monitoring system for fortified


foods by the government. The governmentmonitoring system encompasses two compo-nents: regulatory monitoring and householdmonitoring (22). Regulatory monitoring in-volves a system of periodic inspection visitsand the collection of sugar samples from pro-duction plants and retail commercial outletsfor laboratory analysis of retinol. Householdmonitoring is carried out by means of house-hold visits for collection of sugar samples forretinol content at the point of consumption.The MOH Food Control Unit was grantedoverall responsibility for government regula-tory monitoring of fortified foods (sugar,salt, and wheat flour) at production plantsand retail outlets.

INCAP/PAHO and USAID/MOST pro-vided assistance for establishment of the for-tification QA/QC and monitoring system.Training on QA/QC procedures, sampling,and laboratory methods was provided to theindustry. QA/QC by the industry has pro-ceeded smoothly, since the sugar refineriesare relatively well developed and had al-ready maintained their own QA/QC systemfor other sugar quality standards; thus, theaddition of a new test was not a major prob-lem. Although with some financial restric-tions (e.g., insufficient budgetary allocationsfor transportation and other expenses), regu-latory monitoring has by and large pro-ceeded as planned; e.g., periodic inspectionshave been made, and the anticipated numberof samples have been collected. Householdmonitoring has been incorporated as an ele-ment of national surveys; e.g., the 2000 na-tional micronutrient survey, the 2002–2003Integrated Nutrition Intervention Monitor-ing System (SIVIN). Sustainability of peri-odic household monitoring, however, hasbecome more dependent upon external re-sources, and it is foreseeable that this trendwill continue at least into the short-termfuture.

Since the mid-1990s efforts have beenmade by the MOH, with assistance from ex-ternal cooperation agencies, to improve andenhance the scope of information on health

and nutrition program indicators, includingthe incorporation of relevant nutrition datainto Demographic and Health Surveys(DHS); e.g., strengthening of the supplemen-tation information system attached to EPIand the collection of specific nutrition datathrough DHS in 1998 and 2001. With supportfrom USAID/MOST, the Second NationalMicronutrient Survey (NMS-2000) was con-ducted with the dual purpose of assessingeventual changes in the prevalence of VAD,iodine deficiency disorders, and anemiasince the first survey (NMS-1993) and of pro-viding baseline information for future evalu-ations of the sugar fortification program.While specific nutrition and micronutrientsurveys have been conducted, laboratory as-sessments of micronutrient deficiencies havenot been regularly included in DHS.

In 2001, with technical and financial assis-tance from USAID/MOST, the U.S. Centersfor Disease Control and Prevention (CDC),MI, UNICEF, and INCAP/PAHO, the MOHdesigned the SIVIN monitoring and surveil-lance system, which began to be establishedby mid-2002. SIVIN’s ultimate objective is tocontribute to improving the health and nutri-tional status of women and children throughthe periodic collection, processing, analysis,and use of relevant information on theprocess and outcomes of nutrition programimplementation, as well as on biological in-dicators of nutritional status. The purpose isto optimize policy and program decision-making for increased effectiveness in reduc-ing nutrient deficiencies.

SIVIN’s specific objectives are to collect,analyze, and utilize M&E information on vi-tamin A and iron/folate supplementation forwomen and children in order to improve theprovision, utilization, and coverage of sup-plements and enhance program effective-ness. In addition, it seeks to strengthen andintegrate the existing system for M&E of uni-versally fortified food staples with micronu-trients to assess coverage and quality of theprogram at the household level, and to col-lect, analyze, and utilize information to track


trends in the nutritional status of populationgroups at risk of nutritional deficiencies,with emphasis on micronutrient deficienciesin women and children, in order to evaluatethe impact of nutrition interventions.

SIVIN is a centralized, modular, integra-ted management information system for pe-riodic M&E and decision-making in nutri-tion programs. Initial emphasis has beengiven to micronutrient programs (supple-mentation and food fortification), breast-feeding, and anthropometry indicators.Other nutrition-related programs may be in-tegrated in the future. SIVIN encompassesboth program process and outcome monitor-ing using performance indicators and impactevaluation using biological surveillance indi-cators. SIVIN relies on three sources of infor-mation: service statistics, which consist ofdata routinely gathered by the local healthservices (e.g., coverage of nutrition-relatedservices such as vitamin A and iron supple-mentation); existing nutrition program mon-itoring systems (e.g., data from existing indi-vidual program monitoring systems such asthe one for fortified foods); and a national

household survey, including the collection ofbiological specimens (blood, urine) and foodsamples. The modular system allows for theaddition or deletion of specific informationmodules annually.

MONITORING AND EVALUATION RESULTS

Program Performance

Supplementation coverage rates throughNHCs for children from 1994 to 2003, by yearand round (first, second), are shown in Fig-ures 2 to 4. Coverage gradually has increasedin both rounds since 1994, and levels higherthan 70% have been sustained since 1999.Overall coverage of second rounds has beenalmost as high as that of first rounds (66%versus 74%); this is a remarkable achieve-ment, given that reaching high second-roundcoverage rates is often a formidable chal-lenge. Coverage of infants 6 to 11 months hasbeen only slightly higher (73%) than that ofchildren 12 to 59 months (70%); this should


51 50

62

73

8591 92

88

51 51

19

71 73

93 91

78

86

6664

0

10

20

30

40

50

60

70

80

90

100

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

First Round

Second Round

%C

over

age

FIGURE 2. Coverage of vitamin A supplementation in children 6–59 months through twice-a-year NCHs, Nicaragua, 1994–2003.

Source: Department of Statistics, Ministry of Health of Nicaragua.


69

77

70

80

89

82

69

27

918885

85

94

7774

71

81

75

64

0

10

20

30

40

50

60

70

80

90

100

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

First Round

Second Round

%C

over

age

FIGURE 3. Coverage of vitamin A supplementation in infants 6–11 months through twice-a-year NCHs, Nicaragua, 1994–2003.


48

61

8891 93

88

47 48

18

6963

91

7974

47

85

6574

94

0

10

20

30

40

50

60

70

80

90

100

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

%C

over

age

First Round

Second Round

FIGURE 4. Coverage of vitamin A supplementation in children 12–59 months through twice-a-year NCHs, Nicaragua, 1994–2003.


also be viewed as an outstanding achieve-ment, since opportunities for health servicecontact with children commonly decreasewith age (unless an NHC approach is used).Population coverage estimates are based onafter-census projections; thus, they may besomewhat imprecise due to internal migra-tion after natural disasters (e.g., HurricaneMitch in 1998). Coverage rates in children byroutine distribution through local health ser-vices are negligible (< 1%), and postpartumsupplementation of women remains verylow (12%). In 2001, a cross-sectional assess-ment of health care services throughout thecountry revealed that vitamin A supple-ments were available in 77% of the 1,011 pub-lic health facilities and 44% of the 203 privatefacilities, or a total of 55%.

According to sugar fortification technicalguidelines, the addition of vitamin A in pro-duction plants is expected to range between5 and 25 mg/kg of sugar, with an averagenear 15 mg/kg and at least 90% of the sam-ples above 5 mg/kg. These levels were rec-ommended by INCAP on the basis of ex-pected losses of the vitamin throughout theproduction and marketing process in orderto provide a significant amount to con-sumers, taking into account customary sugarintake. The monitoring system provides peri-odic information on the performance ofsugar, salt, and wheat flour fortification.Main results for sugar from 2000 to 2003 areshown in Table 1. In 2000, six of the sevensugar plants fortified their product for do-mestic consumption (sugar for export is notfortified), with all samples containing morethan 5 mg/kg and an average of 13.2 mg/kg.The small plant that did not initiate fortifica-tion in 2000 was under severe financial trou-ble (it exited the market in 2001), and a sec-ond small plant closed operations in 2002;thus, there are now five sugar refineries. Atretail stores nearly one-fifth of the sampleswere unfortified, and 62% had > 5 mg/kg,for a mean of 7.3 mg/kg; however, these fig-ures were not obtained from a representativesample of retail outlets.

After discounting losses from the plants tothe consumer, the mean vitamin content ofsugar at the households was initially ex-pected to reach at least 5 µgRE/gram; morerecently, taking into account stability and“normal” losses of the vitamin under exist-ing environmental conditions, a minimum of3.5 µgRE/gram has been considered accept-able, as it would still meet a significant pro-portion of the intake gap. In Nicaragua,sugar production (concurrent with the sug-arcane harvest) encompasses about 6 monthsof the year (November to April), and the in-terval between production and consumptionin the non-harvest period may be as long as6 months. In 2000, about 73% of the samplesfrom households contained > 3.5 µgRE/g,and the mean content reached 5.4 µgRE/g.With an average consumption of 65 g perperson/day, table sugar provided an esti-mated 351 µgRE, thus meeting around 85%of the estimated average requirement.

Sugar fortification weakened in 2001. De-spite samples from plants containing a meanof 13.5 mg/kg, only 51% of those from retailstores contained > 5 mg/kg, with an averageof 6.3 mg/kg, and nearly 90% of the onesfrom households showed < 5 mg/kg (the av-erage dropped to 3.1 mg/kg). This was ap-parently the result of the temporary use of aless stable vitamin A fortification compound.


TABLE 1. MOH monitoring of sugar fortification,Nicaragua, 2000–2003.a

2000 2001 2002 2003

Production plants≥3.5 mg/kg 100 100 96 100>5 mg/kg 100 95 93 88Mean (mg/kg) 13.2 13.5 10.3 12.3

Retail stores≥3.5 mg/kg NA 70 72 97>5 mg/kg 62 51 58 74Mean (mg/kg) 7.3 6.3 6.7 8.7

Households 2002–2003≥3.5 mg/kg 73 90 69>5 mg/kg 55 10 54Mean (mg/kg) 5.4 3.1 5.2

aPercent of sugar samples.

In 2002 and 2003, 93% and 88% of the sam-ples from plants, as well as 58% and 74% ofthose from retail outlets, contained > 5mg/kg, with an average content of 10.3 and12.3 mg/kg in the factories, and 6.7 and 8.7mg/kg at retail stores. In the same period,54% of the samples from households con-tained at least 5 mg/kg, with a mean of 5.2 mg/kg.

In 2002–2003 table sugar provided about338 µgRE per person/day. A mean level ofvitamin A of 12.3 mg/kg at productionplants resulted in an average of 5.2 mg/kg atthe household (consumer) level, or about42% of the original addition level. Sugar pro-ducers are currently shifting from 50 kgpacking, which is repacked in retail storeswith potential vitamin A degradation, tosmaller sizes directly for consumers; e.g., 400 g and 2 kg. The goal is that in three years,only small labeled packages (1-lb. to 2-kg)would be available in the market. This is ex-pected to improve vitamin A stability. Cur-rent consumer price is about nine córdobas(US$ 0.55) per kg of table sugar.

Population coverage for periodic (twice-a-year) distribution of anthelminthic medica-tions to children 2–4 years of age remainedconsistently high throughout the 1994–2003period (Figure 5), with no significant differ-ences per round. The coverage of anthelmin-thic medication in children ages 2–4 throughNHCs averaged 81% (89% in the first and73% in the second rounds). Coverage rateswere particularly high (95% or above)throughout the second half of the period. Asis the case with supplementation, estimatedpopulation coverage for deworming may besomewhat imprecise due to differences be-tween 1995 census-based projections and the actual population as a result of internalmigration.

Program Impact

The impact of the VAD control programmay be estimated on the basis of trends ofVAD prevalence over time, provided thatother plausible explanations for eventualchanges in prevalence are taken into account.


98

66

8187

75

9598 98 98 98

7269

35

98

77

98 98 98

13

0

10

20

30

40

50

60

70

80

90

100

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

First Round

Second Round

%C

over

age

FIGURE 5. Coverage of anthelminthic medications in children 2–4 years, Nicaragua, 1994–2003.

Although attribution may be more difficult,trends in infant and child mortality may pro-vide indirect additional evidence of programimpact. National household surveys may be used to evaluate the impact of VAD con-trol programs on biological indicators (23).Impact would be expected on the levels of plasma retinol in children under 5 years of age.

The NMS-2000 carried out prior to thefirst NHC of 2000 revealed a dramatic reduc-tion in the prevalence of VAD (plasma retinol< 20 µg/dL) in children 12 to 59 months ofage from 31.1% in 1993 to 8.6% in 2000, and asignificant increase in mean plasma retinolfrom 23.8 to 31.7 µg/dL (24). Severe VAD(plasma retinol < 10 µg/dL) dropped from7.9% to 0.2%. Thus, program impact on VADin children was first achieved in 2000, just be-fore initiation of sugar fortification. Giventhe absence of other specific interventionsbetween 1993 and 2000, the significant reduc-tion of VAD was mainly attributed to the cu-mulative effect of periodic high-dose vitaminA supplementation with consistently highcoverage. VAD in women was not found to

be a problem of public health significance(10% national prevalence).

According to conventional knowledge,most of the effect of a large dose of vitamin Aon children is expected to vanish after 3 to 4months (25); however, studies on the long-term cumulative impact of repeated supple-mentation rounds had not been reported inthe literature. In Nicaragua, consistentlyhigh population coverage rates maintainedover the six-year period preceding the sur-vey may have gradually increased retinolliver stores and plasma levels over time. Analternative partial explanation would be adefined contribution of the modest to moder-ate improvement observed in some socialand economic indicators as shown in Table 2.High-coverage deworming of children 24–59months may have also contributed to improvevitamin A status; an MOH study in 1996found that the overall prevalence of intestinalparasites had declined from 60% to 30% andthat no severe infestations were found.

The most recent VAD assessment in chil-dren, conducted in 2002–2003 as part ofSIVIN, shows that the plasma retinol distri-


TABLE 2. Changes in selected social and economic indicators, Nicaragua, 1993 and 2001.Indicator 1993 2001

% households with access to piped water (urban/rural) 54 (76/21) 77 (91/59)% households with access to sanitary facilities (urban/rural) 27 (30/16) 85 (95/72)% households in poverty (urban/rural) 50.3 (31.9/76.1) 45.8 (30.1/67.8)% households in extreme poverty (urban/rural) 19.4 (7.3/36.3) 15.1 (6.2/27.4)% ORT use 40 82% primary school enrollment (male/female) 76 (74/77) 80 (79/80)% children enrolled completing primary school 29 55% secondary school enrollment (male/female) 38 (31/44) 60 (55/65)Gross population growth/1,000 population 2.9 2.8Crude birth rate/1,000 population 41 33Life expectancy at birth (years) 66 69Global fertility rate per woman 5.1 3.2GNP % growth previous 10 years –4.4 –0.1% inflation rate 584 45% government expenditures in:

Health 11 13Education 9 15Defense 50 6

Duration of exclusive breast-feeding (months) 0.6 2.5% deliveries assisted by trained personnel 73 90

Sources: 1993: UNICEF. The State of the World’s Children; 1996.2001: Encuesta Nicaragüense de Demografía y Salud (ENDESA); 2001.

bution has dramatically moved up to be-come perfectly normal, with 0.3% of the val-ues < 20 µg/dL and an overall mean of 36.8 ± 5.5 µg/dL, indicating that subclinicalVAD in children and, presumably, in othergroups of the population, is virtually undercontrol (26). The prevalence of infection asindicated by high levels of α-acid-glyco-protein (AGP) remained around 20% be-tween 2000 and 2003, and an inverse rela-tionship was observed between AGP andplasma retinol levels; however, the impact ofinfection was apparently not large enough tobring plasma retinol to deficient levels.

Changes in the distribution of plasmaretinol in children from 1993 to 2003 areshown in Figure 6 and trends in VAD preva-lence in Figure 7. The change observed be-tween 1993 and 2000 could be attributedmainly to supplementation, whereas the dra-matic acceleration from 2000 to 2003 is mostlikely to be largely the result of the combinedeffect of supplementation and sugar fortifica-tion, complemented by other measures (de-

worming, behavior change communications)and modest social and economic improve-ments. During the 1993–2003 period, thesupplementation program regularly main-tained high coverage rates twice a year and,since 2000, sugar fortification has been im-plemented with good quality and coverage(sugar is consumed by 99.3% of the country’sfamilies). A plausible indirect mechanism bywhich sugar fortification may have furthercontributed to improved vitamin A status in children is through increased retinol con-tent of breast milk. This has been docu-mented in a number of studies and wouldappear to hold true in Nicaragua, wherepost-fortification breast milk retinol in fourrural communities reached nearly normallevels (67 µgRE/dL) despite the low cover-age of postpartum supplementation.7

By 2003, in addition to a daily intake ofabout 329 µgRE from vitamin A supplements(two doses of 200,000 international units per


FIGURE 6. Plasma retinol distribution in children 12–59 months, Nicaragua, 1993, 2000, and 2003.

0

5

10

15

20

25

302003

2000

1993

< 10 10–14 15–19 20–24 25–29 30–34 35–39 40–49 50–59 60+

Plasma retinol (µg/dL)

Perc

enta

ge


year), preschool children consuming 20 g ofsugar per day would ingest about 104 addi-tional µgRE from fortified table sugar (plusadditional amounts of vitamin A from sugar-based commercially processed products) fora total intake above 433 µgRE/day, whichwould meet nutrient needs even taking intoaccount the increased needs associated withcommon infectious morbidity. Additionalsupporting evidence for a significant impactof sugar fortification on vitamin A status is provided by a pre-post fortification studyconducted by the University of Nicaragua in 2000–2001 in a group of 21 school-aged children from four rural Nicaraguancommunities, which found twice as much vi-tamin A body stores (estimated by the deuter-ated-retinol-dilution technique) and liver vi-tamin A concentration, as well as a significant(19%) increase in plasma retinol levels afterfortification.8 Non-program factors associ-ated with a moderate improvement in socialand economic indicators, such as GNP

growth, inflation, health care coverage, exclu-sive breast-feeding, sanitary conditions, fer-tility, and poverty reduction (Table 2), mayhave also played a complementary role in re-ducing VAD.

Based on the results of experimental stud-ies (10), a reduction in infant and/or childmortality would be expected as the result ofthe biological impact of supplementation,particularly in countries with serious VADand high levels of child mortality. Interpreta-tion of changes in infant/child mortalityrates estimated from national surveys iscomplicated by methodological problemsand by the many interrelated factors thatmay influence child mortality. Attribution ofmortality trends to specific factors is particu-larly difficult in developing countries with asecular trend towards consistent decline inmortality rates, as is the case in Nicaragua.Estimated infant and child mortality rates byfive-year periods from 1973 to 2001 areshown in Figure 8. Both infant and childmortality rates consistently declined byabout 70% over the past three decades. The


FIGURE 7. VAD prevalence (plasma retinol < 20 µg/dL) in children 12–59 months, Nicaragua, 1993, 2000, and 2003.*

7.9

0.3 0

23.4

8.3

0.3

0

5

10

15

20

25

30

35

1993 2000 2003

Severe VAD (< 10 µg/dL)

Moderate VAD (10–19 µg/dL)

Perc

enta

ge

*Excluding the Atlantic Region.


initially high speed of decline slowed downbetween 1983–1988 and 1988–1993, but re-sumed to higher drop rates in 1993–1998 and1996–2001. Interestingly, this acceleration inthe previously declining rate of mortality re-duction coincides with the implementationof vitamin A supplementation and, althoughthere might be other possible explanations, acontribution through vitamin A supplemen-tation may be plausible.

Program Costs

Unfortunately, information on programcosts is far from complete. Policy and pro-gram development and implementation havebeen funded from the MOH’s own budgetaryresources as well as through external donors;e.g., supplement donations, technical cooper-ation, and program funds provided by inter-national cooperating agencies. This group in-cludes USAID—by far the largest source of

financial support through USAID/Nicaraguafield support and MOST core funding—aswell as MI, and, to a lesser extent, UNICEF,INCAP/PAHO, and the World Bank. Thecost of household monitoring of fortifiedfoods has been until now fully covered by ex-ternal donors (MI, MOST, CDC).

During the 1998–2003 period, USAID fieldsupport to micronutrient programs in Nica-ragua amounted to US$ 1,149,000 (not in-cluding support to SIVIN), of which US$468,700 covered technical cooperation andUS$ 680,300 direct support for program im-plementation. Approximately US$ 300,000was utilized to support the 2000 NationalMicronutrient Survey. USAID field supportwas provided to assist overall NMP imple-mentation, of which VAD control was onlyone program component. For NMP imple-mentation, VAD and anemia control wereprioritized, and VAD control enjoyed thehighest priority up until 2000, when it was


138

92

6563

50

40

100

70

5451

4031

0

20

40

60

80

100

120

140

1973–1978 1978–1983 1983–1988 1988–1993 1993–1998b 1996–2001b

Rat

epe

r1,

000

live

birt

hs

Child mortalityInfant mortality

FIGURE 8. Trends in infant and child mortality by five-year periods, Nicaragua, 1974–1998.a

aEstimated from Demographic and Health Surveys.bThe last two DHS surveys were carried out in 1998 and 2001; i.e., a 3-year versus 5-year interval.

no longer considered to be a significant prob-lem; since then, anemia control has been as-signed the highest priority. Therefore, a rea-sonable assumption would be that about50% of USAID/MOST field support assis-tance in the 1998–2003 period (about US$575,000 or US$ 115,000 per year) was tar-geted to the VAD control program, of whichabout US$ 235,000 would have gone to tech-nical cooperation and US$ 340,000 to pro-gram implementation.

From 1994 to 1997, most vitamin A supple-ments were procured and funded by the MOHusing regular budgetary allocations. Cost perdose ranged between US$ 0.015 and US$ 0.020.The average number of doses distributed tochildren 6–59 months was about 350,000 perround from 1994 to 1997 and around 450,000per round since 1998. The total cost per yearof the supplement amounted to approximatelyUS$ 14,000 up until 1997 and US$ 18,000 since1997. At the MOH estimated annual cost of US$1.02 per child dosed (two rounds per year), in-cluding both supply and delivery costs, thetotal annual cost of the supplementation pro-gram for preschool children would haveranged between US$ 714,000 and US$ 918,000.

The cost of fortifying 180,000 metric tonsof sugar for domestic consumption amountsto about US$ 1,500,000 (procurement of vita-min A, amortization of initial capital invest-ment, QA/QC, and government monitor-ing), or US$ 8.33 per metric ton, most ofwhich would be expected to be transferred tothe consumer. The estimated cost of govern-ment monitoring is about US$ 20,000 peryear. Based on current consumption figures,the cost of sugar fortification for the con-sumer is about US$ 0.26 per person/year, orabout 1.5% of consumer annual expenditurein sugar (US$ 17.46 per person/year).

DISCUSSION AND CONCLUSIONS

VAD in children, and presumably in othergroups at risk, has been virtually controlledin Nicaragua during the 10-year period of

1994–2003. This is largely the result of theNicaraguan Government’s commitment tocontrol VAD, in collaboration with the pri-vate sector (NGOs, food industry) and exter-nal cooperating agencies, through an effec-tive integrated strategy and policy andprogram interventions that are primarilyaimed at improving vitamin A intake by thepopulation at risk. Table 3 shows a chronol-ogy of VAD-related events in the 40-year pe-riod of 1965 to 2004. Successful programs ac-counting for virtual control of VAD haveoccurred over the last 10 years. As has beenoften the case in developing countries, initia-tion of micronutrient actions, including VADcontrol programs, was largely donor-driven;international agencies have played a majorrole in information dissemination, advocacy,and the raising of public awareness and haveprovided start-up and some ongoing fund-ing. However, with strong political commit-ment, MOH institutional ownership andcapacity have strengthened over time. Al-though external technical and some financialsupport for program implementation contin-ues, VAD programs are currently self-sustaining to a large extent, despite the factthat a follow-up NMP after 2000 has not beenformally developed by the MOH.

Increased vitamin A intake to meet the ex-isting gap was achieved by a combination ofpharmaceutical supplementation and fortifi-cation of sugar, complemented by IEC andperiodic deworming of preschool children.Rather than concurrently launching the fullset of program activities, a sequence of inter-ventions was progressively implemented astime and resources permitted. Plasma retinolsignificantly increased in response to twice-a-year high-dose supplementation and de-worming during the six-year period from1994 to 2000, and subsequently reached nor-mal levels after a combination of continuedsupplementation, deworming, and IEC ac-tivities, and the addition of sugar fortifica-tion since 2000.

Nicaragua appears to be the first VADcountry reaching and documenting the



TAB

LE3.

Chr

onol

ogy

ofV

AD

cont

rol-

rela

ted

even

tsin

Nic

arag

ua,1

965–

2005

.A

sses

smen

t,m

onito

ring

,Po

licy

and

Year

and

eval

uatio

npr

ogra

mde

velo

pmen

tSu

pple

men

tatio

nFo

rtifi

catio

nO

ther

inte

rven

tions

1965

1965

–199

2

1993

1994

1995

1996

1997

1998

1999

Nat

iona

lNut

ritio

nSu

rvey

:V

AD

sign

ifica

ntpr

oble

m.

No

actio

n.

Mic

ronu

trie

ntsu

rvey

:sub

-cl

inic

alV

AD

inch

ildre

na

sign

ifica

ntpr

oble

m.

USA

IDas

sess

men

tand

port

-fo

liore

view

ofm

icro

nutr

ient

prog

ram

s.

Eval

uatio

nof

vita

min

Asu

p-pl

emen

tatio

nan

dpo

lioco

v-er

age

inch

ildre

n.

Nat

iona

lMic

ronu

trie

ntC

omm

issi

ones

tabl

ishe

d.

Surv

eyre

port

rele

ased

.Tw

o-ye

arpl

anla

unch

ed.

Inte

nse

cons

ciou

snes

s-ra

isin

g.

Nat

iona

lMic

ronu

trie

ntPl

anpr

epar

edan

dap

prov

ed.

NM

Pfo

rmal

lyla

unch

ed.

Nat

iona

ltec

hnic

alre

gula

-tio

nson

fort

ified

suga

rap

prov

ed.

Polic

yan

dgu

idel

ines

es-

tabl

ishe

d.N

HC

ssu

pple

-m

enta

tion

initi

ated

.

Supp

lem

ents

incl

uded

inof

ficia

llis

tofe

ssen

tial

med

icin

es.

Supp

lem

entd

onat

ions

star

ted.

Supp

lem

enta

tion

regi

ster

edin

child

heal

th/im

mun

iza-

tion

and

wom

en’s

heal

thca

rds

and

tally

shee

ts.P

ost-

part

umsu

pple

men

tatio

nw

ithB

CG

initi

ated

.Sup

ple-

men

tsta

rget

edto

child

ren

6–59

mon

ths.

Neg

otia

tions

with

suga

rin

-du

stry

initi

ated

.

Tech

nica

land

econ

omic

feas

ibili

tyof

suga

rfo

rtifi

ca-

tion

asse

ssed

.

Tech

nica

land

econ

omic

feas

ibili

tyof

oilf

ortif

icat

ion

asse

ssed

.

Inte

r-m

inis

teri

alac

cord

onsu

gar

fort

ifica

tion.

Plan

prep

ared

.Leg

isla

tion

pass

ed.

Suga

rfo

rtifi

catio

npl

anim

-pl

emen

ted,

regu

latio

nsis

-su

ed,p

rem

ixpl

antb

uilt,

mix

ing

equi

pmen

tpro

-cu

red,

finan

cial

assi

stan

cese

cure

d,M

Idon

atio

ngr

ante

d,fo

rtifi

cant

impo

rted

.

Dew

orm

ing

inte

grat

edin

NH

Cs.

Trai

ning

ofhe

alth

pers

on-

neli

nm

icro

nutr

ient

sin

itiat

ed.

Tech

nica

ldoc

umen

tsfo

rhe

alth

staf

fdel

iver

ed.

IEC

form

ativ

ere

sear

chco

n-du

cted

and

repo

rted

.

IEC

plan

form

ulat

ed;m

es-

sage

san

dm

ater

ials

de-

sign

ed,t

este

d,re

prod

uced

.B

CC

base

line

cond

ucte

d.

IEC

mas

sm

edia

com

po-

nent

impl

emen

ted.

An-

thel

min

thic

med

icat

ions

targ

eted

toch

ildre

n24

–59

mon

ths.


00

2001

2002

2003

2004

2005

Mic

ronu

trie

ntSu

rvey

:VA

Dno

long

era

sign

ifica

ntpr

ob-

lem

inch

ildre

n.V

AD

inw

omen

am

ildpr

oble

m.

Mon

itori

ngof

fort

ified

suga

res

tabl

ishe

d.Pr

e-po

stsu

gar

fort

ifica

tion

plas

ma

and

brea

stm

ilkre

tinol

stud

y.

NM

S-20

00re

sults

disc

usse

din

tech

nica

lgro

upm

eetin

g.SI

VIN

desi

gned

.

NM

S-20

00re

port

rele

ased

.SI

VIN

field

test

and

trai

ning

com

plet

ed.S

IVIN

form

ally

laun

ched

.

SIV

INfir

sty e

arco

mpl

eted

,da

taan

alyz

ed. V

AD

virt

ually

unde

rco

ntro

l.

SIV

INfir

st-y

ear

repo

rtre

-le

ased

.VA

Dun

der

cont

rol.

SIV

INse

cond

-yea

rre

port

re-

leas

ed.V

AD

unde

rco

ntro

l.

Onl

yon

eN

HC

per

year

esta

blis

hed.

Suga

rfo

rtifi

catio

nla

unch

edto

geth

erw

ithin

form

atio

nal

cam

paig

n.M

onito

ring

sys-

tem

esta

blis

hed.

IEC

plan

revi

sed,

trai

ning

com

plet

edin

11of

17di

stri

cts.

Trai

ning

com

plet

ed.

virtual control of VAD as a result of concreteactions to address it. The evidence clearlydemonstrates that VAD can be controlledthrough a combination of sequentially im-plemented program interventions. The ques-tion remains as to whether supplementationalone at the high coverage rates achieved inthe past 10 years might have been enough byitself to control VAD. A study conducted inGuatemala in the mid-1990s reported sugarfortification being significantly more cost-effective than either supplementation or di-etary diversification through home garden-ing (27); however, rather than ranking thecost-effectiveness of individual interven-tions, the practical issue remains that of se-lecting the best combination of interventionsthat are feasible and potentially effective in agiven setting.

The Nicaraguan Government adopted asequence of interventions, beginning withimmediate supplementation and dewormingas short-term emergency measures, to becomplemented and eventually substitutedby staple fortification and IEC as a presum-ably more sustainable approach in the long-term. Negotiations aimed at fortificationproved to be time-consuming, thus makingsupplementation necessary in the first place;however, once established, fortification hasbeen shown to be highly sustainable in thecurrent political, marketing, and trade con-text of Nicaragua. The VAD control interven-tion mix as adopted, properly planned, andimplemented, was effective in producing theanticipated impact.

Nicaragua provides an outstanding exam-ple of the successive, periodic, active, institu-tionalized, and integrated distribution of vi-tamin A supplements to children, with highcoverage maintained over a 10-year period.Integrating supplementation as part of apackage of basic health services to be deliv-ered twice a year through National HealthCampaigns (Weeks or Days) has also beenshown elsewhere to be a viable, affordable,and effective tool for achieving consistentlyhigh coverage rates (28). Program ownership

is reflected in systematic district level plan-ning and implementation. NHCs would ap-pear to be more readily accepted and en-dorsed by health authorities than isolatedvertical campaigns for vitamin A distributionalone. As national immunization days arescaled down or phased out in many coun-tries, NHCs offer an effective alternativestrategy to sustain the delivery of vitamin Ato young children at the coverage ratesneeded to realize its full potential to reduceVAD. Twice-a-year delivery of vitamin Asupplements through synchronized NHCsdistribution has yielded excellent results inNicaragua.

Additional supplementation coveragethrough routine health services has re-mained negligible for children and very lowfor postpartum women. Although, in princi-ple, integration of supplementation withinregular health services is a desirable goal,this strategy alone has not yet proven itself tobe effective in reaching high coverage rates.Health facility attendance for preventive ser-vices and contact opportunities tend to dras-tically decline after the 1st year of age, mak-ing it difficult to achieve adequate coverageof preschool children. The NHCs have beenthe most suitable vehicle for periodic high-coverage supplement distribution and otherpreventive actions such as immunizations.Whether or not twice-a-year NHCs continuein Nicaragua will be to a large extent contin-gent upon the government’s sustained com-mitment and resource availability; the possi-bilities for this, however, remain high.Maintaining two rounds per year would becritical for other health and nutrition inter-ventions as well, particularly for immuniza-tions, deworming, and iron supplementationto young children. Given the strong long-term commitment of both the governmentand the industry to sugar fortification, sup-plementation may now be targeted to theyoungest children who are not likely to getsufficient vitamin A from fortified sugar, al-though quantitative information on chil-dren’s sugar intake is not available.


Development of a public-private sectorpartnership for fortification was made possi-ble by an unprecedented degree of both gov-ernment and industry commitment. Nego-tiations were consistently conducted with an open-minded attitude in a cooperative,nonconfrontational environment. Carefulplanning and implementation of the pro-gram were essential once agreements werereached. The government’s firm commit-ment to meet its responsibilities is exempli-fied by its rapid response in assisting the in-dustry with initial financial support and inthe timely provision of legislation and regu-lations. Joint formulation of a preparatorywork plan with concrete deadlines for secur-ing launching of fortification proved to becritical, and both industry and the govern-ment honored their pledges. The industrybuilt the premix preparation plant by thespecified deadline, and the government pro-vided proper training to industry personnelin a timely fashion.

The NCSP strongly advocated for univer-sal mandatory fortification as a means toprevent eventual unfair competition fromproducers of unfortified imported sugar. Fa-vorable conditions for sugar fortification cur-rently exist in Central America, includingNicaragua, since the local sugar industry isprotected by legislation imposing heavy du-ties on imported sugar, thus making importsunattractive despite the international price ofsugar being significantly lower than the do-mestic price. To some extent, the NCSP’spositive attitude towards fortification maybe accounted for by the fact that universalmandatory fortification would provide animportant health support basis for maintain-ing the status quo.

Attempts to remove import tariffs onsugar have threatened sustainability of sugarfortification in other Central American coun-tries (29). Similar threats in Nicaragua, whenthe fortification program was in its earlystages, generated a concerted effort by thecentral government, external cooperationagencies, and other groups against the leg-

islative proposal, which was eventually de-feated. Throughout the first four years ofsugar fortification, a few difficulties havearisen that have been associated with thegovernment’s capacity to monitor and en-force legislation. As an example, the govern-ment failed to enforce the law in 2000 whena small sugar refinery dropped out of theNCSP and did not abide by the fortificationlegislation. The problem eventually came toan end when the noncompliant refinery wentout of business.

Deworming and, despite its relatively lateimplementation, IEC, may have contributed toimprove vitamin A intake and nutrition status.Unfortunately, neither of these has been prop-erly evaluated for impact in reducing parasiteinfestation of preschool children and in chang-ing specific behaviors. An important constraintidentified in the 2000 IEC revision was insuf-ficient attention being paid to enhancing thecommunication skills of health care personneland brigadistas; however, this has not subse-quently been fully addressed because of othercompeting priorities.

Although the virtual control of VAD mayallow for retargeting of some interventionprograms (e.g., supplementation), Nicaraguacannot afford to let VAD accomplishmentslanguish. The most critical current challengein VAD prevention and control for theNicaraguan Government is to secure thelong-term political, institutional, and finan-cial sustainability of VAD policies, programs,and achievements. This will require main-taining the same high level of political com-mitment that has existed since 1994. CentralMOH authorities and international coopera-tion agencies will need to make a concertedeffort to preserve the currently high level ofpolitical will and priority assigned to mi-cronutrients in general and to vitamin A inparticular. Contrary to diseases preventableby immunizations, nutrient deficiencies suchas VAD can be virtually controlled but notpermanently eradicated by public health in-terventions. Continued advocacy, promotionof social sustainability through increased


population awareness, social mobilization,and demand for services (NHCs, supple-ments, anthelminthic medications, and forti-fied foods), as well as continued IEC activi-ties are needed. Equally important would beto maintain integration of VAD and other mi-cronutrient programs.

Potential threats to program sustainabilitymay result from constraints leading to sus-pension or reduction in the frequency ofNHCs, pressure to remove existing trade leg-islation that protects the sugar industry,and/or insufficient resources assigned tohealth and nutrition programs in the absenceof donor-based funding. Eventual financialconstraints are likely to affect the continuityof NHCs, procurement of critical supplies(e.g., supplements), and staff travel related toprogram implementation, supervision, andmonitoring. In the absence of significant ad-ditional vitamin A intake from supplementsand fortified foods, VAD is likely to resume.

LESSONS LEARNED

Nearly three decades passed without ac-tion after the initial identification of VAD as aproblem of public health significance. Thenseveral additional years elapsed followingthe emergence of convincing evidence on theimportant role of vitamin A in child survivalbefore concrete policy and program actionswere initiated in Nicaragua to address theproblem. After such evidence became avail-able and was disseminated, and internationaladvocacy had been fostered, there was a needfor an updated assessment and special con-sciousness-raising efforts to generate a com-mitment on the government’s part to act.Significant impact on VAD was initially doc-umented after six years of large-scale high-coverage supplementation and deworming(with no VAD assessments in the interim),and virtual control was achieved after threeadditional years of a combination of supple-mentation, deworming, fortification, andIEC. The case of Nicaragua exemplifies the

variety and scope of difficulties normally en-countered in the long and complex road lead-ing from science to public health programs(30) and to achieving concrete results asmeasured by biological indicators.

In addition to unprecedented motivation,commitment, technical skills, and clear objec-tives, persistence and patience are alsoneeded by program advocators, planners,and implementers to ensure that all the con-tributing human and financial resources re-main well meshed throughout the cumber-some and oftentimes frustrating processleading to final success in achieving publichealth goals in developing country contexts.A major lesson learned from Nicaragua isthat sustained impact is best achievedthrough a conjunction of multiple interven-tions undertaken sequentially, rather than asingle bullet approach. Several key elementsappear to be associated with the performanceand effectiveness of the Nicaragua VAD con-trol programs, and a number of lessons havebeen learned in this regard throughout thepolicy development and program planningand implementation process. Many of theselessons might seem obvious, and others lessso, yet they are all drawn from a decade of planned and persistent efforts, occasionalfailures, and continuous achievements.

(1) Proper problem identification is criti-cal, but not sufficient, to foster action. Up-dated national or subnational informationcharacterizing the VAD problem is criticalfor consciousness-raising, advocacy efforts,policy and program development, planning,and evaluation. At a minimum, data shouldbe made available on the magnitude of theproblem (clinical and/or bio-clinical indica-tors, vitamin A intake) and on the institu-tional, technical, and financial resourcesavailable, or likely to be available, to addressit. Such information is best collected throughnational or subnational surveys coveringrepresentative samples of households, utiliz-ing a large enough sample size to breakdown the results by major geographic


and/or other strata. In Nicaragua, probablybecause of its relatively small size, no signif-icant differences were found by health dis-trict or even geographic area (except for thenorthern coastal, underpopulated AtlanticRegion). Biochemical indicators are useful,particularly when clinical VAD is not obvi-ous. Sophisticated and costly research maynot be needed, but commonly availableproxy indicators, such as child mortality,may not allow a proper definition of theproblem for advocacy and planning pur-poses. When resources are limited, foodsupply data may be sufficient to enable theidentification of potential vehicles for fortifi-cation without having to resort to costly di-etary intake surveys that are not generallyfeasible in developing countries.

(2) Effective consciousness-raising ofdecision-makers and the general populationshould not be bypassed. Identification of theproblem is not enough, as has been shown tobe the case in Nicaragua during the 1960s.After the 1993 survey, aggressive informationdissemination and consciousness-raising ef-forts were critical for generating awareness of vitamin A deficiency as a priority publichealth problem. Within this context, the avail-ability of statistically valid information on themagnitude and distribution of the problemwas of enormous value. In Nicaragua, the re-search community, academicians, and publichealth authorities had known about the exis-tence of VAD as a significant problem sincethe 1960s. Yet no action was initiated until anupdated assessment was made, the problemwas characterized, and intensive conscious-ness-raising and advocacy efforts targeted todecision-makers and stakeholders generateda strong commitment to act. Since infant andchild mortality rates were not very high(40–60 per 1,000 live births) compared to otherdeveloping countries and a clear ongoingdownward trend had been documented, ad-vocacy efforts placed more emphasis on thepotential impact of VAD control on the sever-ity and duration of highly frequent infectious

morbidity than on child mortality. The mor-tality argument is less compelling in countrieswith low and/or rapidly declining child mor-tality rates.

(3) Strong continued political commit-ment is a prerequisite for program success.Strong motivation and political commitmentwere secured by advancing social (health, nu-trition) and economic arguments and by pro-posing solutions that were politically feasibleand for which institutional resources were, orcould be, made available. Opinion leaders,academicians, prestigious technical profes-sionals, and the media played a critical role.Once the need for action was fully recognizedby opinion leaders and the general popula-tion, decision-makers had a strong motiva-tion to act. On the other hand, the govern-ment’s political commitment was expressedin policy and budgetary decisions. In Nicara-gua, as elsewhere in the world, good inten-tions alone clearly would not have been suffi-cient to respond to the problem at hand, andsymbolic political commitment not reflectedin actual policy and budgetary decisionswould have been, indeed, irrelevant. The de-cision about vitamin A supplementation asan emergency measure was made by thecountry’s highly committed Minister ofHealth herself, and it was accompanied bybudgetary allocations for procurement ofsupplements and for at least partial financingof the NHCs’ implementation, followed bytechnical guidelines for implementation thatwere disseminated and used for training.

(4) Effective public-private sector part-nerships with industry and NGOs pave theroad toward implementation. Public-privatepartnerships are needed for both fosteringfortification (government, food industry)and for securing high coverage of supple-mentation (government, NGOs). In Nicara-gua, developing a government-industrypartnership for fortification required carefulplanning and involved a lengthy and attimes frustrating process that was affected


less by technical constraints than by political,economic, and market issues. A great deal ofpatience was required, as well as a genuinemutual understanding of the interests andlimitations of the other partners, a consensus-building and fair-play attitude, and a strongmotivation to overcome any longstanding is-sues of mistrust. The external cooperatingagencies played a valuable brokerage rolewhich enabled them to serve as facilitators ofthe partnership-building process.

(5) Integration of vitamin A control intoongoing public health and nutrition activi-ties is highly desirable. The Nicaragua expe-rience clearly demonstrated that integratedprograms are likely to be more attractive tohealth sector policymakers and more effec-tive and sustainable over time than isolatedvertical interventions. Integrated programstake advantage of common operational pro-cesses and service delivery mechanisms andchannels, and encourage staff-sharing ofcommon goals. In Nicaragua, integration wasfacilitated by a long tradition of community-based health care services. The VAD controleffort took advantage of the unique opportu-nity for integration of vitamin A supplemen-tation offered by the already-established andhighly successful immunization programusing a campaign approach, which was notrestricted to once-a-year polio vaccines as inthe case of the NIDs. Integration, or at theleast, close coordination, has been main-tained not only within specific VAD controlinterventions but also with other micronutri-ent programs (e.g., anemia control) and, morewidely, within mainstream primary healthcare and nutrition services. Donor-drivensupplementation programs may tend to besingle and vertical, probably as a result ofdonor eagerness to show short-term effects;hopefully, in such a case, the scope of servicesmay be gradually expanded by integratingother preventive services.

(6) Training and retraining of health ser-vice personnel and community health vol-

unteers are essential to program viability.Well-trained, motivated, and adequately su-pervised staff who have the necessaryknowledge and skills are key to effective pro-gram implementation. Training has been aprominent feature in the Nicaraguan mi-cronutrient control program. Initially, whenvitamin A supplementation was integratedinto the NHCs, a rapid training plan was car-ried out to focus on the new intervention.Later on, a substantial amount of technicaland financial resources, including fundingfrom USAID/MOST and other donors, wasassigned to enable more comprehensivetraining; in 1999–2000 about 1,500 MOH andNGO health care personnel, in addition tocommunity health volunteers, were trainedin micronutrients. Since then, refresher train-ing has been systematically included in su-pervisory activities.

(7) Program ownership by health districtsand local units provides a solid foundationfor institutional sustainability. In the initialconsciousness-raising phase, participation ofthe health district staff in information dissem-ination and program planning workshops andensuing information-sharing by district staffwith local units established the foundation forownership of the overall program and of spe-cific activities. Program ownership is re-flected through regular participation by the dis-tricts in planning and evaluation; e.g., of theNHCs, in which vitamin A supplementation isprofiled as a key intervention, and in the mon-itoring of fortified foods. Evaluation meetingswith SILAIS are scheduled twice a year for dis-cussion of the NHCs’ performance, includingsupplementation coverage, and once a year todiscuss annual reports of fortified foods mon-itoring. District program ownership leads tohealthy competition among the districts re-garding supplementation coverage and en-courages district authorities to make timelyprovisions to improve program performance.

(8) Skilled program management and thetiming of supply deliveries are critical, par-


ticularly for supplementation. NHCs aremanaged by the districts with great motiva-tion and skill, as is the monitoring of sugarfortification at production plants in the dis-tricts where these are located. Organizing theNHCs twice a year is a time-consumingprocess that requires skilled managementand effective coordination of the differentpartners involved (health services, NGOs,community health volunteers, and othercommunity groups). Planning and coordina-tion are the responsibility of both the central-and district-level technical coordinationcommittees. Effective social mobilization isachieved through a concerted effort led bythe districts with significant communicationssupport from the central level. The biannualcampaign nature of the supplementationprogram makes it possible to secure suppliesby submitting timely requests for vitamin Asupplements to the donors well before theNHCs’ implementation. However, lack of aneffective supplement management logisticssystem has contributed to extremely lowcoverage through routine health services.

(9) Building on a strong health infra-structure and community support providesa significant advantage. Part of the successachieved in Nicaragua may be attributed toits extensive local health services infrastruc-ture. With 28 local health centers with beds,144 health centers without beds, and 814health posts in 149 municipalities, Nicaraguais justifiably proud of its public health infra-structure. It also enjoys a strong tradition ofcommunity mobilization in support of healthprograms and a history of successful publichealth interventions (e.g., virtual control ofiodine deficiency disorders, a relatively highcoverage of prenatal care and delivery careby trained personnel, increased exclusivebreast-feeding, consistently high rates of im-munizations), and a roster of nearly 10,000(one per 600 inhabitants) trained and/ortrainable and motivated community volun-teers (brigadistas). In this sense, Nicaraguaoffers an ideal context for local public

health interventions; unfortunately, this maynot be the case in many developing coun-tries. But it does make a compelling case forthe need to build from the bottom up, both interms of basic infrastructure and in mobiliz-ing community advocacy, participation, anda spirit of ownership regarding the neededintervention(s).

(10) Supervision and monitoring andevaluation systems provide timely informa-tion for decision-making. A supervisorysystem was developed early on which in-cluded practical guidelines to be followed bydistrict supervisors. Implementation of thesystem has been fully operational for theNHCs, but much less so for routine healthservices due to resource limitations; e.g., in-sufficient funds allocated for transportation.Similar limitations have existed for the im-plementation of M&E systems, particularlyfor the monitoring of food fortification.However, these obstacles have, for the mostpart, been overcome through financial sup-port from external donors; e.g., the house-hold monitoring of fortified foods was incor-porated within the 2000 NMS throughsponsorship by USAID and other donors, itwas carried out in 2001 with financial sup-port from INCAP and MI, and it was inte-grated in 2002 into the donor-funded SIVIN.This support has enabled M&E to proceedrather smoothly and has thus providedtimely feedback to program managers; un-fortunately, the decision-making process offully utilizing M&E results is still painfullyslow. On the other hand, supplementation isfully integrated into the supervisory andmonitoring system for immunizations.

(11) An effective information, education,and communications strategy is crucial. So-cial communications have been given highpriority and, therefore, substantial resourceshave been allocated for this purpose by boththe Nicaraguan Government and donors.Initially, in 1994–1995, an informational cam-paign aimed at raising awareness and advo-


cacy to generate commitment was carriedout. An IEC plan was then developed whichbegan to be implemented in 1999 after inten-sive training of field personnel. Informa-tional campaigns were carried out to coin-cide with the launching of fortificationprograms, one in 1997 along with wheatflour fortification and a second one in 2000with sugar fortification.

(12) Social mobilization and communityparticipation in NHCs allows for high cov-erage of services. As noted earlier in lessonnine, social mobilization and active commu-nity participation are not new phenomena inNicaragua. This dynamism also feeds prepa-rations for the NHCs through concerted ef-forts by the central and district MOH techni-cal coordination committees. NHCs begin tobe prepared several weeks in advance. In ad-dition to securing supplies for the differentpreventive services offered (vaccines, vita-min A supplements, anthelminthic medi-cations, oral rehydration salts, recordingforms), coordination committees regularlylaunch a one-week national communicationcampaign with the purpose of informing thepopulation about the importance of anddates for the forthcoming NHCs and invitingcommunities and relevant partners to mobi-lize support for and participate in the NHCs.The NHCs social mobilization efforts are reg-ularly supported by the MOH and interna-tional donors, and partnerships have beenestablished that leverage implementation re-sources beyond the health sector.

(13) Synergistic and noncompetitive in-ternational cooperation is feasible and re-warding. Besides being consistently strongadvocates, USAID and its local field staff,INCAP, PAHO, UNICEF, MI, and, more re-cently, other additional donors, have beenstrongly committed to providing technicaland financial support to the National Mi-cronutrient Commission and the MOH forimplementation and evaluation of the Na-tional Micronutrient Plan, including the

VAD control program. Unprecedented levelsof interagency coordination have been estab-lished with a spirit of selfless collaborationrather than competition. In addition toUSAID’s direct technical and financial assis-tance through its VITAL, OMNI, and MOSTprojects, in 1999 USAID/Nicaragua devel-oped the PROSALUD initiative, a coordi-nated effort to expand coverage of child sur-vival services in three provinces throughincreased participation by private voluntaryorganizations in service delivery (CARE,Save the Children, Partners of the Americas,Project HOPE, the Adventist Developmentand Relief Agency International, ProjectConcern International), including supple-mentation and IEC. INCAP/PAHO has as-sisted with advocacy efforts and providedtechnical cooperation in program M&E (e.g.,QA/QC and monitoring of fortified foods,SIVIN). In the late 1990s, PAHO providedkey assistance to strengthen the informationsystem for M&E of supplementation. A num-ber of international and local NGOs areactive in child survival and nutrition, andparticipate in micronutrient program imple-mentation at the community level, particu-larly in vitamin A and iron/folate supple-mentation and IEC, following initial training.

REFERENCES

1. Institute of Nutrition of Central America andPanama, US Interdepartmental Committee of Nutri-tion for the National Defense. Nutritional Evaluationof the Population of Central America and Panama: Re-gional Summary, 1965–1967. Washington, DC: USDepartment of Health, Education and Welfare; 1972.(DHEW Publication HSM 72–8120).

2. McLaren DS, Oomen HA, Escapini H. Ocular mani-festations of vitamin A deficiency in man. Bull WorldHealth Organ 1966;34(3):357–361.

3. World Health Organization. Control of Vitamin A De-ficiency and Xerophthalmia. Report of a Joint WHO/UNICEF/USAID/Hellen Keller International/IVACGMeeting. Geneva: WHO; 1982. (Technical Report Se-ries 672).

4. Sommer A. Assessment of xerophthalmia and themass vitamin A prophylaxis program in El Salvador(September 1973–December 1974). J Trop Pediatr En-viron Child Health 1976;22(3):135–148.


5. Arroyave G, Aguilar JR, Flores M, Guzmán MA.Evaluation of Sugar Fortification with Vitamin A at theNational Level. Washington, DC: Pan AmericanHealth Organization; 1979. (Scientific Publication384).

6. Arroyave G, Mejía LA, Aguilar JR. The effect of vi-tamin A fortification of sugar on the serum vitaminA levels of preschool Guatemalan children: a longi-tudinal evaluation. Am J Clin Nutr 1981;34(1):41–49.

7. Mora JO, Dary O, Chinchilla D, Arroyave G. VitaminA Sugar Fortification in Central America. Experienceand Lessons Learned. Arlington, Virginia: MOST, TheUSAID Micronutrient Program; 2000.

8. Sommer A, Tarwotjo I, Hussaini G, Susanto D. In-creased mortality in children with mild vitamin Adeficiency. Lancet 1983;2(8350):585–588.

9. Sommer A, Tarwotjo I, Djunaedi E, West KP Jr, Loe-den AA, Tilden R, et al. Impact of vitamin A supple-mentation on childhood mortality. A randomizedcontrolled community trial. Lancet 1986;1(8491):1169–1173.

10. Beaton GH, Martorell R, Aronson KJ, Edmonston B,McCabe G, Ross AC, et al. Effectiveness of vitamin Asupplementation in the control of young child morbidityand mortality in developing countries. ACC/SCNState-of-the-Art Reviews. Geneva: United NationsAdministrative Committee on Coordination, Sub-committee on Nutrition; 1993. (Nutrition Policy Dis-cussion Paper 13).

11. Sommer A, West KP. Vitamin A Deficiency. Health,Survival, and Vision. New York: Oxford UniversityPress; 1996.

12. World Bank. World Development Report 1993. Investingin Health. New York: Oxford University Press; 1993.

13. WHO/UNICEF/IVACG Task Force. Vitamin A Sup-plements. A guide to their use in the treatment and pre-vention of vitamin A deficiency and xeropththalmia.Geneva: World Health Organization; 1997.

14. World Health Organization. Integration of vitamin Asupplementation with immunization: policy and pro-gramme implications. Report of a meeting, 12–13 Janu-ary 1998, UNICEF, New York. Geneva: WHO; 1998.(WHO/EPI/GEN/98.07).

15. West KP Jr. Extent of vitamin A deficiency amongpreschool children and women of reproductive age.J Nutr 2002;132(Suppl 9):2857S–2866S.

16. Ezzati M, López AD, Rodgers A, Vander Hoorn S,Murray CJ, Comparative Risk Assessment Collabo-rating Group. Selected major risk factors and globaland regional burden of disease. Lancet 2002;360(9343):1347–1360.

17. Gillespie S, Manson J. Controlling Vitamin A Defi-ciency. ACC/SCN State-of-the-Art Reviews. Geneva:United Nations Administrative Committee on Coor-

dination, Subcommittee on Nutrition; 1994. (Nutri-tion Policy Discussion Paper 14).

18. Ruel MT, Levin CE. Assessing the Potential for Food-Based Strategies to Reduce Vitamin A and Iron Deficien-cies: A Review of Recent Evidence. Washington, DC:International Food Research Institute; 2000. (Discus-sion Paper 92).

19. Mora JO, Gueri M, Mora OL. Vitamin A deficiencyin Latin America and the Caribbean: an overview.Rev Panam Salud Pública 1998;4(3):178–186.

20. Nicaragua, Ministerio de Salud. Encuesta nacionalsobre deficiencia de micronutrientes en Nicaragua, 1993:informe final. Managua: Ministerio de Salud; 1994.

21. PAHO. Integrated Vision for Vitamin A Supplemen-tation in the Americas. Regional Meeting Report,2–4 May 2001. Managua, Nicaragua. Pan AmericanHealth Organization HPP/HPN/MN/49-17. Wash-ington, D.C., 2001.

22. World Health Organization. Guidelines on Food Forti-fication with Micronutrients. Allen L, de Benoist B,Dary O, Hurrell R (eds.) World Health Organiza-tion, Department of Nutrition. Geneva, 2004.

23. World Health Organization. Indicators for AssessingVitamin A Deficiency and Their Application in Monitor-ing and Evaluation of Intervention Programmes. Reportof a WHO/UNICEF Consultation. Geneva, 9–11 No-vember 1992. Geneva: WHO; 1996. (MicronutrientSeries WHO/NUT/96.10).

24. Nicaragua, Ministerio de Salud. Encuesta nacional demicronutrientes. Nicaragua, 2000. Managua: Ministe-rio de Salud; 2001.

25. Flores H, Campos F, Araujo RC, Underwood BA.Assessment of marginal vitamin A deficiency inBrazilian children using the relative dose responseprocedure. Am J Clin Nutr 1984;40(6):1281–1289.

26. Nicaragua, Ministerio de Salud. Sistema Integrado deVigilancia de Intervenciones Nutricionales (SIVIN).Primer informe de progreso 2002–2003. Managua: Min-isterio de Salud; 2004.

27. Phillips M, Sanghvi T, Suárez R, McKigney J, FiedlerJ. The costs and effectiveness of three vitamin A in-terventions in Guatemala. Soc Sci Med 1996;42(12):1661–1668.

28. Houston R. Why They Work: An Analysis of Three Suc-cessful Public Health Interventions. Vitamin A supple-mentation programs in Ghana, Nepal and Zambia. Ar-lington, Virginia: MOST, The USAID MicronutrientProgram; 2003.

29. Solomons NW, Bulux J. Vitamin A fortification sur-vives a scare in Guatemala. Sight and Life Newsletter1998;2:26–30.

30. Sommer A. Moving from science to public healthprograms: lessons from vitamin A. Am J Clin Nutr1998;68(Suppl 2):513S–516S.


BACKGROUND

Up until the 1990s, recommended intakesof folate were based on the prevention ofanemia, especially during pregnancy, a timeof high vulnerability to folate deficiency.Since then, evidence has shown that low fo-late intake, even if sufficient to avoid anemia,is nonetheless associated with importantnegative effects on health. Today, low folateintakes are common around the worldamong individuals consuming a limited andunvaried diet. Conclusive evidence showsthat when folate intake increases, there areimportant health benefits. Most neural tubedefects (NTDs) can be prevented by the peri-conceptional ingestion of folic acid (1, 2).Blood folate concentrations that are adequateto prevent anemia are nonetheless associatedwith an increased risk of NTDs (3). Likewise,formerly acceptable red cell folate levels maybe associated with an increased risk of car-diovascular disease and stroke (4). Serumand red blood cell folate levels on the lowerend of the normal range also increase the riskof colorectal cancer (5). Based on this newand growing body of evidence, the currentinternational public health focus is no longerlimited to the prevention of anemia, but in-stead has expanded to include the preven-tion of birth defects such as NTDs and a re-

duction in the risk of cardio- and cerebrovas-cular diseases and of some cancers. Thestrong scientific evidence linking increases infolic acid intake with a reduction of NTDsrisk has been translated into public healthpolicies through international recommenda-tions, which concur that all women of repro-ductive age should increase their intake offolate to reduce the risk of having a babywith an NTD (6, 7).

The current challenge is to implement ap-propriate strategies at the population level toprevent NTDs. A number of developedcountries have implemented policies con-cerning diet, supplements use, and food for-tification in order to increase folate intakeamong women of childbearing age. Foodfortification has been shown to be effective in the prevention of NTDs, while dietarychanges and prophylactic supplementationwith folic acid have shown only limited im-pact. Therefore, in lower-resource communi-ties, food fortification appears to be the mostpotentially successful intervention for in-creasing folate intake.

An overview of the key issues related to the role of folate in human metabolicprocesses is presented in the first part of this

FOLIC ACID FORTIFICATION OF WHEAT FLOUR AND THE PREVENTION OF NEURAL TUBE DEFECTS IN CHILE:

A SUCCESSFUL EXPERIENCE

Eva Hertrampf1

93

1Associate Professor, Institute of Nutrition and FoodTechnology (INTA), University of Chile, Santiago.

chapter, as well as a discussion of some of theclinical and epidemiological characteristicsof NTDs and of the current strategies beingutilized for the prevention of NTDs and theireffectiveness. These considerations are fol-lowed by a description of the implementa-tion of mandatory folic acid fortification ofwheat flour as recently introduced in Chile,an experience that could serve as a casestudy for other countries in the Region of theAmericas and other parts of the world.

FOLATE IN HUMAN METABOLICPROCESSES

Folate is a generic term for compoundsthat have a common vitamin activity, includ-ing compounds that are naturally present infoods as well as the synthetic form, folic acid,which is used in supplements and for foodfortification. Folic acid, the fully oxidizedmonoglutamyl form, is more stable in foodsand exhibits greater bioavailability than nat-ural folate (8).

Food sources of folate include green leafyvegetables, citrus fruits and juices, wholegrain bread, and legumes. Natural folates arevery labile, resulting in a significant loss ofbiochemical activity during harvesting, stor-age, processing, and preparation, which mayoccur over periods of days or weeks; this isin contrast to the stability of the syntheticform of folic acid found in fortified foods,which may remain almost completely stablefor even years. Natural folates from foods areall conjugated to a polyglutamyl chain con-taining different numbers of glutamic acids.This polyglutamyl chain is broken down tomonoglutamate in the brush border of themucosal cells by the enzyme γ-glutamyl hy-drolyase prior to their absorption in the in-testine, as only the monoglutamate forms aretransported into cells (8, 9). Since folic acidcontains only a single glutamate, its bioavail-ability is higher than natural folate. As a con-sequence, the low bioavailability (25%–50%)

and poor chemical stability of the natural fo-late determine a rather poor supply of folatefrom the diet in contrast with the significantamounts supplied by fortified foods. Thisconcept has a practical application in defin-ing the dietary folate equivalent (DFE),which is used to convert all forms of dietaryfolate and folic acid from fortified foods toequivalent amounts. Since folic acid in forti-fied products is 1.7 times more bioavailablethan food folate, 100 µg consumed asspinach would equal 100 µg DFE, and 100 µgconsumed as folic acid in fortified breadwould equal 170 µg DFE. Therefore, the DFEof a mixed diet would be calculated as fol-lows: µg food folate + (1.7 × µg synthetic folicacid) (6).

Once transported into cells, folic acid andnatural food folates are converted to tetra-hydrofolate, thus becoming chemically iden-tical. The primary form of folate enteringhuman circulation is 5-methyltetrahydrofo-late monoglutamate. Metabolically, naturalfolates and folic acid are converted to coen-zyme forms required in numerous one-carbon transfer reactions involved in the syn-thesis, interconversion, and modification ofnucleotides (purine and thymidine), aminoacids (methionine from homocysteine), andother essential structural and regulatorycompounds (10). Most of these reactions aresensitive to folate deficiency and can also beimpaired in the absence of folate deficiency.Deficiencies of vitamin B12 (also iron and ri-boflavin) can appear to be folate deficiencyand/or exacerbate a primary folate defi-ciency. At the same time, the impact of thesedeficiencies on folate metabolism is ad-versely affected by genetic background (11).

BIOMARKERS OF WHOLE-BODYFOLATE STATUS

Biomarkers of folate status include serumfolate, red blood cell folate, elevated serumhomocysteine and/or S-adenosylhomocys-

94 Folic Acid Fortification of Wheat Flour and the Prevention of Neural Tube Defects in Chile

teine (SAH) levels, increased uracil contentin DNA, DNA hypomehylation, megaloblas-tic anemia, and neutrophil hypersegmenta-tion. The most commonly used are serum,red cell folate, and serum homocysteine.Serum folate reflects very recent folic acidconsumption; levels fall quickly after a re-duction in intake and might be artificiallyhigh in the presence of vitamin B12 defi-ciency. Thus, looking at serum folate is insuf-ficient to determine folate status. Red cell fo-late, however, reflects longer-term intakesince folate remains in the red blood cell forits entire life span of 120 days; it has a strongcorrelation with liver, and therefore, tissuestores. Serum homocysteine is a sensitive in-dicator of folate status. It is affected not onlyby the deficient range of red blood cell folate,but also by normal and even above normallevels of red cell folate (12). Homocysteinecan also be increased in the presence of vita-min B12 or B6 deficiencies. Any elevation inhomocysteine, even at levels where overt fo-late deficiency is not an issue, may be unde-sirable because it is a risk factor for chronicdisease.

Currently, there are some constraints withrespect to the definition of folate deficiency atthe population level, especially in developingcountries. First, most of the folate status stud-ies are based only on plasma folate determi-nations. Secondly, there is a recognized vari-ability of analytical methodology to measurefolate, resulting in higher folate levels whenradioassays, and not microbial assays, areemployed (13). Thirdly, current cutoff levelswere set based on microbial assays (6), andthey are usually applied to results obtainedwith other techniques. It seems importantthat cutoff levels be revised.

Impaired folate metabolism is associatedwith risk for developmental anomalies anddiseases including neural tube defects,cardio- and cerebrovascular diseases, andcancer. Both nutrient status and genetic back-ground are independent, but interacting, riskfactors for these disorders. However, the

mechanisms that cause the pathology andthe reasons why folate prevents the occur-rence and recurrence of these disorders areunknown.

NEURAL TUBE DEFECTS

Neural tube defects are a major group ofbirth defects that occur when the brain,spinal cord, or the covering of these organs(bones and muscles) has not developedproperly. These congenital malformations in-clude open spina bifida, anencephaly, andencephalocele, and are considered to be vita-min deficiency disorders that may be pre-vented through the observance of appropri-ate public health measures. Anencephalyand spina bifida are the most common typesof NTDs. Infants born with anencephaly arestillborn or die within hours of birth. Spinabifida results from failure of the spine toclose during the first month of pregnancy.Children with spina bifida can have varyingdegrees of paralysis of their lower limbs, beconfined to a wheelchair, or have bowel andbladder problems.

After cardiac defects, NTDs are the mostcommon birth defects worldwide. The rate ofbirth prevalence varies among countries, eth-nic groups, and socioeconomic levels. Aglobal average of 20 in 10,000 live births hasbeen reported, with figures varying from0.25 in 10,000 (Finland) to 125 in 10,000(South Wales) (14). NTDs are of multifactor-ial polygenic origin, meaning that they aredetermined by the interaction of variousgenes and their alleles with multiple envi-ronmental factors, among which folate playsan important role. The metabolic alterationsof folate metabolism and inadequate folateintake play a fundamental role among the as-sociated factors that determine NTDs. In ad-dition, gene polymorphisms that code forkey enzymes and receptors for folate metab-olism and transport are associated with anincreased risk of NTDs (11). However, the

Hertrampf 95

biochemical and developmental mechanismswhich lead to the pathology, as well as thosewhich enable folate to successfully preventthe occurrence and recurrence of these disor-ders, have not yet been identified.

EVIDENCE SHOWING THE EFFICACY OF FOLIC ACID IN THE PREVENTION OF NTDs

The relationship between diet, social class,and congenital malformations was first de-scribed in the 1970s in England (15). A groupof researchers noted that congenital malfor-mations affecting the central nervous system,including NTDs, were more common inwomen of lower socioeconomic status whoalso had lower first trimester levels of redcell folate. It was suggested that low serumlevels of vitamins represented poor diet andthat periconceptional multivitamin supple-mentation might prevent some congenitalanomalies, including NTDs. The Medical Re-search Council in England undertook aplacebo-controlled study using a factorialdesign with four arms: multivitamins withfolic acid (4 mg/day), multivitamins alone,folic acid alone (4 mg/day), and placebo. Theaim was to test in women with a previousNTD pregnancy whether there was a realpreventative effect, and if so, whether folicacid alone was the active ingredient orwhether multivitamins intake was responsi-ble for the positive effect. In 1991, this studyshowed that NTDs could be reduced byabout 75%, and this was due to folic acidsupplements, not multivitamins withoutfolic acid (1). In 1992, Czeizel and Dudaspublished the results of a randomized trial ofmultivitamins (including 800 µg/day of folicacid) in women discontinuing contraceptionto become pregnant. The 2,104 women tak-ing the multivitamins with folic acid had alower rate of congenital malformations over-all and no NTDs, compared to six NTDs inthe 2,052 placebo-treated women, represent-ing the expected occurrence rate (2).

APPROACHES TO INCREASING FOLATE INTAKE

Increasing folate intake purely throughdietary sources is unlikely to increase awoman’s folate levels sufficiently to reducethe risk of an NTD-affected pregnancy. Thebioavailability of natural folate is only halfthat of folic acid added through supplemen-tation or fortification. Therefore, to meet theequivalent of 400 µg of folic acid daily, about800 µg of dietary folate would need to beconsumed per day. For example, a womanshould consume 500 g daily of raw spinachor 900 g of boiled spinach or raw broccoli inorder to effectively reduce the risk of anNTD-affected pregnancy.

In recent decades, it has become obviousthat women with the highest risk of NTDs areunlikely to obtain adequate amounts of natu-ral folate from foods and that they should thusbe encouraged to take a periconceptional folicacid supplement or consume foods fortifiedwith folic acid in order to increase folic acidconsumption. Yet public health efforts promot-ing the use of supplements have not been ef-fective in preventing NTDs. In the UnitedStates (16), United Kingdom (17), and theNetherlands (18), where around 50% of thepregnancies are planned, even with aggressivecommunication and educational campaigns,fewer than 40% of women consume folic acidsupplements during their periconceptional pe-riod. These data indicate that folic acid aware-ness has not been translated into behaviorchange. In developing countries, the coveragecan be expected to be even lower due to theavailability of fewer resources for educationalcampaigns, difficulties in ensuring compliance,and lack of access to information about andservices for periconceptional folic acidsupplementation.

Meanwhile, fortification of cereals withfolic acid has shown significant increases ofblood folate levels (19, 20) and also signifi-cant reductions in NTD frequencies in theUnited States and Canada (21, 22). Followingmandatory fortification of all enriched cereal


grain products since January 1998 in theUnited States, red cell folate levels rose froman average of 410 nmol/L to 714 nmol/L(19). The birth prevalence of NTDs fell from37.8 per 10,000 live births before fortificationto 30.5 per 10,000 live births conceived aftermandatory folic acid fortification, represent-ing a 19% decline (21). In Canada, folic acidfortification was associated with an evenmore dramatic decline of 48% in NTDs (22).

For these reasons, increasing folate levelsthrough folic acid fortification of foods is animportant public health strategy for reachinga large number of the target population. Cur-rently, 19 countries in the Americas are forti-fying wheat flour with folic acid, in additionto iron. The impact of this strategy on im-proving folate status and preventing NTDshas not been evaluated except in Costa Rica (23). Recently, a Pan American Health Organization/U.S. Centers for Disease Con-trol and Prevention/March of Dimes techni-cal consultation recommended guidelines toselect the optimal level of folic acid fortifica-tion, taking into consideration the nutritionalrequirement, consumption level of the foodvehicle, and costs in order to maximize theefficacy of fortification programs (24).

FOLIC ACID FORTIFICATION OFWHEAT FLOUR IN CHILE

Congenital anomalies have become moreimportant causes of infant morbidity andmortality as the prevalence rates of infec-tious diseases and nutritional problems dur-ing childhood have decreased. This is thecase in Chile, where infant mortality is8.9/1,000 (25). Congenital malformations arethe second cause of infant mortality in thiscountry, following prematurity. In Chile, theincidence corresponds to 1.7/1,000 livebirths, according to the ECLAMC registry(Spanish acronym for Estudio ColaborativoLatinoamericano de Malformaciones Congénitas,or Collaborative Latin American Study ofCongenital Malformations), and rates have

not changed between 1967 and 1999 (26). Ac-cording to this NTDs incidence rate, an esti-mated 400 babies affected with NTDs areborn every year. Furthermore, in Chile, thetermination of pregnancy and therapeuticabortions are not permitted by law.

Factors such as the high cost of lifelongmedical attention for a patient with spina bi-fida and the incalculable emotional cost onthe families affected by NTDs have trans-formed this condition into a major publichealth problem in the country. This situationled a group of academics and program plan-ners from the Ministry of Health, as well asrepresentatives from the national mill indus-try, to identify folic acid fortification of wheatflour as a promising strategy for increasingthe population’s intake of folic acid. Thisconclusion was reached following a numberof considerations: (1) wheat flour is a staplefood throughout the country; (2) milling forbread-making corresponds to 90% of thetotal wheat milled, and over 70% of wheatflour is used for making the types of breadtypically consumed by Chileans (80 g ofwheat flour/100 g of bread), known as ma-rraquetas and hallullas; (3) flour mills in thecountry are technologically well developed,and quality assurance systems for fortifica-tion are already in place; these features havepermitted, since 1951, the successful processof wheat flour fortification with iron as fer-rous sulfate (30 mg/kg), thiamine (6.3mg/kg), riboflavin (1.3 mg/kg), and niacin(13.0 mg/kg) (27); (4) the mean intake ofwheat flour as bread in Chile is very high,approximately 200 g/day (28); (5) regulatorymonitoring is conducted on a permanentbasis by the Ministry of Health’s Institute ofPublic Health at the premix vendor and milllevels; (6) the cost of adding folic acid to thepremix is low (approximately US$ 0.15/tonof wheat flour) so that it may be absorbed bythe milling industry (29); and (7) the totalcost of rehabilitation for a child affected withspina bifida in Chile has been roughly esti-mated as US$ 120,000 (from birth to 18 yearsof age), whereas the cost of adding folic acid

Hertrampf 97

has been estimated to be US$ 175,000/year(29); hence, just one case of NTD preventedin a year would permit the recovery of nearlythe entire cost of fortifying wheat flour withfolic acid for a complete year.

Starting in January 2000, the Ministry ofHealth of Chile mandated a regulation re-quiring that folic acid be added at a level of2.2 mg/kg to the premix currently used inwheat flour. This policy, based on bread con-sumption by the target group, was expectedto result in a mean additional intake of ap-proximately 400 mg/day in women of child-bearing age (15 to 44 years). It is important tonote that folic acid-fortified foods such asbreakfast cereals are not universally avail-able, are economically out of reach for mostof the population, and are not culturally ac-cepted. At the same time, there is very little,if any, consumption of folic acid supple-ments. Within this context, bread fortifiedwith folic acid was envisioned to representthe principal source of the nutrient thatwould benefit the entire population.

IMPACT EVALUATION OF THE FOLIC ACID FLOUR

FORTIFICATION PROGRAM

The situation described above providedan excellent opportunity to assess the effec-tiveness of the folic acid flour fortificationprogram in the reduction of the risk of NTDsin a population with characteristics differentfrom those of Canada and the United States.The impact evaluation of the Chilean inter-vention was undertaken by a group of re-searchers composed of nutritionists and ge-neticists from the University of Chile’sInstitute of Nutrition and Food Technology(INTA). It was sponsored by the Pan Ameri-can Health Organization and financed by theMarch of Dimes, U.S. Centers for DiseaseControl and Prevention (CDC), and ChileanMinistry of Health, with the collaboration ofthe University of Florida. The assessment fo-cused on the effectiveness of the folic flour

fortification program in increasing bread fo-late content and in improving folate status inwomen of childbearing age, as well as theprogram’s effectiveness in reducing the fre-quency of NTDs at the population level, andfolate intake levels of the study group wereassessed both before and after the program’simplementation in Chile.

Folic Acid Content of Bread

The Institute of Public Health, which isthe scientific and technical branch of Chile’sMinistry of Health, monitors iron and B-complex vitamins, but not folic acid con-tent in wheat flour, because an adequatemethodology for monitoring purposes is notcurrently available. To measure folic acid inbread, 1 kg of bread (marraquetas and ha-llullas) was purchased over the counter at 50randomly selected bakeries in the Metropoli-tan Area of Santiago. Samples were obtainedthree and six months after fortificationstarted in these same bakeries. Folate was ex-tracted from the samples using a modifica-tion of the tri-enzyme extraction method(30). Folate content was measured at the Uni-versity of Florida using the microplate adap-tation of the microbiological assay (31). Thefolate content for the 100 bread samples was202 ± 94 µg/100 g of bread (range 22–416µg/100 g). Only 9/100 contained < 37 µgfolic acid per 100 g, suggesting that thesewere made from unfortified flour. Distribu-tion of the values confirmed that wheat flourwas fortified four months after the law man-dated the addition of folic acid fortificationwith the expected content.

Folic Acid Consumption from Bread andChanges in Blood Folate ConcentrationLevels

The National Health Service’s Maternaland Child Health Program covers at least70% of the Chilean population and operatesthrough a series of Outpatient Primary CareClinics that are located throughout the coun-


try. Seven hundred fifty-one women, all ofwhom were of childbearing age, had at leastone child (but no family history of NTDs),and who were currently utilizing services atone of three outpatient clinics (Alejandro delRío, La Granja, and La Faena) in Santiago,Chile, were studied. Women were recruitedand studied from October to December 1999(before fortification), and assessed again be-tween October and December 2000 (after for-tification). Six hundred and five women(81%) completed the follow-up. Causes ofdropout before follow-up were: moving outof reach (75), rejection of second venipunc-ture (65), death (2), and in jail (2). Subjectsparticipating in both assessments and thoselost before the follow-up were similar withrespect to bread consumption and blood fo-lates. Other characteristics of the group in-cluded the following: (1) body mass index(26.4 kg/m2 ± 5.1); (2) multiparous (2.2 ± 1.2children); (3) 12.6% anemic (Hgb < 12 g/dL);(4) 75% breast-fed last child > 6 months; (5) 23% used an oral contraceptive; and (6) ~ 60% did not smoke or consume alcohol.In the follow-up group, average bread con-sumption was estimated based on a combina-tion of a 24-hour recall and a food-frequencyquestionnaire specifically designed to assessintake of bread and other wheat flour-basedfoods, folic acid-fortified foods, and vitaminsupplements. Estimated folic acid intake wascalculated based on bread consumption de-rived from the mean value of data obtainedfrom both the 24-hour recalls and food-frequency questionnaires and the mean folatecontent of bread. The effect of fortification onblood folate concentration was evaluated in afollow-up study. Serum and red blood cell fo-late and vitamin B12 concentrations were an-alyzed using the Bio-Rad Laboratories (Her-cules, California, 1989) QuantaPhase II FolateAssay kit.

Folic Acid Consumption

The estimated median bread intake was245 and 239 g/day before and after fortifica-

tion, respectively. On a daily basis, 98% ofthe women consumed bread, and 89% in-gested over 180 g/day. Ninety-seven percentof the bread analyzed, corresponding to thetype of bread typically consumed in Chile,was industrially processed. None of the sub-jects consumed other folic acid-fortifiedfoods, and none reported taking folic acidsupplements. Mean folic acid intake was 427(95% CI 409–445) g/day based on estimatesof the daily intake of folic acid from fortifiedbread and reported consumption of thewomen studied. Almost half of them (48%)consumed > 400 g of folic acid daily. Only 3%consumed < 100 g/day. The intake of folicacid from bread for the rest of the group(49%) corresponded to values varying be-tween 100 and 400 g/day (30).

Changes in Blood Folate Concentration Levels

The effect of habitual consumption of folicacid-fortified foods on folate levels is ac-cepted as the best method for determiningwhether people are consuming more folicacid. Evaluation of folate nutritional status inthe 605 women in the follow-up group con-firmed the improvement in folate intake,showing a remarkable increase in serum andred blood cell folate concentrations after theprogram was implemented. Prior to fortifica-tion, the mean serum and red blood cell fo-late concentrations were 9.7 ± 4.3 and 290 ±102 nmol/L, respectively, as compared to37.2 ± 9.5 and 707 ± 179 nmol/L post-fortification (p < 0.0001). As expected, vita-min B12 concentrations did not changeduring this time (266 ± 105 and 268 ± 165pmol/L). The distribution curves for serumand red blood cell folate concentrations be-fore and after fortification show a strikingshift to the right (A and B), in contrast withthe vitamin B12 distribution curves, whichshowed no change (C) (Figure 1).

These findings demonstrate that regularconsumption of a folic acid-fortified staplefood is highly effective in improving folate

Hertrampf 99

status in women of childbearing age. Serumand red blood cell folate concentrations sig-nificantly increased after 10 months of con-sumption of folic acid-fortified wheat flour.This improvement in blood folate status may

be attributable to the consumption of folicacid-fortified wheat flour. The study groupdid not consume other folic acid-fortifiedfoods. In addition, folic acid supplementswere not taken by any of the study subjectssince they have not been mandated or madeavailable to this low-income populationgroup by Chilean public health services.Therefore, the wheat bread fortified withfolic acid was the main source of this nutri-ent in the population studied.

Folate Deficiency in the Group

Both the CDC (32) and the U.S. Instituteof Medicine (6) cutoffs for serum and redblood cell folate concentrations were ap-plied to radioassay analyses performed inthis study. The prevalence of low folate lev-els, presenting risk for deficiency, variedwidely thereby emphasizing the necessity torevise the criteria for defining folate defi-ciency (Table 1). It is important to highlightthat although the majority of the study pop-ulation presented low plasma and red bloodcell folate concentrations before the fortifica-tion started, only five women presented ane-mia associated with these low values, andno subjects presented macrocytosis as mea-sured according to mean corpuscular vol-ume.2 Therefore, their folate status was notsufficiently low to cause clinical signs suchas anemia.

IMPACT OF FOLIC ACIDFORTIFICATION ON THE ELDERLY POPULATION

In a group of Chilean elderly (aged 70 orover), who were being followed up by agroup of researchers at INTA at the sametime as the start of the folic acid fortification,significant increases in serum folate levelsafter six months of fortification were re-ported (33). Since this age group is at a


Source: Hertrampf E, Cortés F, Erickson D, Cayazzo M, Freire W,Bailey LB, et al. Consumption of folic acid-fortified bread im-proves folate status in women of reproductive age in Chile. J Nutr2003;133(10):3166–3169. Reprinted with permission.

FIGURE 1. Serum folate, red cell folate, andvitamin B12 distribution curves before and afterfolic acid fortification of wheat flour in women

of reproductive age, Santiago, Chile.

2Eva Hertrampf, unpublished observations.

0 20 40 60 80 100

0 200 400 600 800 1000 1200

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higher risk of vitamin B12 deficiency, in-creased intakes of folic acid provided by for-tified wheat flour could be considered as anobjection to mass food fortification due to therisk of masking vitamin B12 deficiency (B12deficiency without anemia because of addi-tional folic acid intake). Vitamin B12 defi-ciency presents either with anemia, neuro-logical symptoms, or both. High doses offolic acid may correct the anemia caused byvitamin B12 deficiency (because folic acidand vitamin B12 have a similar effect) andmay lead to a delay in diagnosis of the un-derlying vitamin B12 deficiency, causing irreversible neurological damage. Expertsworldwide accept that this is only likely to happen with folate intakes > 1 mg/day (6, 34).

Up until now, there is no evidence of harmwith the folic acid levels supplied by fortifiedfoods. Interestingly, in a recent study, agroup of 1,573 elderly in the United Statesshowed no evidence of an increase in low vi-tamin B12 concentrations without anemiaafter fortification of cereals with folic acid(35). In Chile, based on data suggesting thatthe elderly population (33–36) and women offertile age (31) are at risk of vitamin B12 defi-ciency, a suitable approach to this problemmight be to introduce B12 fortification inaddition to folic acid fortification in wheatflour. It is important to note that folate de-ficiency is also widespread in the elderly(36); therefore, correcting hyperhomocy-steinaemia through folic acid fortificationmight considerably reduce deaths from coro-nary heart disease and stroke.

CHANGES IN NTD FREQUENCY

Blood folate levels have been shown tocorrelate with folate consumption and ap-pear to correlate with NTD rates as well (37,38). Nevertheless, blood folate levels are stillan intermediate outcome. The real measureof the impact of increased folic acid con-sumption is the reduction of NTD rates. Wedecided to monitor if prevalence of NTDsdeclined after mandatory folic acid fortifica-tion as a means to evaluate its effectiveness.

In Chile, 99% of all deliveries occur in in-stitutional settings, and 80% of these takeplace in facilities belonging to the nationalpublic health care system. About 40% of con-genital malformations are diagnosed in pre-natal controls; however, as earlier noted, thetermination of pregnancy and therapeuticabortions are prohibited by law. A neonatalscreening program for phenylketonuria andcongenital hypothyroidism covers 98% ofnational births. NTD registry is part of rou-tine neonatal care, and since NTDs are con-sidered serious anomalies, only in rare casesdo they escape diagnosis. Newborns withspina bifida are discharged after undergoingsurgery. Stillbirths must be audited to insureproper medical care, and autopsies aremandatory in all the cases.

In 1998, in Chile the only surveillance sys-tem in place for congenital malformationswas that belonging to ECLAMC (26), whichregisters 7% of total births in Chile, fromthree maternity hospitals, none of whichwere public hospitals located in Santiago.Birth certificates do not include information

Hertrampf 101

TABLE 1. Risk of folate deficiency in a group of women of repro-ductive age according to different reference ranges.Serum folate NHANES < 3.2 nmol/L IOM < 7 nmol/L(% below ref. range) 1.3 25.0

Red blood folate NHANES < 181 nmol/L IOM < 305 nmol/L(% below ref. range) 10.6 65.0

Source: adapted from Hertrampf E, Cortés F, Erickson D, Cayazzo M, Freire W, BaileyLB, et al. Consumption of folic acid-fortified bread improves folate status in women of re-productive age in Chile. J Nutr 2003;133(10):3166–3169.

about malformations, and given that theChilean health system does not include a na-tional birth defect registry, with the assis-tance of the CDC and ECLAMC, we estab-lished a hospital-based surveillance systemin the nine Santiago-based public hospitalsto register NTDs. The registry prospectivelyincluded all births (live births and still-births), beginning in the year 1999, with abirth weight of > 500 g. The number of birthsoccurring in these hospitals is approximately60,000 per year, which represents 60% ofbirths in Santiago and 25% throughout Chile.In the absence of a national registry, this sur-veillance system was seen as a potentiallyuseful mechanism capable of providing amore accurate picture of NTDs frequency bypartially correcting for sources of underesti-mation of NTDs, such as the termination ofaffected pregnancies and inadequate still-birth registry.

In each hospital one member of the staff (aneonatologist or registered nurse) was re-cruited and trained by the research team toreview all births, and then register and de-scribe all NTD occurrences. Types of NTDsregistered were anencephaly, encephalocele,and spina bifida, regardless of whether asso-ciated or not with other malformations. Incases where two NTDs occurred concomi-tantly in a newborn, the defect occurring in ahigher position along the spine was consid-ered. A specially trained clinical geneticistwas hired to monitor the correct registrationof NTDs during the four years of the reg-istry’s duration (1999–2002). Data obtained

was reviewed monthly using the followingsources: audits for deaths under 1 year old,fetal death audits, hospital discharge reports,delivery records, registry of newborns, reg-istry of malformed newborns, registry ofstillbirths, autopsy protocols, and clinicalrecords. Validation of the collected data wasperiodically performed by the rest of theresearch team through the sources of infor-mation described above. Total prevalencerates were calculated as the total number ofneural tube defects per 10,000 births.

Folic acid fortification was mandated by Jan-uary 2000, and compliance was verified byApril 2000 through assaying the folic acid con-tent of bread. Data was divided in two tempo-rally defined groups: the pre-fortification pe-riod, consisting of data collected betweenJanuary 1999 and December 2000, because neu-ral tube development of the babies born dur-ing that period was not exposed to folic acidfortification (there is evidence that fortificationof wheat flour was in place since April 2000,so the babies conceived since April 2000 andborn since January 2001 were benefited), andthe post-fortification period, consisting of datacollected between January 2001 and December2002.

Preliminary analysis of the data shown inTable 2 reveals that the total rate of NTDs, in-cluding live and stillbirths, decreased by 40%from the pre-fortification period (1999–2000)to post-fortification (2001–June 2002), from17.0 to 10.1 per 10,000 births (RR 0.60, 95% CI046–0.77). These results indicate that wheatflour fortification with folic acid is feasible


TABLE 2. Total NTD rates for pre-folic acid fortificationa (January 1999 toDecember 2000) and post-fortificationb (January 2001 to June 2002) inSantiago, Chile (preliminary results).

Pre-fortification Post-fortification RR (95% CI) Decline %

NTD ratesc, d 17.0 10.1 0.60 (046–0.77) 40

a120,636 births.b88,538 births. cNTD births/10,000 births. dLive and stillbirths.

on a national scale and that this strategyholds significant potential in the effectiveprevention of NTDs in only a short period oftime.

The evaluation of public health interven-tions is of major importance, since this mech-anism generates information that is crucial tofuture planning and provides the foundationfor advocacy of the intervention’s effective-ness and sustainability, which, in turn, facili-tates the acquisition of the necessary re-sources and funding for implementation.The optimal design of the impact evaluationof a program is a “probability evaluation,”which entails the comparison of two ran-domly assigned program-exposed or non-exposed groups (39). This permits the gener-ation of results and conclusions aboutprogram performance with the greatest con-fidence, making it possible to establishcausality after controlling for potential con-founding factors. However, its use is limitedfor economic, logistical, and ethical reasons.In the present study, we used a “plausibilityevaluation” design (39) in which the base-line (pre-fortification) and end line (post-fortification) situations were compared. Thispermits us to make an argument of plausibil-ity that reduction in the NTDs rate, which oc-curred over a short period of time and tem-porally coincided with the program, wasindeed an effect of the program. Two otheraspects that support this plausibility argu-ment are the increased intake of folic acidfrom fortified bread and the dramatic changein folate status in a group of women of repro-ductive age.

COST-EFFECTIVENESS OF FOLIC ACID FORTIFICATION

In a cost-effectiveness study currently inprogress (40), the incremental cost of folicacid fortification was evaluated by compar-ing total costs for one year of fortificationwith those for one year without fortification.Costs included in this analysis were those as-

sumed by the milling industry (adding folicacid to the premix, quality control) and costsaverted per case of prevented spina bifida(medical care, surgery, rehabilitation during20 years). Costs not included in this analysiswere those of the milling industry infrastruc-ture (since it was preexisting), costs of addi-tional medical complications, and indirecteconomic and emotional costs to familymembers and caretakers. Although the latterrepresents an enormous burden for the af-fected individuals, family members, and so-ciety in general, the very nature of thesekinds of costs renders them difficult to trans-late into numbers.

Results of this analysis have shown thatthe cost of folic acid fortification per womanof reproductive age receiving the target in-take of 400 µg/day was a mere US$ 0.16. Thecost of surgery and rehabilitation (extendedto 20 years of life) per child with spina bifidawas shown to be approximately US$ 100,000.When applying this cost to the 110 cases ofspina bifida prevented by the folic acid forti-fication program, total savings for the healthcare system were approximately US$ 11million.

FACTORS CONTRIBUTING TO THESUCCESS OF THE FORTIFICATION

INTERVENTION

There are several possible factors that haveplayed a key role in the success of this inter-vention. These include: (1) the existence of agroup of committed academics advocatingfor the implementation of a national folic acidfortification program; (2) the subsequentmandate for flour fortification supported bylegislators; (3) the willingness of the millingindustry to accept the addition of folic acid tothe premix in use and to incur additionalcosts related to this process; (4) the low cost ofthe program; and (5) the scientific collabora-tion and financial support received from in-ternational agencies throughout all stages ofthe intervention.

Hertrampf 103

AREAS NEEDING FUTURE RESEARCH

(1) Is it possible to improve the degree ofprevention already achieved in Chilewith wheat flour folic acid fortifica-tion? According to efficacy studies,70% of NTDs are preventable by con-trolled folic acid supplementation.However, results from effectivenessstudies in Canada, Chile, and theUnited States have shown a 40% re-duction in the NTD rate. It is unclearwhether by modifying certain factors,such as removing technical and prac-tical barriers in the fortification pro-cess, and improving vitamin B12 sta-tus in women of reproductive age,this current ceiling could be raised.

(2) Fill a critical gap in regulatory moni-toring fortification programs byadapting a simple, rapid, relativelylow-cost methodology to measure thefolic acid content of wheat flour andother food vehicles.

(3) Assess other positive medium- andlong-term effects of increased folicacid intake on the vascular patholo-gies occurring during pregnancy andadulthood, among others.

(4) Evaluate surveillance of unknownand possibly deleterious effectscaused by folic acid fortification.

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26. Nazer H, López-Camelo J, Castilla EE. ECLAMC:estudio de 30 años de vigilancia epidemiológica dedefectos de tubo neural en Chile y en Latino-américa. Rev Med Chile 2001;129(5):531–539.

27. Hertrampf E. Iron fortification in the Americas. NutrRev 2002;60(7 Pt 2):S22–S25.

28. Castillo C, Atalah E, Benavides X, Urteaga C. Pa-trones alimentarios en adultos que asisten a consul-torios de atención primaria en la región metropoli-tana. Rev Med Chile 1997;125:283–289.

29. Chile, Ministerio de Salud. Norma técnica para la for-tificación de la harina de trigo con vitaminas y minerales.Santiago: Ministerio de Salud; 1999.

30. Martin JI, Landen WO Jr, Soliman AG, EitenmillerRR. Application of a tri-enzyme extraction for totalfolate determination in foods. J Assoc Off Anal Chem1990;73(5):805–808.

31. Hertrampf E, Cortés F, Erickson D, Cayazzo M, FreireW, Bailey LB, et al. Consumption of folic acid-fortified bread improves folate status in women of re-productive age in Chile. J Nutr 2003;133(10): 3166–3169.

32. Centers for Disease Control and Prevention. Folatestatus in women of childbearing age—UnitedStates, 1999. MMWR Morb Mortal Wkly Rep 2000;49(42):962–965.

33. Hirsch S, de la Maza P, Barrera G, Gattas V, Peter-mann M, Bunout D. The Chilean flour folic acid for-tification program reduces serum homocysteine lev-els and masks vitamin B-12 deficiency in elderlypeople. J Nutr 2002;132(2):289–291.

34. United Kingdom, Department of Health, Commit-tee on Medical Aspects of Food and Nutrition Pol-icy. Folic Acid and the Prevention of Disease: Report ofthe Committee on Medical Aspects of Food and NutritionPolicy. London: Department of Health, StationeryOffice; 2000.

35. Mills JL, Von Kohom I, Conley MR, Zeller JA, CoxC, Williamson RE, et al. Low vitamin B-12 concen-trations in patients without anemia: the effect offolic acid fortification of grain. Am J Clin Nutr2003;77(6): 1474–1477.

36. Olivares M, Hertrampf E, Capurro MT, Wegner D.Prevalence of anemia in elderly subjects living athome: role of micronutrient deficiency and inflam-mation. Eur J Clin Nutr 2000;54(11):834–839.

37. Daly LE, Kirke PN, Molloy A, Weir DG, Scott JM.Folate levels and neural tube defects. Implicationsfor prevention. JAMA 1995;274(21):1698–1702.

38. Daly S, Mills JL, Molloy AM, Conley M, Lee YJ,Kirke PN, et al. Minimum effective dose of folic acidfor food fortification to prevent neural-tube defects.Lancet 1997;350(9092):1666–1669.

39. Habicht JP, Victora CG, Vaughan JP. Evaluation de-signs for adequacy, plausibility and probability ofpublic health program performance and impact. IntJ Epidemiol 1999;28(1):10–18.

40. Llanos A, Cortés F, Hertrampf E, Uauy R. Cost-effectiveness analysis of a national folic acid fortifi-cation program in Chile. Pediatr Res 2004;55(4): 280A.

Hertrampf 105

Integrated Strategies at the Local Level

SUMMARY

Recent breast-feeding statistics from Bra-zil,3 indicating high rates of breast-feeding (amedian duration of nearly 10 months), areboth encouraging and impressive, especiallywhen compared to 1975 national census fig-ures showing that one out of every twoBrazilian women who breast-fed had com-pletely discontinued this practice by the sec-ond or third month after their child’s birth.Similarly, the 1986 Demographic and HealthSurvey revealed a breast-feeding rate in thiscountry of only around 4%—the lowest ex-clusive breast-feeding rate from 0 to 4months in all of Latin America.

This chapter focuses on the evolution ofBrazil’s national breast-feeding program,emphasizing the role played by internationalpolicy recommendations of the World HealthOrganization (WHO) and United NationsChildren’s Fund (UNICEF) in transformingthe status of breast-feeding in a country thatis not only Latin America’s largest in geo-graphical terms, but also one that is charac-terized by dynamic cultural, ethnic, and so-cioeconomic diversity. This chapter will alsoexplore how the formulation of policies andinterventions adopted in Brazil might serveas a basis for the development and/or re-view of new international policies and how

these, in turn, may be adapted within na-tional and community frameworks.

In Brazil, the studies providing data onbreast-feeding make it possible to divide thischapter’s analysis into four periods: the1970s, the beginnings of reactions for andagainst breast-feeding, which also coincidedwith peak use of infant formulas; the 1980s,when large-scale campaigns in promotion ofbreast-feeding received wide coverage in themass media; the 1990s, when policies in de-fense of breast-feeding, and planning andtraining activities to promote it, began totake root; and, finally, the twenty-first cen-tury. The challenge for this initial phase ofthe new century is the need to promote ex-

IMPLEMENTATION OF BREAST-FEEDINGPRACTICES IN BRAZIL:

FROM INTERNATIONALRECOMMENDATIONS TO LOCAL POLICY

Marina Ferreira Rea1 and Maria de Fátima Moura de Araújo2

109

1Director of Maternal and Child Health Division, In-stitute of Health, Ministry of Health of São Paulo, Brazil;medical doctor; senior scientific researcher and post-graduate professor, Universidade de Campinas, SãoPaulo; breast-feeding specialist for Wellstart Interna-tional; and member of the International Baby Food Ac-tion Network (IBFAN).

2Assistant Professor, Health Sciences Teaching Foun-dation, Ministry of Health of the Federal District,Brasília, Brazil; nutritionist specializing in clinical andhuman nutrition; former Breast-feeding Coordinator,Ministry of Health of Brazil (1998–2003).

3Data on breast-feeding interventions cited for themost recent period described in this chapter, particularlythe late 1990s and the 2000–2002 period, were taken par-tially from documents and presentations; these weremodified and analyzed under the sole responsibility ofthe authors.

clusive breast-feeding through the sixthmonth of life and continued breast-feedingthereafter with appropriate complementaryfoods until at least 2 years of age (a WHO de-cision adopted in 2001, supported by Brazil-ian leadership at the Fifty-fourth WHOWorld Health Assembly), while taking intoaccount special groups, pursuant to theWHO/UNICEF Global Strategy for Infantand Young Child Feeding. The network ofhuman-milk banks—an area in which Brazilhas demonstrated global leadership—maybe the best alternative for these specialgroups, such as babies with HIV-positivemothers who cannot breast-feed them. Thehuman-milk bank initiative, as well as otherinnovative actions, challenges, and possiblesolutions which draw on Brazil’s experience,will also be described in this chapter.

INTRODUCTION

The three principal challenges facingbreast-feeding promotion programs in thetwenty-first century may be summarized asfollows:

(1) how to ensure exclusive breast-feedingfrom birth through the first six monthsof life;

(2) how to introduce safe and adequatecomplementary foods into the dietwithout interrupting breast-feedingfrom 6 months up to 2 years of age orbeyond; and

(3) how to promote adequate child nutri-tion for groups whose special needs arenot addressed within the framework ofbreast-feeding recommendations tar-geted toward the general population, asis the case of HIV-positive mothers,women with infants without legal pro-tection in the workplace, mothers inemergency situations (i.e., victims of nat-ural disasters, civil war, or famine; liv-ing in refugee settings), and otherswhose unique circumstances warrant a

specialized application of breast-feedingrecommendations.

In May 2001, ministers of health attendingthe Fifty-fourth WHO World Health Assem-bly recommended that all children receivebreast milk exclusively until approximatelysix months after birth and that breast-feedingcontinue thereafter for a period of at least upto age 2 years (1). This policy decision wasadopted following a careful review of the sci-entific literature (2) and years of debate in-volving commercial interests that have notalways been favorable to the goals of publichealth. The document notes that the globalrecommendation is intended as a guide forinfant and young child feeding practices andthat in applying it, public health authoritiesshould take into account local circumstances,including environmental, cultural, and otherrisk factors. On the other hand, it stressesthat in order to achieve exclusive breast-feeding during the first six months of life,mothers need breast-feeding protection and support for lactation, a reality that isachieved only through clear national policiesand legislation regarding maternal and childhealth.

In 1984, the first meta-analysis was pub-lished showing that exclusive breast-feedingfrom birth through 4 to 6 months of age pro-tects children against death by infectious dis-eases (3). This analysis was followed by acase-control study in Porto Alegre andPelotas, resulting in data that today are citedexhaustively in the literature. These dataquantify and give meaning to such protec-tion; i.e., the greater the degree to which chil-dren are exclusively breast-fed, the lesser therisk of their dying from diarrhea or otherprevalent childhood infections, especiallyduring the first two months of life (4).

For reasons that remain unclear, scientificvalidation of this type has not always beenused to promote breast-feeding, however.Despite this, the knowledge accumulatingover the last decade and a half on this topichas been nothing short of revolutionary: it

110 Implementation of Breast-feeding Practices in Brazil

has clearly demonstrated that several dis-eases or conditions may actually become sig-nificantly worse when breast-feeding doesnot occur, including necrotizing enterocolitis(5), diabetes (6), allergies (7), and pneumonia(8). Breast-feeding is very important forpreterm and low-birthweight babies, result-ing in greater rates of intelligence (9), visualacuity (10), and lower blood pressure among13- to 16-year-olds (11). Today we also knowthat breast milk, in addition to providing itsadequate and vital dose of immunoglobulinat the beginning of life, continues to be animportant source of proteins (some uniqueand irreplaceable) and calories, as well as mi-cronutrients, such as vitamin A, during thesecond year of a child’s life; moreover, it pro-vides one-third of the energy necessary forchild growth (12).

Infant formula was prescribed for manyyears, given the lack of knowledge and un-derstanding regarding the nutritional andimmunological value of breast milk, the im-portance of breast-feeding in terms of itsphysiological and emotional benefits, and itsrole in the reduction of infant morbidity andmortality. Women also incur the benefits ofbreast-feeding, as evidenced in decreasedrates of ovarian (13–15) and breast (16–20)cancers and of coxofemoral subluxation dueto osteoporosis (21–23), as well as in the ex-tended postpartum infertility it provides,thereby enabling greater spacing betweenpregnancies (24–26).

Until the late 1970s, programs and/or activ-ities to promote breast-feeding were designedwithout very much coordination, analysis, orcriteria. The considerations influencing the de-cision to stop breast-feeding—i.e., the culturaland socioeconomic determinants, the market-ing of breast-milk substitutes, and inadequatecounseling and inaccurate information givenby health care professionals on breast-relatedproblems during the immediate postpartumperiod—continued to take their toll. Conse-quently, these factors, taken together withpoorly designed breast-feeding programs andservices, may have been responsible for the in-

creased rates of early weaning and use ofartificial milk and feeding bottles during thisperiod.

Toward the end of the 1970s and through-out the 1980s, a number of breast-feedingpromotional activities elsewhere in theworld, however, began to show promise inexpanding the practice of breast-feeding. Themost successful of these were well structured,but above all, multisectoral in their approachand well coordinated among the participat-ing partners. In 1975, the Baguio Hospital inthe Philippines was an important precursor(27). Infant mortality dropped 95% at this fa-cility following implementation of a series ofactivities directly or indirectly promotingbreast-feeding, such as prohibiting the use offeeding bottles, allowing “rooming-in” of in-fants with their mothers, using breast milkfor ill or premature newborns, and providinginstructional training for the health careteam. In the hospitals and clinics wherewomen were provided with prenatal andpuerperium care, the children received post-partum care and the mothers adequate coun-seling and support for exclusive and supple-mental breast-feeding, health professionalswere able to increase breast-feeding rates.

This type of support should include, interalia, information on the best time to initiatebreast-feeding; how to properly position andlatch the baby onto the breast; the advan-tages gained from breast-feeding; the needfor feeding on demand; the drawbacks ofusing pacifiers, artificial nipples, and feedingbottles; and instruction on how to extractbreast milk manually (28).

Within a more comprehensive framework,Canada provides perhaps the best examplewith which to illustrate the evolution of a na-tional policy to promote breast-feeding (29).In that country between 1965 and 1971, only25% of mothers breast-fed their children. In1978, upon realizing the importance of secur-ing the broad-based support of physicians be-fore initiating any breast-feeding program,the respected Canadian Journal of Public Healthpublished a position paper. This was the cat-

Rea and Araújo 111

alyst for initiating a national policy to pro-mote breast-feeding. In the first phase of pol-icy development, which focused on healthprofessionals, policy planners analyzed thefactors behind the pharmaceutical industry’ssuccess in securing the endorsement and useof its products by physicians and their pa-tients. Thus, in order to “sell” the product—in this case breast-feeding—an attractive kitwas developed which included backgroundon the scientific basis for breast-feeding, in-formation on its clinical management, aposter which could be displayed in maternaland child health care facilities, and letters ofendorsement from leading scientific profes-sional associations and the country’s ministerof health. Some 62,000 kits were distributed.The impact of the kit was subsequently eval-uated, utilizing a sample of 3,000 profession-als, who indicated that the kit was useful forpurposes of self-knowledge and that theposter was effective in stimulating greater in-terest in breast-feeding issues on the part oftheir patients.

The second phase targeted first-timemothers with a booklet entitled How Breast-feeding Works, published by the CanadianAcademy of Pediatrics, La Leche League-Canada, and Health Canada. After distribut-ing some 850,000 copies, the impact of thebooklet was tested on a sample of 500 moth-ers, with a high percentage reporting that theinformation presented was new to them andthat they considered it useful. In a thirdphase of the program, films on breast-feed-ing were shown at group workshops, reach-ing a combined audience of some 150,000people. In the fourth phase, a survey wasconducted to determine the number nation-wide of children under age 2 being breast-fed. Accordingly, it was found that the 25%rate of breast-feeding between 1965 and 1971had jumped to 69% by 1982. This survey alsoincluded questions about the distribution ofinfant formula samples in maternity wardsand revealed that mothers who reported re-ceiving these samples were nearly threetimes more likely to discontinue breast-

feeding during the first month postpartumthan mothers who did not receive the sam-ples. Among the mothers who received sam-ples, 80% to 90% continued to give their ba-bies the same brand of infant formula as thesamples they had received in the hospital.The fifth phase of the policy developmentprogram was Canada’s endorsement of theInternational Code of Marketing of Breast-milk Substitutes (ICMBMS), which will be described later on in this chapter, and hospital-wide support for a policy to pro-mote breast-feeding.

Papua New Guinea is another countrythat has long recognized the need for breast-feeding promotion interventions to be sup-ported by clear policies (30). There, a school-based breast-feeding promotion campaignwas launched in response to low breast-feeding rates. Teachers were providedbreast-feeding information kits that includedaudiovisual aids and descriptions of sug-gested activities. The campaign also in-cluded radio spots and articles in the printmedia and enjoyed support from the busi-ness community, whose members wereurged to limit the sales of feeding bottles. Asa result of the campaign, it became clear thatenacting legislation in support of the inter-ventions in progress could help increasebreast-feeding rates in the country. Conse-quently, a ban on commercial advertising ofbreast-milk substitutes was enacted, as wellas regulations on the sale of feeding bottles,pacifiers, and artificial nipples. Accordingly,feeding bottles were only sold when pre-scribed by a health professional. Once thelaw had been in effect for some time, it wasobserved that feeding bottles were used onlywhen prescribed and that breast-feedingrates indeed increased.

The experiences of Canada and Papua NewGuinea offer somewhat unique glimpses intothe effectiveness of various strategies designedto increase breast-feeding rates, given that, forwhatever reason, very few studies conductedto date have attempted to evaluate the impactof specific breast-feeding promotion actions


and/or programs. In order to do this in Brazil,one such survey was administered in the met-ropolitan areas of São Paulo, in the country’ssoutheast, and Recife, in the northeast, bothprior to (1981) and six years following (1986)the launching of the country’s national breast-feeding program (PNIAM) (31). More studiesof this type are needed, for reasons we will dis-cuss later on in this chapter.

Reflecting on the circumstances surround-ing the PNIAM, both before the program ex-isted and after it was formed, and also hav-ing had the opportunity to experienceseveral such moments in the history ofbreast-feeding both from within and outsidethe country, the authors of this chapter willattempt to present a historical perspective onhow Brazil was able to achieve the dramaticimprovements in its national breast-feedingrates as described at the beginning of thischapter. We recognize, however, that someelements might be lacking due to incompletedocumentation. Consequently, the use of re-search that includes interviews with the ac-tors involved in the various phases, recordssearches in small cities, and unpublished dis-sertations and/or theses would be quite use-ful in order to shed light on unansweredquestions regarding what was done up until1989 (32).

Following a presentation of the historicalperspective, the authors will discuss the re-thinking of policies and actions to promote,protect, and support breast-feeding—poli-cies and interventions which are currentlybeing developed at the national and interna-tional levels—beginning with whether theyhave or have not been implemented, and ifnot, we describe some of the difficulties andpossible obstacles to their full implementa-tion. The influence of Brazilian policy andexperiences on the decisions taken at inter-national conferences and, likewise, the im-plementation of international recommenda-tions in Brazil, is a subject that merits furtherdebate and study by scientists and healthmanagers. For the purposes of this chapter,as mentioned earlier, the discussion of the

process in Brazil will be divided chronologi-cally into the 1970s and before, the 1980s, the1990s, and the twenty-first century.

THE 1970s AND BEFORE: CREATING AWARENESS OF BREAST-FEEDING BENEFITS

While there are no national populationstudies that document breast-feeding rates inthe decades prior to the 1970s, isolated stud-ies suggest that the practice of breast-feedingin Brazil reached an all-time low during the1970s. A review of the National HouseholdSurvey corroborates this point, indicatingthat in 1975 the median breast-feeding ratefor Brazilian women was 2.5 months (33).

A number of forces were in play duringthis period which either overtly or subtlydiscouraged the adoption of breast-feedingpractices. These included:

(1) Pediatricians with little knowledge of lac-tation management (34): In previous decades,pediatricians routinely encouraged the useof feeding bottles and individualized infantformulas, fixed breast-feeding schedules,and the administration of water and tea be-tween feedings, and they would especiallyprescribe the feeding bottle if they believed achild was not gaining weight as fast as itshould, diagnosing the problem as “hy-pogalactia.”

(2) Commercial promotion of breast-milk sub-stitutes: At the time, unethical advertising ofinfant milk and baby products (includingbaby bottles and pacifiers) were regularlyfeatured in the global mass media, and thedemand for these products was in part cre-ated through the use of clever labels featur-ing attractive, well-fed babies in pleasantsurroundings. Breast-milk substitutes (at thetime advertised as “like mother’s own milk”)were also marketed, using a variety of tacticsincluding baby beauty contests, appealingadvertising photographs, and the practice ofsupplying free milk products to the children

Rea and Araújo 113

of pediatricians. Moreover, there was no in-centive for pediatricians to promote the prac-tice of breast-feeding at learning institutionsspecializing in childhood diseases and ab-normalities, inasmuch as infant formula rep-resentatives had ready access to professorsand students at these schools, a situationwhich proved its worth over time as a highlyefficient and sustainable marketing tech-nique (35).

(3) Free distribution of powdered milk: Thispractice was almost always carried out bythe Government through what were knownas supplemental food programs, in whichmothers were entitled to receive powderedinfant formula or whole milk beginning withthe birth of the child. In 1979, there were ninesuch programs operating in the country (36).Distribution also took the form of surplusmilk donations from producer countries—this practice was particularly widespread inthe country’s northeastern states and had theeffect of causing the poorest sectors of thepopulation to become dependent on the useof mingau (a kind of gruel-like substance pre-pared with flour and powdered milk) to feedbabies; this phenomenon is well documentedin an anthropological study by NancyScheper-Hughes (37). The question ariseswhether this “mingau culture” that becameestablished in the 1970s is responsible for thelow indicators of exclusive breast-feedingthat continue to persist today in northeasternBrazil.

(4) Rigid routines in maternity wards: New-borns were kept in the nurseries (or neonatalintensive care units), and mothers weretaken to these facilities to breast-feed theirbabies at specific times of the day. Nighttimefeedings were not allowed. Maternity wardroutines also included the use of feedingpauses after the birth of the newborn and theintroduction of pre-lacteal fluids, the use offeeding bottles in the nursery, inadequate orinaccurate instructions, an excessive concernwith hygiene of the nipples, and no guidanceon how to latch and hold the baby for breast-feeding (38, 39).

In 1974, concern over premature weaningand the role of products that interfere withbreast-feeding led Pernambuco’s Minister ofHealth Fernando Figueira to ban feeding bot-tles and free milk in the state’s health unitsand maternity hospitals.4

The first study to document impropermarketing practices of breast-milk substi-tutes in Brazil appeared in 1977 (35). It de-scribed advertising techniques in use in layjournals dating back to 1916, as well as thosewhich appeared in respected scientific jour-nals such as Pediatria Prática and the Jornal dePediatria. This study clearly demonstrateshow mothers and pediatricians were beingprogressively influenced by subliminal mes-sages idealizing the use of feeding bottles aseasy and convenient—a practice pediatri-cians could manipulate to their own advan-tage by creating and then prolongingdependency by mothers on the feeding bot-tle’s use.

By the mid-1970s, international attentionhad focused on a controversial report by SouthAfrican journalist Mike Muller entitled TheBaby Killer (40), which denounced the uneth-ical promotion and sale of powdered milkproducts for infants in the Third World, par-ticularly in poor rural African communitieswhere high rates of child malnutrition andmortality presented a grave public health con-cern. This report was translated into Por-tuguese and was widely circulated in Brazil.Consequently, as part of the WHO Collabora-tive Study on Breast-feeding, the World HealthOrganization evaluated 15 companies, includ-ing Abbott-Ross, American Home Products,Wyeth, Borden, Carnation, Gerber, and Nestlé(41), who were believed to be engaging in de-ceptive promotional practices targeting physi-cians, retail businesses, and mothers of new-born children. The study shows conclusivelythat the majority of the companies wished tosidestep altogether the allegations placed be-fore them, denied any wrongdoing, and in


4Decree No. 99, published 12 March 1974 in the DiárioOficial de Pernambuco.

many cases blamed the mothers themselves formisunderstanding and/or incorrectly usingtheir products. Many company representativesalso denied an interest in competing with orencouraging the substitution of their productsfor the practice of breast-feeding, noting thattheir marketing efforts stressed the use of theirproducts only when breast milk was insuffi-cient, and emphasizing, in their own defense,that as a response to the WHO study, thesemessages were further modified to stress that“breast milk is better but . . . when breast-feeding is not possible, [product X or Y] maybe used with effective results if instructions areproperly followed.”

The information uncovered by this studyserved as a wake-up call and led interna-tional organizations to revisit their decision-making processes. For example, data col-lected in Ethiopia, India, Nigeria, and thePhilippines shed light on the enormousavailability of breast-milk substitutes mar-keted to mothers (e.g., 54 such substituteswere sold in the Philippines alone) and thehigh cost of these products (15 to 30% of percapita GDP in this same country).

In 1979, the Joint Meeting of WHO andUNICEF on Infant and Young Child Feedingwas held, which included presentations onbreast-feeding activities by participants anddiscussions among the international actors inthe field who were already concerned withthe widespread practice of early weaning.One of the recommendations from this eventcalled for the drafting of a code of ethical be-havior to guide the marketing of productswhich interfere with breast-feeding and en-courage early weaning. The Brazilian delega-tion at the Joint Meeting was headed by thepresident of the National Food and NutritionInstitute (INAN), which collaborated on thepreparation of such a code. The authors ofthis chapter feel that INAN’s contribution tothe drafting process greatly facilitated thelaunching in Brazil of its own nationalbreast-feeding program, known as thePNIAM (Programa Nacional de Incentivo aoAleitamento Materno), only two years later.

The work of the INAN team in preparingbackground material and preliminary docu-ments which were eventually incorporatedinto the International Code of Marketing ofBreast-milk Substitutes (ICMBMS) also hadinternal consequences, in the sense that it ledthe team to discuss wider strategies for ad-dressing the country’s own problem of earlyweaning. In 1980 INAN sought assistancefrom the Pan American Health Organization(PAHO) and UNICEF in the development ofa breast-feeding promotional video designedto raise awareness and stimulate supportamong key actors, including politicians, pub-lic health authorities, the mass media, com-munity leaders, and the church. The videoincluded witness testimonies from well-known pediatricians and a special messageby the country’s president, João Baptista deOliveira Figueiredo, and placed the value ofbreast milk within an economic context, ap-pealing to viewers to consider the country’svast size and population, and the economicburden placed both on mothers and thecountry of artificial milk products. The videowas shown in locales throughout the coun-try, including to a gathering of Brazil’s stateministers of health and social security, whopledged their collective support to the deci-sion to implement the PNIAM.

The experiences of Brazil during this pe-riod strongly indicate that the emergence of anational political conscience in favor ofbreast-feeding, supported by arguments putforth at the international level by partici-pants at the 1979 WHO/UNICEF Joint Meet-ing, provided an essential foundation in sup-port of local programming activities (42). Inthis sense, the policy decision taken byBrazilian authorities in 1981 to launch thePNIAM—administered through cooperationamong several government ministries andrelated agencies—might be viewed as a strat-egy that successfully capitalized on an inter-national climate increasingly favorable to thepromotion of breast-feeding. At the sametime, the policy directly addressed the publichealth sector’s concern with the country’s

Rea and Araújo 115

high early weaning rates and offered con-crete scientific and economic evidence of theneed for Brazilian mothers to return to thepractice of breast-feeding.

THE 1980s: BUILDING SUPPORT FOR A NATIONAL PROGRAM

A 1981 evaluation of breast-feeding con-ducted in the metropolitan areas of SãoPaulo and Recife revealed that the medianduration of breast-feeding was 2.8 monthsand 2.4 months, respectively, which meansthat 50% of women breast-fed for less than three months (31). Given the earlier-presented 1975 census data finding that themedian breast-feeding rate was 2.5 months,it became clear that breast-feeding rates inBrazil had changed little or not at all in theintervening six years.

In February 1981, the Government man-dated INAN, through a specially namedmanagement team and technical workgroup, to coordinate the PNIAM.5 The mostsalient activities undertaken during this timewere: (1) the provision of national coordina-tion and support for state- and community-level initiatives, (2) a mobilization of all keyactors working in the field of breast-feeding,and (3) ensuring well-organized media cam-paigns. Consequently, an evaluation of thePNIAM conducted in 1986 found that in SãoPaulo the duration of breast-feeding had in-creased from 2.8 to 4.2 months, while in Re-cife it went from 2.4 to 3.5 months. And inRecife, exclusive breast-feeding, which hadbeen extremely low in duration—only 15days—climbed to an average duration of 32days (31) when measured against compara-ble populations and instruments of data col-lection and analysis.

The social mobilization process, whichbegan with nationwide presentations of the

video described in the previous section, wasfollowed up with the first media campaign,with coverage by nearly 100 television chan-nels reaching some 15.5 million families and600 radio stations with a listening audienceof approximately 20 million households.Four print media campaigns were alsolaunched with the objective of attracting thesupport of well-known personalities withthe ability to influence public opinion. In ad-dition, over a period of 45 days, the slogan“Breast-feed your child for at least the firstsix months of life” was featured on some 10million sports lottery tickets; householdwater, electricity, and telephone bills; per-sonal bank account statements; and othersimilar types of commercial documents. Sev-enteen radio spots, each focusing on a differ-ent aspect of the disadvantages of earlyweaning, were developed and disseminated,and the scripts of these were also recordedfor distribution via some 9,000 public ad-dress systems in use at formal and informalcommunity gatherings. This phase of thecampaign also included the printing of some1.5 million instructional brochures for moth-ers and 400,000 pamphlets for health profes-sionals, in addition to an illustrated breast-feeding training manual targeted to thislatter group.

By the end of 1981, the goal of setting upan office in each of the Brazilian states, whichcould in turn coordinate the work of locallybased agencies and other groups involved inthe program, had been achieved. This suc-cess was largely attributable to the high pro-file role played by the Catholic Church, theliteracy movement, mothers’ groups, andprofessional associations such as the Brazil-ian Federation of Gynecology and Obstetricsand the Brazilian Society of Pediatrics, thelatter of which secured a place for the issueof breast-feeding on the agendas of its scien-tific congresses and related events, providedfree space in the Society’s journal and otherpublications, and utilized its professionalnetwork to distribute more than 70,000copies of print materials to its members.


5Established by Decree 10/02/1981, published in theDiário Oficial da União.

The exact number of events held duringthe social mobilization process, as well as thenumber of participants involved in their or-ganization and mothers and other familymembers who directly benefited from them,will perhaps never be known. What isknown is that prior to the social mobilizationcampaigns, uniform standards and method-ologies related to breast-feeding were basi-cally nonexistent, as were reliable instruc-tional materials. Among the very few textsexisting in Portuguese (albeit not formallypublished until a while later) was one byMurahovski et al. (43) based on a pioneeringteaching project on breast-feeding in Santos.

With support from UNICEF, two nationalsurveys were conducted. The quantitativesurvey provided the PNIAM with basicdata—some of which have already beencited in this chapter—on the situation ofbreast-feeding in Brazil (34), and the qualita-tive survey sought to determine the most ef-fective ways in which awareness campaignsin the future could reach mothers and healthprofessionals with well-designed messagesto counter early weaning practices.6

Following the PNIAM’s launching, theMinistry of Social Security instituted a seriesof changes in hospital and delivery care poli-cies, including that of a “rooming-in” policywhich would allow mothers and their new-borns to stay in the same room together. Asnoted earlier, prior to this time, maternitywards generally observed rigid routineswhich included physically separating themother and child during postpartum care,using serum dextrose as a routine prelactealfood product, imposing specific times forbreast-feeding, and other similar measuresindicative of inadequate clinical lactationmanagement (34). Thus, for its time, theadoption of a mother-child rooming-in pol-icy represented an enormous departure fromtraditional health care practices.

Policies designed to protect breast-feedingpractices began to emerge during the 1980s,

supported and strengthened by Brazil’s ap-proval of the ICMBMS at WHO’s Thirty-fourth World Health Assembly in May 1981and the Government’s adoption of the Codeas official law. Of particular concern were theproblems of working mothers and the tangi-ble benefits they and their young childrencould reap as the result of national regula-tions safeguarding their health.

Even prior to the national Code’s adop-tion, and certainly more systematically onceit took effect, infant milk product companieshad fallen under intense pressure from advo-cates of the International Baby Food ActionNetwork (IBFAN)7 to modify infant formulalabels and to halt their unethical marketingpractices. The membership of the initialBrazilian IBFAN chapter, which began its ac-tivities in 1983, was small and perhaps forthis reason, it was difficult for the group tomonitor marketing practices in any compre-hensive fashion. On the other hand, in lightof IBFAN’s international boycott on Nestléinfant milk products and the fact that thiscompany held a virtual monopoly on sales ofinfant formula in Brazil, the country reapedindirect benefits, since Nestlé formula labelsand its advertising techniques were modifiedhere as well (44). Initially, this boycott wascalled off following a 1984 meeting in Mexicoafter Nestlé agreed to abide by the Code’s re-quirements and was monitored closely for aperiod of six months by the InternationalNestlé Boycott Committee in eight differentregions around the world.

Between 1982 and 1983, a second massmedia breast-feeding promotion campaignwas launched in Brazil. Building on the expe-riences of the 1981 campaign and mindful offindings emanating from the quantitative andqualitative surveys conducted that same year,the campaign included a strategic planning

Rea and Araújo 117

6Unpublished data.

7A network of NGOs and individuals formed in 1979in Geneva, Switzerland, for the purpose of defendingbreast-feeding from abusive marketing practices bymanufacturers of breast-milk substitutes.

component.8 Since the quantitative surveyhad shown that some 85%–90% of mothersinitiated breast-feeding (34), the campaignwas able to design well-targeted messageswhich, instead of urging women to merelybreast-feed their newborns (such as wouldhave been the case, for example, in the UnitedStates, where less than 60% of mothers initi-ated breast-feeding), encouraged women tosupport the practice in general, and, specifi-cally, its continuation, through such slogans as“Breast-feeding: Keep it up; every womancan!” At the same time, in addressing thecauses of early weaning, the campaign reliedon information gathered from the qualitativesurvey, which revealed that women who be-lieve their milk to be “weak” were prone toanxiety and thus to introduce early comple-mentary feeding with the feeding bottle;other women feared their breasts would sagas a consequence of breast-feeding; while stillothers felt that working outside the homewould preclude the possibility of being ableto continue breast-feeding; and finally, somewomen believed in following the instructionsof their pediatricians, whose formal trainingduring this period had focused more on howto prescribe infant formula than on clinicallactation management and imparting thisknowledge to their patients. Special messagesresponding to these concerns were incorpo-rated into five television and radio public ser-vice announcements presented by popularBrazilian personalities of the entertainmentindustry, all of whom donated their time andfees to the campaign.

The country’s top three television net-works ran these promotional spots duringcommercial breaks; they were also featuredprominently in conjunction with Brazil’smost-watched television soap opera. Thiscoverage reached an approximate viewingaudience of half a billion in São Paulo and

169 million in Recife,9 as well as similarlylarge numbers in other Brazilian cities. It isworth noting that during this period, therewas no advertising of infant formula; on theother hand, commercials for Nestlé babyfood were frequently broadcast, as werethose for a variety of feeding bottles and ar-tificial nipples; also seen sporadically werecommercials for the locally produced Ninhobrand of fluid milk used in the preparationof homemade infant formula.

Campaign planning activities also in-cluded the distribution of a breast-feedingpromotional background kit to print journal-ists, whose interest in the topic resulted inthe publication of 78 articles in popular mag-azines between 13 February and 27 March1983 in 25 Brazilian cities.10

In the months following the second cam-paign, a series of events occurred. In Decem-ber 1983, weakened coordination promptedthe Ministry of Health to rescind the pro-gram status of breast-feeding promotion in-terventions, including them instead as activ-ities within the Ações Integradas de Saúde(Integrated Health Actions) structure. On theother hand, between 1984 and 1986, a num-ber of breast-feeding promotional activitiescontinued to be organized at the level of theindividual Brazilian states. During this sameperiod, UNICEF also began shifting its prior-ities toward the GOBI (Growth, Oral Rehy-dration, Breast-feeding, and Immunization)primary child health interventions.

In 1985, INAN and the Fernandes FigueiraInstitute of Rio de Janeiro worked together to found a number of human-milk banks(HMBs), which prior to this time, had existedin only a handful of the country’s hospitals.

At the international level, a milestone inthe history of breast-feeding took place in1986, when the Thirty-ninth World HealthAssembly issued a resolution to clarify Arti-cle 6 of the ICMBMS. It stated that “Since the


9Castelo Branco Media Department, undated document.10Jelliffe EFP, Jelliffe DB. The Brazilian National Breast-

feeding Program. 1983 trip report.

8Erica Witte, member of the public relations team re-sponsible for the campaign, in a videotaped speech enti-tled “Breast-feeding: Who Wins, Who Loses” (IBFAN,Brazil, 1989, directed by S. Afran).

large majority of infants born in maternitywards and hospitals are full term, they re-quire no nourishment other than colostrumduring their first 24–48 hours of life . . . ” andthat “only small quantities of breast-milksubstitutes are ordinarily required to meetthe needs of a minority of infants in these fa-cilities, and they should be available in waysthat do not interfere with the protection andpromotion of breast-feeding for the major-ity.” The resolution urged WHO MemberStates to “ensure that the small amounts ofbreast-milk substitutes needed for the minor-ity of infants who require them . . . are madeavailable through the normal procurementchannels and not through free or subsidizedsupplies.” Finally, in reference to formulasthen being marketed for children over 6months of age, the resolution noted: “thepractice being introduced in some countriesof providing infants with specially formu-lated milks (so-called ‘follow-up milks’) isnot necessary.”

The final years of the 1980s represented aperiod of renewed program coordinationand the final stages of activity implementa-tion by various technical committees whosework had focused on specific breast-feedingissues since the PNIAM’s inception. Accord-ingly, in 1987, primary emphasis was placedon the ICMBMS Committee, the Human-milk Bank Committee, the Committee onWorking Women, the Education Committee,and the Community Committee. The resultswere decisive and in 1988 laid the founda-tion for at least four breast-feeding promo-tion policies: in December, Brazil approvedits own version of the ICMBMS, known as the Marketing Regulations for InfantFeeding Products (NBCAL), and issued a comprehensive government directive es-tablishing the operating requirements for the country’s HMBs. Another landmarkachievement for the breast-feeding promo-tion movement was the incorporation intothe new Brazilian Constitution of two newbenefits in support of breast-feeding: theright of workers to four months of maternity

leave in order to facilitate exclusive breast-feeding, and the right of fathers to five daysof paternity leave in order to provide sup-port during the critical period following themother and child’s release from the healthcare facility and return home.

In May 1988, the Ministry of Health issueda series of regulations regarding health stan-dards for HMBs and providing for technicaltraining of staff at these facilities. The regula-tions also transformed the first of the coun-try’s HMBs, established at Rio de Janeiro in1943, into a national reference center respon-sible for coordinating the development andsurveillance of HMBs. It is also worth notingthat the coordinating team, beyond merelyestablishing HMBs for local collection, pro-cessing, and storage of breast milk for distri-bution to needy newborns, also utilizedthese facilities as centers for breast-feedingpromotional activities. Over time, many ofthe HMBs came to be known as Breast-feeding Promotion Centers and continue tooperate under this name until today, utiliz-ing and reinforcing the same philosophyunder which they were originally created.

In 1989, WHO and UNICEF drafted a doc-ument that today plays a crucial role in allprogramming activities for work in the areasof prenatal care and the initiation and contin-uation of breast-feeding. The Joint WHO/UNICEF Statement on Protecting, Promot-ing, and Supporting Breast-feeding: The Spe-cial Role of Maternity Services (45) set out aseries of recommendations entitled “TenSteps to Successful Breast-feeding,” whichtogether summarize the essential measuresto be taken by health care facilities. These in-clude the preparation of a written breast-feeding policy and training of all staff for thepolicy’s implementation. Following thistraining, health care providers would be re-sponsible for informing all pregnant womenabout the benefits and management ofbreast-feeding; helping mothers to initiatebreast-feeding within half an hour of birth;showing them how to breast-feed and howto maintain lactation even if they should

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be separated from their infants; facilitating24-hour rooming-in of mother and child;encouraging breast-feeding on demand; dis-couraging the use of bottles, artificial nip-ples, and pacifiers; and fostering the estab-lishment of breast-feeding support groupsand referral of mothers to these followingtheir hospital or clinic discharge. Inasmuchas there were no international guidelines inplace during this period for the training ofpersonnel on breast-feeding practices andprenatal and delivery routines, the WHO/UNICEF initiative filled a very importantvacuum in the community of public and pri-vate health care professionals.

THE 1990s: GLOBAL POLICY FUELS LOCAL ACTION

The earlier-cited meta-analysis conductedby Feachem and Koblinsky in 1984 (3), as wellas the Victora et al. study (4), both clearlydemonstrating the significant boost to healthafforded to children by mothers who had ex-clusively breast-fed them during the initialmonths of life, had been widely disseminatedin Brazil by the early 1990s. By this time, themessage regarding the benefits of breast-feeding was very clear: exclusive breast-feeding (i.e., feeding with breast milk exclu-sively and no other liquids, including water ortea) from birth through 4 to 6 months of ageprotected children against diarrheal diseases,respiratory infections, and other infectious dis-eases. This knowledge, as reflected in the lit-erature of this period, could now be used as thefulcrum for creating new indicators, recom-mendations to physicians, messages to moth-ers and their families, and indeed for retool-ing the organic content of breast-feedingpromotion programs themselves.

At the close of the 1980s, and armed withthis new knowledge, authorities at WHO,UNICEF, and a variety of bilateral and tech-nical organizations came together to formu-late a strategy that would take stock of thevarious determining factors interfering in the

practice of exclusive breast-feeding andwould revisit programs that had been partic-ularly effective in promoting the practice. Asa result of this effort, the Interagency Groupon Action on Breast-feeding (IGAB) was cre-ated. The IGAB promoted a series of specifictechnical meetings with the objective of gain-ing better insight into how these determiningfactors function. Meetings were organized tofocus on such topics as health services andhospitals; mothers’ and community groups;training, communication, and education; theICMBMS; and the situation of the workingwoman, the latter of which was held in Brazilin March 1990. This process culminated withthe production and adoption of the InnocentiDeclaration on the Protection, Promotion,and Support of Breast-feeding by partici-pants at the WHO/UNICEF policymakers’meeting on “Breast-feeding in the 1990s: AGlobal Initiative” held in Florence, Italy, on30 July–1 August 1990. Among those invitedto share their experiences in the develop-ment of breast-feeding promotion programswere Brazil and the president of INAN.

Why is the Innocenti Declaration important?In contrast to previous international documentsthat had been produced by health authorities,it was the fruit of a long and highly participa-tory process of analysis and resulted in clearlydefined goals and operational targets to bereached by the countries over the next fiveyears. Essentially, the Declaration recom-mends supporting and promoting the decisionof women to exclusively breast-feed during thefirst four to six months of the child’s life andto continue breast-feeding with appropriateand adequate complementary foods for up to2 years of age or beyond. The Declaration rec-ommended four primary strategies to achievethese ends by the year 1995: (1) the appoint-ment of a national breast-feeding coordinatorof appropriate authority and the establishmentof a multisectoral national breast-feedingcommittee composed of relevant governmententities, NGOs, and health professional asso-ciations; (2) ensuring that every health facilityproviding maternity services fully practiced all


of the WHO/UNICEF-recommended “TenSteps to Successful Breast-feeding”; (3) takingthe necessary action to give effect to the prin-ciples and aim of all articles of the ICMBMSand subsequent relevant World Health Assem-bly resolutions in their entirety; and (4) enact-ing “imaginative legislation” protecting thebreast-feeding rights of working women and establishing the adequate means for itsenforcement.

It is important to note that at the time ofthe Declaration, exclusive breast-feeding wasrecommended for the first four to six monthsof life, as there had been no well-developedstudies conducted to document the effects ofan exclusive diet of breast milk during theentire first six months of life in terms of ade-quate child growth and nutrition, nor hadthe benefits of such breast-feeding beenrecognized in terms of child morbidity/mortality and the health of the mother. Or,said another way, the great majority of revo-lutionary research findings regarding thebenefits of breast-feeding to the child (3–12)described in this chapter’s Introduction didnot emerge until later on during the 1990s,and much of the information regarding thepositive effect of breast-feeding on themother’s health (13–26) is even more recent.For these reasons, the recommendation of ex-clusive breast-feeding for the first six monthsof life (i.e., versus four) came about only aftera 2000–2001 literature review of over 3,000references (2) and a WHO technical evalua-tion on the subject (1).

In September 1990, the World Summit forChildren, attended by heads of state andgovernment, representatives from a varietyof United Nations agencies, and a large num-ber of international NGOs, was held in NewYork City. In the area of nutrition, the goalsestablished for the decade called on govern-ments to guarantee the “empowerment of allwomen to breast-feed their children exclu-sively for four to six months and to continuebreast-feeding, together with complemen-tary food, well into the second year”; guar-antee by 1995 that 50% of hospitals attending

1,000 or more childbirths per year receiveBaby-friendly Hospital certification; and toend the practice of distributing breast-milksubstitutes at health service facilities (46).These goals were also designed to facilitatework on reaching year-by-year targets, andthis process, in turn, provided feedback onhow well the PNIAM was working towardthe achievement of all its goals and indicatedareas requiring special efforts.

In Brazil, the 1990s were a time character-ized by the ongoing implementation and con-solidation of actions that had been previouslyunderway, but more importantly, by the large-scale training of health professionals and theinitiation of other supporting and awareness-raising activities, such as the Baby-friendlyHospital Initiative (BFHI), commemoration ofWorld Breast-feeding Week, the Friendly Post-man Breast-feeding project (described later onin this section), the Firefighters for Life proj-ect (described in this chapter’s section on thetwenty-first century), and a series of breast-feeding surveys.

In 1991, WHO and UNICEF launched theBFHI in an effort to transform practices inmaternity hospitals worldwide and to facili-tate breast-feeding by ensuring that womenin maternity care have full information andsupport to breast-feed their infants in an en-vironment free of commercial influences.Health facilities seeking BFHI accreditationwere required to follow the organizations’“Ten Steps to Successful Breast-feeding”guidelines, the most stringent of which wasthat they were “under no circumstances [to]provide breast-milk substitutes . . . free ofcharge or at low cost.” The Initiative createdthe very first international evaluation refer-ent solely for hospitals, which contributed tothe humanization of maternal and child pub-lic health care (47).

In March 1992, the Ministry of Health,working through the PNIAM/INAN and the Grupo de Defesa da Saúde da Criança, andwith technical and financial support fromUNICEF and PAHO, began taking the initialsteps to implement the BFHI in Brazil.

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In June 1994, the Ministry of Health11 stan-dardized the public hospital accreditationprocess for Baby-friendly Hospital (BFH)certification. In 1996, the PNIAM added fiveadditional requirements for BFH hospitalcertification to be used as indicators to mea-sure the quality of maternal and child healthcare at the given facility. To the best of theknowledge of the authors of this chapter,Brazil is the only country in the world thatrequires a pre-evaluation phase of com-pliance with the “Ten Steps to SuccessfulBreast-feeding” guidelines, the fulfillment ofadditional requirements as part of the Baby-friendly Hospital certification, and is also theonly country, as far as the authors have beenable to ascertain, that provides financial in-centives to certification as a Baby-friendlyHospital (48).

The certification process is relativelystraightforward, yet thorough. A hospitalseeking BFH status must first fill out a self-evaluation questionnaire, the request forwhich must be initiated by the pertinenthealth authorities. Immediately thereafter,these authorities send an evaluator certifiedby the Ministry of Health at the state level toconduct a pre-evaluation of the hospital andthen present an analysis of the findings.When the results of the hospital’s pre-evaluation are deemed to be acceptable, theevaluator will recommend that the Ministryconduct a comprehensive evaluation of thehospital, to be carried out by two indepen-dent, certified evaluators from outside thearea where the hospital is located. The resultsof the comprehensive evaluation are thenforwarded to authorities at the Ministry ofHealth’s breast-feeding coordination unit forfinal analysis and dissemination of the re-sults. As previously noted, hospitals wishingto receive BFH certification must first com-ply with all of the “Ten Steps to SuccessfulBreast-feeding” by fulfilling at least 80% ofthe extended global criteria established by

WHO and UNICEF for each of the 10 steps.Once a hospital has completed the certifica-tion process and has satisfactorily met all thenecessary criteria, it receives a placard bear-ing a reproduction of Pablo Picasso’s 1963painting Maternité, which is the internationalsymbol and logo of the BFHI. In most in-stances, a special commemorative ceremonyis organized in which the placard is awardedby the pertinent local and federal authoritiesto the hospital (48, 49).

In the event that the institution in ques-tion does not meet the criteria of a givenstage (i.e., the pre-evaluation or comprehen-sive evaluation), it is provided guidelines toassist it in achieving compliance with thatstage, and a new timeframe is then estab-lished for the next evaluation.

In 1999, seven years after the BFHI’s im-plementation in Brazil, questions arose re-garding the quality, effectiveness, and sus-tainability of this strategy. In response to thissituation, the Ministry of Health reevaluated137 Baby-friendly Hospitals, which ac-counted for 90% of the total 152 BFH-certified institutions operating in the countryat the time (50). Given that no suitablestandardized instrument for BFH reevalua-tion existed at the time, the hospital pre-evaluation instrument was used instead. Thestudy identified some compliance-relateddifficulties regarding the BFHI “Ten Steps,”especially Step 5 (“Show mothers how tobreast-feed and how to maintain lactationeven if they should be separated from theirinfants”), followed by Step 10 (“Foster theestablishment of breast-feeding supportgroups and refer mothers to them on dis-charge from the hospital or clinic”) and Step 2(“Train all health care staff in skills necessaryto implement this policy”). The Ministry ofHealth’s BFHI reevaluation revealed that92% of the 137 hospitals continued to complywith the “Ten Steps” at the desired level ofquality, thus ensuring the right of children tohave access to breast milk. The reevaluationprocess proved to be essential as a means forverifying the BFHI’s effectiveness and conti-


11Decrees # 1.113 and 155.

nuity, thus guaranteeing that the actionstaken were helping to achieve the expectedresults and objectives and were identifyingareas requiring adjustment, which, in turn,helped health services further the PNIAM’soverarching objectives.

In 1992, the Mother and Child Institute ofPernambuco, located in the city of Recife,was the first hospital to receive BFH certifica-tion. Subsequently, four hospitals were certi-fied in 1993, followed by eight more in1994—or double the number of the previousyear. In 1995, the number of BFH-certifiedhospitals tripled to 26. In 1996, a total of 39hospitals were certified, whereas in 1997there were only 16, due to a sharp drop in ap-plications for comprehensive hospital evalu-ations. In 1998, another 20 hospitals receivedBFH certification, followed by 26 more in1999 (48). In that same year, the results of ahospital reevaluation caused one Baby-friendly Hospital in the state of Rio Grandedo Norte to lose its accreditation. PerhapsBrazil’s vast size and the BFH’s strict evalua-tion criteria can help explain the slowdownin BFHI hospital certification, which fell offin 1997 after the addition of the five new cer-tification requirements. A 1998 study con-ducted in 45 noncertified maternity hospitalslocated in São Paulo revealed that about one-quarter of the public hospitals and one-thirdof the private hospitals failed to comply withany of the BFHI’s “Ten Steps.” Only twopublic hospitals had adopted at least sevenof the “Ten Steps.” The study concluded thatpractices detrimental to the initiation and es-tablishment of breast-feeding, such as sepa-rating the mother and baby after childbirthand the widespread use of infant prelactealproducts and supplements, continued to beobserved frequently—and at high levels—inSão Paulo area hospitals (51).

If new maternity hospitals had continuedto be certified at the rate seen in 1995, Brazilwould have likely had on the order of 400BFH-certified hospitals by 2000. At 1990s’World Summit for Children, the country hadcommitted itself to the goal of BFHI certifica-

tion of up to 50% of its hospitals with obstet-ric beds and more than 1,000 births per yearby 1995 (48). Yet, given the enormous num-ber of maternity hospitals in Brazil, maternaland child health advocates knew even then,at the time of the Children’s Summit, that thecountry, in realistic terms, would most likelyachieve this goal for closer to 15%, versus50%, of the hospitals in the country. Conse-quently, planning in this regard had to bereadjusted, as will be discussed in the nextsection of this chapter.

Concerned that the policies agreed uponat the beginning of the 1990s and the cru-cially important goals related to them mightnot be implemented—not only in Brazil butin other countries around the world aswell—UNICEF, various NGOs (IBFAN, LaLeche League, the International LactationConsultant Association, and Wellstart Inter-national, among others), and leading breast-feeding experts and maternal and childhealth advocates came together to create theWorld Alliance for Breast-feeding Action(WABA) in February 1992. This coalitionproved instrumental in mobilizing the par-ticipation of key groups and individuals dur-ing World Breast-feeding Week (WBW), cele-brated each year during the first week ofAugust, who in turn utilized the opportunityto highlight and reinforce a variety of mes-sages regarding such issues as the BFHI, thesituation of working women, education onthe importance of breast-feeding, and theICMBMS. Today in Brazil, WBW is cele-brated in communities large and smallthroughout the country, thereby fulfilling inletter and spirit the social mobilization rolefor which the commemoration was origi-nally created (52).

Prior to 1995, WABA served as the coordi-nator of activities commemorating WorldBreast-feeding Week, after which time theMinistry of Health took over the productionof all campaign materials, gearing them toadhere to WABA’s specific internationaltheme chosen for each year’s observation. Aspart of the activities of the 1996 WBW, a part-

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nership known as the Friendly PostmanBreast-feeding project was established withthe postal service, initially in the state ofCeará. By 1999, the Ministry had imple-mented this project in nine states of the north-east. As part of the initiative, letter carriers re-ceive training from health units to enablethem to answer basic questions related tobreast-feeding. At the beginning of WBW andcontinuing throughout the entire month, theywear specially designed yellow vests embla-zoned with promotional messages and dis-tribute an informational booklet to the homesof expectant mothers and those with youngchildren along their delivery routes (53).

In the mid-1990s, WHO and UNICEFlaunched a set of four training courses onbreast-feeding targeting different popula-tions: an 18-hour course on “Baby-friendly”certification for hospital teams; an 80-hourtraining course for facilitators of breast-feeding courses; a 40-hour counseling coursefor those who have direct interaction withmothers and babies; and a 12-hour awareness-raising course for health care managers and su-pervisors. All of these materials were translatedinto Portuguese at the initiative of the Brazil-ian IBFAN network and were subsequentlyused by the Ministry of Health.

By the late 1990s, human resources train-ing had become one of the most importantactivities of the PNIAM. Stemming frommanagement efforts initiated in 1998, plan-ning was based on well-defined goals and re-sources, which included reevaluating the ef-fectiveness of the various componentssupporting the PNIAM, including WBW,BFHI-related training, and compliance withICMBMS, among others. Outgrowths ofthese activities included a training course forHMB personnel and another on NBCAL, theBrazilian version of the ICMBMS, offered byIBFAN members. This high level of activityresulted in the training of more professionalsbetween 1998 and 2002 than at any othertime previously in the history of the PNIAM.

Public health authorities responsible forthe surveillance of proper food labeling and

advertising, personnel working in the fieldof consumer protection, and staff of the attor-ney generals’ offices at the state level were allinvited to undergo NBCAL training. Thesetraining courses were held between 1999 and2000, and included a practical compliancemonitoring component, which, for the firsttime, provided the Ministry of Health withdata that would allow it to determine levelsof compliance with NBCAL by the babyfoods and products industry in its advertis-ing and marketing of baby foods, pacifiers,artificial nipples, and feeding bottles.

The 1999 National Survey on the Preva-lence of Breast-feeding, carried out by theMinistry of Health in all the Brazilian statecapitals and in the Federal District, analyzeda sample of 48,845 children under 1 year ofage. The results of this study showed thatduring the first month of life, 53.1% of chil-dren in the areas studied were breast-fed ex-clusively, whereas rates of exclusive breast-feeding fell off sharply thereafter, down to9.7% in the interval between 151 and 180days. With regard to the timely use of com-plementary feeding (breast milk with the ad-dition of complementary foods between 6and 9 months of age), 48.9% of the childrenstudied received complementary feeding atthe appropriate time. In the 9- to 12-monthage group, only 44.2% of children continuedto be breast-fed.12

THE TWENTY-FIRST CENTURY:RESPONDING TO THE

REMAINING GAPS

Since 1999, and with support of a legalconsultant from the Office of the AttorneyGeneral of the Federal District, the Ministryof Health has opened an ongoing dialoguewith the baby foods and products industryand has established fines and other punitivemeasures to be applied to those companiesfound in violation of any of the articles of


12Ministry of Health, unpublished data, 1999.

NBCAL, which are considered as law. Thiscoordination among governmental entitiessignified a critical juncture in and of itself, inthe sense that it pointed out the need to re-vise the NBCAL a second time (its first revi-sion had been in 1992). The Code was re-formed between 2000 and 2001, and resultedin the publication of new, more comprehen-sive and detailed decrees. Following publica-tion of the second revision of NBCAL, in2002, the Ministry of Health, in conjunctionwith the IBFAN network, developed an up-dated course to prepare new trainers and toprovide refresher training for food safety in-spectors and public health professionals.

Baby-friendly Hospitals accreditation,which had fallen to its lowest point in 1997,perhaps due to the addition of the five newrequirements, subsequently experienced arecovery and then an upward trend. In 2001the Ministry of Health decided to implementa program of systematic reevaluations ofBaby-friendly Hospitals13 every three years,to be performed by Ministry-certified exter-nal evaluators applying a reevaluation in-strument that had been developed byUNICEF for this purpose.

Planning efforts designed to speed up BFHaccreditation in Brazil included developmentof a 42-course intensive training program onthe BFHI, in which 1,819 health administra-tors and unit managers from 859 hospitalsand maternity wards in 24 states participatedbetween 2000 and 2002 (50). The training se-ries culminated with the drafting by traineesof a specific plan of action for the implemen-tation of the BFHI at the hospitals under theirresponsibility. Approximately one year fol-lowing the training, participants would thenmeet with local Ministry of Health personneland technical experts to discuss and completea special written form based on the “TenSteps to Successful Breast-feeding” and thecountry’s five additional BFH requirements.By ascertaining whether each of the steps and

requirements had been achieved, partiallyachieved, or not achieved, participants werebetter able to focus on specific compliance-related difficulties, which in turn facilitated aprocess of mutual support and joint problem-solving (50).

In 2002, an additional 57 hospitals re-ceived BFH certification, which by Decemberof that year brought the total number to 258Baby-friendly Hospitals distributed among24 Brazilian states. That year also marked thehighest number of BFH certifications securedto date, an achievement most likely due, atleast in part, to the positive role played bythe training and follow-up meetings betweenhospital administrators and unit managerswith the BFHI review teams. Meetings of thistype were held in 18 different states andproved their ability to help accelerate theBFH certification process by providing valu-able feedback and support to hospital ad-ministrators and unit managers for overcom-ing the remaining obstacles in their path toofficial certification (50).

There is no uniform geographical distri-bution of Baby-friendly Hospitals in Brazil,perhaps due to varying degrees of motiva-tion among the regional teams and their levelof organizational capacity. However, accord-ing to a 2003 study, the highest concentrationof BFHs is found in the country’s northeast,where 48% of hospitals have received certifi-cation, followed by the southeast (17%), thesouth (17%), central-west (13%), and north(5%). Of these hospitals, 47% are public, 34%are philanthropic, 9% are private, 8% areteaching hospitals, and 2% are military (50).

The same study revealed that only 163 ofthe 630 hospitals with more than 1,000 child-births per year had BFH certification, equiv-alent to 26% of the goal set for 1995. OfBrazil’s 27 states, only seven were able tomeet that goal. The other states did notachieve certification of 50% of their hospitalswith more than 1,000 childbirths per yearuntil December 2002. This study under-scored the need to rethink strategies andplan new types of interventions. Neverthe-

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13Ministry of Health Decree No. 29 of 22 June 2001.

less, for a number of reasons that have notyet been sufficiently analyzed, certificationdropped off in 2003 and 2004: only 290 hos-pitals had received BFH certification by theend of 2003, and only 300 by July 2004. Inother words, considering that in 2004 therewere more than 3,000 hospitals with mater-nity beds in the country, less than 10% of thecountry’s maternity hospitals had receivedBFH certification.

The growth of the network of HMBs,which currently number 160, has been re-markable in recent years, especially due toteam monitoring and training in all parts ofthe country. Each year, there are approxi-mately 44,500 preterm and 187,000 low-birthweight babies born in Brazil (i.e., morethan 230,000 babies), in addition to thoseborn with various other types of conditions,including children of HIV-infected mothers(the latter currently representing less than1% in Brazil). During 1999 alone, the HMBsbenefited approximately 100,000 children,while in 2000 some 60,000 registered donorsgave on the order of 79,000 liters of breastmilk. Despite these numbers, this networkstill has much work to do in order to meetongoing demand, even though home collec-tion of donations of surplus milk hasincreased significantly in states where theFirefighters for Life project has been imple-mented. In this project, firefighters receivetraining to encourage the donation of sur-plus breast milk, answer basic questions, andoffer advice to donor mothers on problemsassociated with breast-feeding, such asproper hygiene for the extraction and storageof breast milk donated to HMBs. In 1997, ofthe 12,203 liters of breast milk collected inone Brazilian state, 8,242 liters were collectedby local fire stations (50). In 2002, the Min-istry of Health organized the first-ever na-tionwide seminar for Firefighters for Life,which included the participation of firefight-ing managers from every corner of the coun-try. One objective of the gathering was toraise awareness among firefighters andencourage firehouses in every state and com-

munity to adopt and participate in the proj-ect. Just as the popularity of these commu-nity partnerships increases, there is a grow-ing need to evaluate their impact at the local,state, and national levels.

Premature or low-birthweight babies bornto HIV-infected mothers can receive pasteur-ized milk from the HMBs; however, due tocurrent supply constraints, no pasteurizedbreast milk is available for such babies whenthey are of normal birthweight or born toterm. Consequently, Brazil’s HIV/AIDS pol-icy on the feeding of these newborns recom-mends no breast-feeding and the use of in-fant formula distributed by the Governmentfree of charge through the first six months ofthe child’s life and thereafter the use of dis-tributed whole milk.

Since 2001, efforts have been stepped upto encourage countrywide participation bylocal branches of the national postal servicein activities held in conjunction with WorldBreast-feeding Week. In 2002, nearly 23,400letter carriers received training on how to ef-fectively communicate basic messages re-garding the importance and advantages ofbreast-feeding to family households alongtheir regular mail routes. As in the case of theinitiatives utilizing the country’s firefighters,the impact and scope of those involving thepostal service remain unevaluated to date(53), even though these activities haveshown promising initial results. During 2002it was estimated that some 3.4 million expec-tant mothers and children under 1 year ofage benefited from them.

Between 2001 and 2002, the Ministry ofHealth launched a new breast-feeding pro-motion project, entitled the Iniciativa UnidadeBásica Amiga da Amamentação (Friends ofBreast-feeding Health Units Initiative) orIUBAAM, as a means of promoting, protect-ing, and supporting breast-feeding throughthe country’s basic health units, with theend-goal of each adopting the precepts of the BFHI’s “Ten Steps to Successful Breast-feeding.” This initiative is yet another activ-ity that the basic health units, in conjunction


with hospitals, can undertake to consolidatebreast-feeding as a universal practice, and atthe same time it enables them to make theirown significant contribution to the healthand well-being of the mothers and babiesunder their care. The “Ten Steps to Success-ful Breast-feeding of the IUBAAM” were de-veloped on the basis of a systematic review(54) that included experimental and quasi-experimental interventions conducted aspart of prenatal care and during the monitor-ing of the mother and baby, and proved to bean effective tool for extending the duration ofbreast-feeding. While based on the BFHI“Ten Steps,” the IUBAAM version substi-tutes Step 4’s hospital version (“Help moth-ers initiate breast-feeding within half an hourof birth”) with “Listen to the concerns, expe-riences, and doubts of pregnant women andmothers regarding the practice of breast-feeding, and strengthen their self-reliance,”and Step 7’s 24-hour rooming-in hospitalpractice with “Instruct nursing mothers onthe lactation amenorrhea method and othercontraceptive methods compatible withbreast-feeding.”

IUBAAM implementation, in addition toproviding benefits for mothers and childrenaccessing care from the basic health care net-work, will also strengthen Brazil’s BFH-certified hospitals, inasmuch as basic healthunits with “Friends of Breast-feeding” certi-fication can become references for the hospi-tals, in terms of complying with Steps 3 (“In-form all pregnant women about the benefitsand management of breast-feeding”) and 10(“Foster the establishment of breast-feedingsupport groups and refer mothers to them ondischarge from the hospital or clinic”) of theBFHI. As earlier mentioned in this chapter,the 1999 BFH reevaluation brought to lightdifficulties in compliance by hospitals withseveral of the steps. If implemented properlyas an official Government program, the Min-istry of Health and breast-feeding consul-tants feel that the IUBAAM initiative (oper-ating in only one Brazilian state as of thewriting of this chapter) and the ongoing BFH

certification process can serve as mutuallybeneficial reinforcing agents in consolidatingthe achievements to date of Brazil’s PNIAM.

THE FUTURE OF BREAST-FEEDING

As the world approached a new millen-nium and the Innocenti Declaration its 10thanniversary, the international organizationscommunity recognized the need to revisit thegoals of the Declaration and, in 2002, to re-think what became known as the GlobalStrategy for Infant and Young Child Feed-ing.14 The foundation of this strategy is thereaffirmation of the Declaration’s basictenets; i.e., the need to promote, protect, andsupport exclusive breast-feeding for sixmonths as a global public health recommen-dation and to seek optimal ways in which tointroduce safe and appropriate complemen-tary feeding, without interruption of breast-feeding, until at least the second year of lifeor beyond. The strategy also encompassesthe great challenge of the first years of thiscentury, which is how to implement thesetwo recommendations for groups with spe-cial needs, including HIV-infected mothers;families living in emergency situations, suchas natural disasters, famine, and civil unrest;families living in refugee settings; and moth-ers and their children facing other types ofexceptionally difficult circumstances.

Some organizations have already steppedup to this challenge: WHO and UNICEFhave developed a counseling course on in-fant feeding for HIV-infected mothers;whereas UNAIDS, WHO, and UNICEF haveprepared materials on HIV and infant feed-ing, how to approach breast-feeding andbreast-milk substitutes in emergency situa-tions, and practical advice and tips on com-plementary feeding.

In Brazil, messages and policies to pro-mote exclusive breast-feeding for the first six

Rea and Araújo 127

14Approved as Resolution 25 at the Fifty-fifth WHOWorld Health Assembly, May 2002.

months of life have been available and inforce for more than 10 years. Consequently,the Brazilian Government was able to takedecisive action to help ensure adoption of aWHO resolution urging countries to protect,promote, and support exclusive breast-feeding for six months as a global publichealth recommendation at the Fifty-fourthWorld Health Assembly in 2001, inasmuch asthe country had proven conclusively that theprevalence of exclusive breast-feeding can beincreased. National surveys confirmed an in-crease of nearly 10 times in the prevalence ofexclusive breast-feeding from 0 to 4 monthsof age, which was approximately 3.8% in1986 and had increased nearly 10 times by1996 (55), with rates reaching 35.6% in thecountry’s state capital cities during 1999.15

Taking into account the successes andshortcomings of the national breast-feedingprogram over the last few years and the needto continue to improve exclusive breast-feeding rates, the thrusts of the PNIAM in the immediate and medium-term futurewill include: to continue to support andstrengthen the numerous breast-feeding ad-vocacy and promotional initiatives under-way at the community, state, and nationallevels; to transform the focus in professionalhealth training and practice toward baby-friendly care of newborn infants and to en-courage still-uncertified hospitals to strive toachieve BFH status as soon as possible; toprovide support to ensure that all currentBFHs maintain their certification in the future; and to improve support for breast-feeding programs at the primary care levelthrough efforts oriented toward universalimplementation by basic health units of theIUBAAM initiative. As family health teamsand community health promoters, our chal-lenge will also be to evaluate the role of thenumerous interventions discussed in thischapter in achieving the dramatic tenfold im-provement in exclusive breast-feeding ratesover the past two decades, as well as to mea-

sure the relative impact of each on the na-tional rates of child morbidity, mortality, andphysical and mental development. The au-thors of this chapter believe that an evalua-tion of this type is long overdue and one thatwould, at the same time, yield a clear blue-print for future actions, validating the exten-sive efforts carried out by different individu-als and institutions on this issue to date andproviding clear answers to those who stillquestion the crucial role of breast-feeding inprotecting and improving integral maternaland child health.

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28. Lutter CK, Pérez-Escamilla R, Segall A, Sanghvi T,Teruya K, Wickham C. The effectiveness of a hospital-based program to promote exclusive breast-feedingamong low-income women in Brazil. Am J Public Health1997;87(4):659–663.

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34. Berquó E, Cukier R, Spindel CR, Rea MF. Caracteri-zação e Determinantes do Aleitamento Materno naGrande São Paulo e na Grande Recife. São Paulo: Cen-tro Brasileiro de Análise e Planejamento; 1984.(Cadernos Cebrap, Nova Série 2).

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SUMMARY

In an attempt to address the food and nu-tritional insecurity of low income populationgroups living in peri-urban areas of Lima,Peru, a project was designed, developed, andimplemented between the years 1991 and1993. At that time, individuals belonging tothis population segment were facing the dev-astating effects of hyperinflation on theirfamily economies, with a progressive reduc-tion of their purchasing capacity which, inturn, affected their accessibility to basic foodsources.

The project was implemented by the Pe-ruvian Institute of Nutritional Research (In-stituto de Investigación Nutricional, or IIN) uti-lizing an extended partnership betweengrassroots organizations of communitykitchens (known as comedores populares), themass media, the private sector, and interna-tional cooperation agencies. It consisted ofthe identification, through a periodic sur-veillance of prices, of the foods that pro-vided the most cost-effective units of energyand protein based on current food prices inlocal markets. These foods became known as the “best buy” foods and were used todesign and develop nutritionally soundrecipes through a fully participatory processwith members of the comedores populares.

Nutrition messages were also developed topromote recipes incorporating “best buy”foods. Recipes and messages were dissemi-nated through the mass media and in face-to-face educational activities. After fivemonths of implementation, the project wasevaluated and showed significant rates ofexposure to the dissemination and educa-tion activities, recall of recipes and mes-sages, and use of the promoted recipes.

This project demonstrated that it is possi-ble to improve the accessibility to and properuse of foods by low income populations liv-ing in peri-urban areas through an innova-tive strategy that captures the values given tofoods by people. The basic conceptualmethod of the project is also being appliedby the Pan American Health Organization(PAHO) in other types of initiatives to facethe overweight and obesity epidemic in theRegion of the Americas.

BACKGROUND

The dramatic growth of cities in the devel-oping world over the past decades hasbrought with it the challenge of widespread

THE BEST BUY PROJECT IN PERU:NUTRITION RECOMMENDATIONS WITHIN THE CONTEXT OF LOCAL

URBAN MARKET REALITIES

Bruno M. Benavides1

131

1Program Officer, Latin America and Caribbean Re-gion, Partners in Population and Development, Dhaka,Bangladesh.

urban poverty. The global average rate of ur-banization is expected to surpass the ruralone by 2005 (1). Urban rates per region arepredicted to reach 83% in Latin America andthe Caribbean, 53% for Asia and the Pacific,and 55% for Africa by the year 2030.

Efforts to address the unique problems as-sociated with urban poverty have beenquickly surpassed by the rate of povertygrowth in urban areas. The problems of theurban poor have become increasingly morepressing, including the issues of how thispopulation segment can secure an adequatelivelihood and the ways in which sufficientfamily income affects key indicators ofhuman welfare, such as food security and nu-trition. Food security is the basic right of allpeople to have access to the food they need.Food security exists when all populationgroups, at all times, have physical and eco-nomic access to sufficient, safe, and nutritiousfoods which meet their food preferences anddietary needs for an active and healthy life.Ensuring food security and appropriate nu-trition of the urban population—and in par-ticular of the poorest households—has be-come a major challenge worldwide.

Following migration to urban areas, tradi-tional food habits shift towards urban mod-els using different, ready-to-use, and afford-able foods. Food insecurity and inadequatefood practices, combined with unhealthy liv-ing conditions, lead to a high prevalence ofmalnutrition, where under- and overnutri-tion, frequently accompanied by micronutri-ent deficiencies, increasingly coexist. This, inturn, has a negative impact on urban devel-opment by diminishing people’s capacity towork and diverting resources to health care(2). However, issues of food security and nu-trition associated with urban poverty havegarnered either little, or misleading, atten-tion from decision- and policymakers (3).

Food and nutrition security in urban areasis a function of availability, accessibility, andthe proper use of foods. Making foods avail-able for the growing millions of people livingin cities is a tremendous logistical challenge.

It is a huge task to feed a city of several mil-lion people, or even of several hundred thou-sand, who require many tons of food eachday. This requires much coordination amongproducers, transporters, market managers,and retailers who work in stores, on thestreet, and in open-air markets. However,nutrition experts have reported that, on aver-age, the availability of food is adequate inLatin American countries (4).

People living in urban areas are heavilyreliant upon purchasing foods in the localmarkets. Low resource urban dwellers usu-ally experience difficulties in purchasing ad-equate amounts of food to meet their needsand preferences. Most, if not all, of the foodconsumed in cities must be purchased, andpoor families can spend as much as 60–80%of their income on food. However, due tolow family income and high market prices,many urban households are unable to meettheir own needs; an important nutrition gapbetween socioeconomic groups is expressedby more malnourished children and in-creased consumption of lesser-quality foodsin the lowest income brackets of householdsin urban Latin America (4).

Not only is proper nutrition very difficultwhen little money is available for food; thisproblem is compounded when the skills toeffectively use available resources are lim-ited. Several efforts have been made to un-derstand how food security is affectedwithin the context of urban poverty, howpoor families behave in market economies,and what impact this behavior has on theirnutrition and health. A longitudinal studyconducted in poor peri-urban districts ofLima (5) from 1972–1973 and 1979–1980found that economic changes in Peru—an in-crease in food prices between these time pe-riods averaging 12.66 times and a decrease infamily income—affected the daily diet com-position of families. These changes aresummarized in Table 1 and represented a de-creased intake of animal protein, fat, cal-cium, and riboflavin. In spite of these dietarychanges, the study reported no significant al-

132 The Best Buy Project in Peru

teration of children’s anthropometric in-dexes, suggesting that families could makeappropriate nutritional adjustments evenunder adverse economic circumstances.

Adapting feeding behavior according tothe availability and accessibility of foods inurban markets has also been reported re-cently in other contexts. In Maputo, Mozam-bique, where the urban poverty rate isaround 60%, only a small portion of theurban poor have access to land to grow theirown food. In 2002, shortages in maize pro-duction increased the price of this product;the Institute of Statistics reported that foodmade up more than 60% of the average fam-ily’s total expenditure and that poor house-holds were eating more rice than usual dueto the sharply rising prices of maize (6).

The skills used to adapt poor families’diets to negative economic changes have lim-itations when the magnitude and speed ofthese changes are exceptionally high, affect-ing urban food security in the poorest house-holds. From 1988 to 1990, Peru experiencedan economic crisis of unprecedented propor-tions that caused the price index of goods toincrease by 5,900 times (7). According to anunpublished study, poor families increasedthe percentage of income set apart for foodpurchasing from 57% to 68.8%; despite thisadjustment, the percentage of poor house-holds that did not fulfill their daily energyrequirements increased. During this period,government food donation programs werealso affected, reducing their coverage by 68%from 760,000 to 245,000 individuals (8).

Comedores populares, or community kitch-ens, have played an important and tradi-tional role in diminishing the impact of eco-nomic crisis on low income families in Peru.They first arose as a survival strategy amonggroups of residents as marginal settlementsgrew around the country’s major urban areasduring the 1960s and 1970s. The peri-urbanzones occupied by these rural migrantslacked such basic infrastructure as water,sewage, health services, and education. Theprecarious nature of these living conditionscompelled the new inhabitants to organizethemselves to secure and provide the miss-ing services. Women formed Mother’s Clubs,and some of these clubs began buying foodin bulk and preparing meals as a group tofeed their families.

The Peruvian Government providedfoods, funds, and basic equipment to thesegroups. Some NGOs channeled additionalfood funded by international cooperationagencies, but mostly helped to develop thecapacity of the comedores populares by provid-ing opportunities for women to access creditand obtain training in administration, man-agement, food preparation, and nutrition.Among the outcomes, different studiesfound an improved self-esteem and a senseof empowerment among the women, as wellas strengthened social connections amongfriends and workers. Over the long term,these program elements contributed tobroader community and economic develop-ment, particularly through the women’s em-powerment and increased confidence in theirabilities. The kitchens multiplied and even-tually became a major channel for distribut-ing food to the urban poor (9).

However, the comedores populares were notexempt from the effects of the economic cri-sis of the 1980s. An assessment of the nutri-tional value of their meals found deficienciesin energy in half of the comedores studied(10), strongly suggesting that the previouslyobserved capacity to adapt the diet of poorfamilies to the urban market context had be-come greatly diminished under the severe

Benavides 133

TABLE 1. Observed changes associated with eco-nomic changes in food selections by low incomefamilies, 1979–1980 vs. 1972–1973.

Increased Same DecreasedFood intake intake intake

Meat 3Milk 3Eggs 3Fish 3Cereals 3Fried foods 3Legumes 3Vegetables 3

crisis conditions. Some interventions weredesigned and implemented by NGOs to helpthe comedores populares by providing infor-mation on the nutritional value of theirmeals, resulting in a maintenance of appro-priate energy and protein content despite thehigh inflation rate during the interventionperiod (11).

THE BEST BUY PROJECT

Taking into account this background, thePeruvian IIN designed and implemented theBest Buy Project.2 The purpose of the projectwas to contribute to the improvement of nu-trition among low income peri-urban fami-lies. The goal of the project was to improvethe performance of the comedores populares byencouraging them to purchase foods in amore cost-effective way. The project’s strat-egy was to provide updated information onthe foods that were the most affordablesources of energy and protein based on cur-rent market prices, as well as nutrition edu-cation activities.

Extended Partnership and Commitment

The project was financed by the CanadianCooperation in Peru initiative (Fondo de Con-travalor Perú-Canadá) and lasted three years.Multiple partnerships were established forthe implementation process. Memorandumsof understanding were signed between theIIN and 247 comedores populares from Lima’speri-urban districts of San Juan Miraflores,Chorrillos, Puente Piedra, and El Agustino;these documents clearly described the mu-tual responsibilities for the project’s imple-mentation.

The country’s largest private bank, theBanco de Crédito del Perú, agreed to partici-

pate by financing the production of projectmessages and recommendations and dissem-inating these through the mass media andthe company’s branch offices throughout thecountry. The leading media outlets, includ-ing national television channels, radio sta-tions, and newspapers, provided free time orspace for the dissemination of the project’smessages and recommendations.

Project Methodology

The project used a participatory strategyto facilitate the construction of practical, vi-able, accessible, and acceptable recommen-dations as a result of the convergence of ap-plied nutritional knowledge; the existingcommunity knowledge, values, and culture;and the use of appropriate technology. Thisstrategy was implemented in the followingsteps (12):

Baseline assessment: The purpose ofthis formative study was to provide criti-cal information for the design and refine-ment of the project’s implementation. Dif-ferent qualitative research techniqueswere used. A survey of comedores populareswas conducted to gather information onthe most commonly used foods, knowl-edge and attitudes on nutrition, andmedia exposure; focus-group interviewsof the comedores populares’ cooks were car-ried out to identify the values and reasonsbehind specific food selections; in-depthinterviews of the comedores populares’ lead-ers allowed the project’s staff to familiar-ize themselves with the logistics of thevarious organizations, including all thesteps involved in the purchasing of foodand supplies; and finally, observation offood preparation permitted the identifica-tion of cooking techniques and tips. Themain results of the assessment were:

Commonly used foods: A list of preferredfoods was developed, allowing the fooddatabase to be used by the project to be re-


2Project Directors: Hilary Creed-Kanashiro and BrunoBenavides. Key project staff: Sofia Madrid, GracielaRespicio, Dora Herrera, and Rocío Leon.

duced to a manageable size. A comple-mentary list of the most-used local mar-kets was also prepared and utilized forprice surveillance.

Values behind food selection: The mostvalued food attributes were, in order ofimportance, taste, economy, volume, andeasiness in cooking.

Exposure to media: Radio was the mostprevalent form of media used by themembers of the comedores populares. A listof the radio stations most frequently lis-tened to was developed and used for thedissemination of messages.

Cooking techniques: It was observed thatfor half of the days, the menus were defi-cient in energy, while protein content wasdeficient in three out of four observationdays. An important finding was that asimilar nutritional content of the come-dores’ menus could be obtained with 70%of the money actually spent by comedores.3

A significant observed difficulty was theability to scale a recipe initially designedfor a family into one that could be used ina comedor; oftentimes, the initial propor-tions were altered, especially in recipes in-volving meats and eggs.

Continuous local prices surveillance:Based on the list prepared of preferredfoods, the corresponding prices of thesewere gathered periodically from the list ofpreferred local markets. At the beginning,the surveillance was carried out on aweekly basis. After some months, it be-came clear that the variation in prices wassmall, and the frequency was thuschanged to every two weeks. The initialintention was that members of comedorespopulares would gather the price data, butthe leaders of these subsequently asked tobe relieved of this duty because of theirnumerous other responsibilities. The proj-

ect staff then assumed surveillance activi-ties themselves, using standardized formsspecially developed for this purpose. Theforms included the date of surveillance,the district, name of the market, and atable in which the food names were en-tered in the first column, and the secondand third columns included blank fieldsfor the unit of purchase and the price perthat unit, respectively. Two markets perdistrict were collected each time, allowingan average price of the foods per unit ofpurchase to be obtained, and thus repre-senting a broad picture of prices in the low income peri-urban local markets ofLima.

Identification of the “best buy” foods:Using the Nutrient Contents Table of Pe-ruvian Foods developed by the IIN andthe actual average price of food in localmarkets, a specially designed softwarecalculated the price of each unit of energyand protein for each food. The formulaused was as follows:

First step: calculation of the price offood gross 100 g

where:Pg = price of food gross 100 gp = price per unit of purchaseu = unit of purchase in grams

Second step: calculation of the price ofthe food’s net weight (Fnw)

The price of food gross 100 g was assigned to the food net weight. For ex-ample: jurel’s (a Peruvian type of fish)gross 100 g represents jurel’s net 65 g, inconsequence:

where:Pn = price of food net 100 gFnw = food net weight

PnPg

Fnw=

× 100

Pgp

u=

× 100

Benavides 135

3Creed H, Benavides B, Madrid S, Respicio G, HerreraD, León R. Informe Final, Proyecto “La Mejor Compra.”Instituto de Investigación Nutricional. Lima: 1992.

Third step: calculation of the price of anutrient’s unit

where:Pun = price of one nutrient’s unitN = number of nutrient’s units containedin 100 g of food

Once the price of each unit of nutrientswas calculated, foods were then sorted inascending order, based on each’s price ofenergy (kcal) and protein units. The foodswith the most economical price units ofenergy and protein were identified as the“best buy” and were selected for recipedevelopment and testing.

The analysis of 30 months of price sur-veillance in local markets also providedvaluable information (Table 2). A group offoods produced in the country was consis-tently in the top of the analytical efficiencylist of foods. A second group of foods,which included imported foods or thoseusing imported supplies in their produc-tion, never appeared in the “best buy” po-sitions. A third group was formed byfoods with moves to the “best buy” posi-tions following a seasonal pattern. Thefourth group included foods that movedup and down the tables according to sub-sidy policies. Other foods showed no spe-cific pattern.

PunPnN

=

Recipe design: Two techniques wereused for this purpose.

Successive filters: The project staff de-signed recipes using the list of “best buy”foods for energy and protein, based on asound nutritional combination of foodgroups. These combinations were:

CEREAL + BEANS,CEREAL + BEANS + ROOTS,CEREAL + BEANS + FISH, and CEREAL + ROOTS + FISH.

The designed recipes were tested in afirst filter, which consisted of reading therecipe ingredients and cooking proce-dures to members of the comedores popu-lares. Using only their perception of taste,price, volume, and easiness in cooking,the testers selected or rejected recipes.

The recipes that were selected werethen tested in a second filter, which con-sisted of cooking the recipes and offeringthem to members of the comedores popu-lares during focus-group interviews, inwhich the recipe’s actual appearance andtaste were tested. Again, recipes were ac-cepted or rejected.

Those accepted were finally preparedby the comedores populares themselves, andtheir members were subsequently inter-viewed to verify whether or not therecipes had satisfied them and their rela-tives at home.


TABLE 2. Observed patterns of efficiency reported after 30 months of food pricesurveillance.Group 1: Always “best buy” Group 2: Never “best buy”

Cereals: rice, local wheat, cornmeal

Legumes: soy beans, local bean varieties, peas, lima beans, soy flour

Fish: jurel, lorna, merluza (local varieties of fish)

Sweets and oils: sugar, shortening, mixed oils

Group 3: Seasonally “best buy”

Roots: white potato, yellow sweet potato, cassava

Meats: giant squid

Meats: beef, poultry, eggs, seafood, viscera

Dairy: milk powder, evaporated milk, cheeses

Roots: yellow potato

Legumes: chickpea

Fruits and vegetables

Group 4: “best buy” when subsidized

Cereals: wheat flour, wheat noodles

Recipe fairs: The list of “best buy” foodswere also shared with cooks in the come-dores populares, who were invited to pro-vide suggestions as to how to preparerecipes with these foods, based on theabove-mentioned combinations of foods,and then were allowed to improvise andapply their own experience and skills.Each comedor suggested a number ofrecipes in each food combination. Thenthe cooks short-listed these by combina-tion using the criteria of taste, price, vol-ume, and easiness of cooking, and finallyeach comedor selected one that would rep-resent them in a recipe fair. During thefair, the participating comedores preparedtheir selected recipe in an exhibition andoffered samples to the other participants;they also shared the recipes’ ingredientsand cooking techniques.

Recipe dissemination: The designed,tested, and approved recipes were thendisseminated. The dissemination includedthe ingredients and their amounts, thecooking techniques employed, and thenutritional values of each recipe. Indica-tions of the recipe for special needs werehighlighted; for example, those with im-portant quantities of iron were promotedas useful in the prevention and treatmentof anemia.

Four elements were kept in mind dur-ing the dissemination process: the recipesshould be attractive and acceptable, thecooking techniques should be easily un-derstood, the target population shouldfeel that the recipe is useful in addressingtheir specific needs, and they should bestrongly encouraged to try the recipes.

The recipes were disseminated usingthe following media:

Face-to-face education activities in thecomedores populares: Project staff visitedeach participating comedor on a regularbasis to provide the newly developedrecipes and loan support to nutrition edu-cation activities. The project designed aposter and a special recipe book which

highlighted the best recipes designed bythe comedores populares, according to theabove-mentioned four elements. On aver-age, each participating comedor received5.2 visits during the project’s three-yearduration.

Recipe fairs: This activity was also usedfor recipe development, as mentionedabove. Selected comedores prepared recipesusing their own newly created recipes andshared these with other comedores. Cook-ing techniques and nutritional informationwere important components of this ex-change.

Mass media: Recipes, lists of “best buy”foods, and nutritional recommendationswere disseminated using a special weekly30-minute program broadcast duringprime time on the country’s largest televi-sion channel; a total of 163 programs wereproduced and aired. Two additional tele-vision stations disseminated the recipesand messages as part of each’s highest-rated daily news program. The two mostimportant radio stations in the countryalso disseminated the recipes and mes-sages on a daily basis; 1,220 radio pro-grams were produced and disseminated.Finally, four newspapers sharing a signifi-cant readership also participated by dis-seminating a daily space dedicated to pro-motion of the recipes and messages,totaling 557 articles.

Project Results

A survey in probabilistic samples ofhouseholds, participating comedores, andnonparticipating comedores was conductedfive months after the launching of the dis-semination of the project’s recipes and nutri-tional recommendations. The survey wascarried out between 10 a.m and 2 p.m. In thecase of households, the person in charge ofcooking during the survey day was inter-viewed. In the case of comedores, one cookwas randomly selected among the cookingteam on the survey’s day.

Benavides 137

Four variables were studied: exposure tothe mass media campaign; recall of the proj-ect’s recipes following media exposure; re-ported use of the project’s recipes, i.e., whenthe interviewee reported the preparation ofat least one recipe, at least one time, as pro-moted by the project; and the observed useof the project’s recipes, i.e., interviewers re-quested to see the recipe that was being usedor that had already been prepared at the mo-ment the survey was carried out. This lastvariable was only explored in both types ofcomedores.

The following were the reported findingsof the survey,4 which are also presented inFigure 1:

Exposure: Sixty percent of the interviewedhouseholds, 70% of the participating comedores,and 57% of the nonparticipating comedores re-ported that they had seen, listened to, or readabout the Best Buy Project and/or its messages.The high exposure was attributed in part towidespread television coverage. These differ-ences were not statistically significant.

Recall: Among those who reported posi-tive exposure to the mass media campaign,58% of the households, 87% of the participat-ing comedores, and 77% of the nonparticipat-ing comedores recalled at least one projectrecipe. The recall was significantly higher inboth types of comedores when compared tohouseholds.

Reported use: Participating comedores re-ported a significantly higher use of at leastone project recipe (76%) than nonparticipat-ing comedores (11%) and households (40%).

Observed use: Twenty-two percent of theparticipating comedores were preparing aproject recipe during the day they were sur-veyed, in comparison with 7% of nonpartici-pating comedores. This difference was statisti-cally significant.

Discussion

The evaluation showed that the projectachieved its goal of improving the selectionof foods by comedores populares and hencecontributed to the improved accessibility bylow resource families participating in thesegrassroots organizations to adequate foods.The basic concept of the “best buy”—to ob-tain better nutrition at the lowest possiblemarket price—has enabled scientific knowl-edge to become better attuned with theneeds and expectations of low income urbanfamilies and create a feasible, relevant, andlow-cost appropriate technology solution toaddress the accessibility to and proper use offoods in urban contexts.

The results also showed the importantcontribution of the mass media in communi-cating the nutritional messages of the projectand in facilitating the promotion of its goals.The use of the project’s recipes was, however,much higher when face-to-face activitieswere also in place, highlighting the latter’scontribution to the achievement and sustain-ability of effective behavioral change.

The results of the surveillance analysis areimportant because they provide policymak-ers with valuable information regarding thepotential impact of specific policies on theavailability and accessibility of foods inurban contexts. It should be noted that theBest Buy Project was focused on improvingthe accessibility to energy and proteinsources, which explains why fruits and veg-etables were never an efficient purchase op-tion. Thus, the analysis did not include othermicronutrients.

Other Applications of the “Best Buy”Concept: the Planut® Nutritional Planner

Poverty in urban settings, even in affluentsocieties without problems of accessibilityand availability, is associated with low in-takes of fruits, vegetables, and dairy prod-ucts, resulting in deficient levels of vitamins,minerals, trace elements, and fiber (13). Not


4Benavides B, Creed H, Jacoby E, Madrid S. Reportede Evaluación de “La Mejor Compra.” Instituto de In-vestigación Nutricional. Lima: 1991.

all socioeconomic conditions that facilitateweight gain faced by poor families are undertheir control (14). Consequently, poor fami-lies are affected by the paradoxical combina-tion of undernutrition and obesity.

Children from poor families are morelikely to suffer obesity than the general pop-ulation (15–17). In addition, over the pasttwo decades, obesity has increased amongchildren (18), especially those from poorfamilies (15, 17). Other studies have also doc-umented that food insecurity has a paradox-ical association with overweight statusamong women, resulting in a potentially in-creased incidence of obesity-related chronicdiseases (19).

The software Planut® Nutritional Plannerhas been designed, developed, and dissemi-nated through the Region of the Americas,and it is being used by a variety of profes-sionals and institutions, facilitating the im-plementation of PAHO’s recommendationsfor weight gain prevention and obesity con-trol (20).

An important conceptual upgrade ofPlanut® is that the focus of attention has been

shifted from nutrients composition to the di-etary balance of food groups. Planut® isbased on a series of dietary guidelines pre-pared by the Countrywide Integrated Non-communicable Diseases Intervention Pro-gram of the Regional Office for Europe of theWorld Health Organization (21), which areconsistent with recommendations already in-cluded in most of the national guidelinesprepared by PAHO Member Governments inthe Region of the Americas.

One of the strengths of Planut® is the useof existing food composition tables from 14countries of the Region, facilitating its wideruse by professionals throughout the Ameri-cas. However, the use of these tables may im-pose limitations on actual application, sincemost of the tables contain insufficient infor-mation on some important nutrients, such asfat composition breakdown including cho-lesterol and other micronutrients. In view ofthis reality, it would seem imperative that na-tional efforts to update the nutrition infor-mation included in their country composi-tion tables receive increased priority andsupport, since in many cases these tables

Benavides 139

0 10 20 30 40 50 60 70 80 90 100

Participatingcomedores

Non-participatingcomedores

Households

Obs Use Rep Use Recall Exposure

Percentage

FIGURE 1. Results of the Best Buy Project.

were developed at a previous point in timewhen there existed a different paradigm ofthe given population’s nutritional needs.

During the development of the tool, an-other important pitfall of the informationavailable for consumers was identified.While the current nutritional guidelines areoriented to the promotion of a balancedcombination of different food groups, thenutrition information included in product la-beling only includes data on nutrient compo-sition with no information on the proportionof different food groups in the processedfood. As a result of this deficiency, all pro-cessed foods were removed from the nutri-tion composition tables to ensure that usersof Planut® will receive only reliable and ac-curate information. New improvements inproviding nutrition information to con-sumers will necessitate changes in food la-beling requirements that include detailed in-formation on food group composition.

REFERENCES

1. United Nations, Population Division. World Urbaniza-tion Prospects: The 1996 Revision. New York: UN; 1997.

2. de Haen H. Enhancing the contribution of urbanagriculture to food security. Urban Agriculture Mag-azine June 2002; Special Issue for the World FoodSummit: five years later. Available at: http://www.ruaf.org/uam_specials/uam_rome_2002.pdf

3. Maxwell D. The Political Economy of Urban Food Secu-rity in Sub-Saharan Africa. Washington, DC: Interna-tional Food Policy Research Institute; 1998. (FCNDDiscussion Paper 41).

4. Sánchez-Griñán MI. Nutrition security in urban areasof Latin America. Washington, DC: InternationalFood Policy Research Institute; 1998. (2020 VisionBrief 49).

5. Creed H, Graham G. Changes over time in food in-takes of a migrated population. In: White PL, SelveyN, eds. Malnutrition: Determinants and Consequences:Proceedings of the Western Hemisphere Nutrition Con-gress VII held in Miami Beach, Florida, August 7–11,1983. Vol 10: Current Topics in Nutrition and Dis-ease. New York: Alan R. Liss Inc.; 1984:197–205.

6. U.N. Office for the Coordination of HumanitarianAffairs, Integrated Regional Information Network.Mozambique: Concern over urban food security.Press release, 3 December 2002. Available at: http://www.irinnews.org/report.asp?ReportID=31224.Accessed on 1 May 2004.

7. Instituto Nacional de Estadística e Informática, Di-rección Técnica de Indicadores Económicos. Citedin: Organización Cuánto. Perú en números 1991. An-uario estadístico. Lima: Cuánto S.A.; 1991:737.

8. Perú, Ministerio de Salud, Dirección Técnica dePlanificación Sectorial. Cited in: OrganizaciónCuánto. Perú en números 1991. Anuario estadístico.Lima: Cuánto S.A.; 1991.

9. Garrett J. Comedores Populares: Lessons for Urban Pro-gramming from Peruvian Community Kitchens. Wash-ington, DC: International Food Policy Research In-stitute; 2001.

10. Cuentas M. FOVIDA y la alimentación popular. In:Galer N, Núñez P, eds. Mujer y comedores populares.Lima: SEPADE; 1989:81–118.

11. Carrasco N, Creed H, Huffman S. Experiencia deapoyo y evaluación nutricional de un comedor co-munal en Lima Metropolitana. Rev Chil Nutr 1989;17(Suppl 1).

12. Creed H, Benavides B, Madrid S, Respicio G, He-rrera D, León R. La mejor compra: guía metodológicapara su aplicación en diferentes condiciones locales.Lima: Instituto de Investigación Nutricional; 1991.

13. Center on Hunger and Poverty. Childhood Hunger,Childhood Obesity: An Examination of the Paradox[Internet Site]. Available at: http://nutrition.tufts.edu/pdf/publications/hunger/hunger_and_obesity.pdf. Accessed on 2 June 2004.

14. Anand RS, Basiotis PP, Klein BW. Profile of Over-weight Children. Washington, DC: U.S. Departmentof Agriculture, Center for Nutrition Policy and Pro-motion; 1999. (Nutrition Insights 13).

15. Jones DY, Nesheim MC, Habicht JP. Influences inchild growth associated with poverty in the 1970’s:an examination of HANESI and HANESII, cross-sectional U.S. national surveys. Am J Clin Nutr1985;42(4):714–724.

16. Rolland-Cachera MF, Bellisle F. No correlation be-tween adiposity and food intake: why are workingclass children fatter? Am J Clin Nutr 1986;44:779–787.

17. Yip R, Scanlon K, Trowbridge F. Trends and patternsin height and weight of low-income U.S. children.Crit Rev Food Sci Nutr 1993;33(4-5):409–421.

18. Gortmaker SL, Dietz WH Jr., Sobol AM, Wehler CA.Increasing pediatric obesity in the United States. AmJ Dis Child 1987;141(5):535-540.

19. Townsend MS, Peerson J, Love B, Achterberg C,Murphy SP. Food insecurity is positively related tooverweight in women. J Nutr 2001;131(6):1738–1745.

20. Pan American Health Organization. Diet, Nutritionand Physical Activity. 132nd Session of the ExecutiveCommittee, Provisional Agenda Item 4.13. Wash-ington, DC: PAHO; 2003. (Document CE132/21,Rev. 1 Eng.).

21. World Health Organization. CINDI Dietary Guide.Copenhagen: WHO Regional Office for Europe;2000.


BACKGROUND

The lack of regular physical activity, alsoknown as a sedentary lifestyle, has been con-sidered one of the most prevalent and worri-some public health problems in recent years.It is a risk factor associated with the develop-ment of the principal noncommunicable dis-eases. Various epidemiological studies havedemonstrated very clearly that the risk phys-ical inactivity poses to health is greater thanthat of known factors, such as tobacco use,high cholesterol levels, high blood pressure,and overweight (1, 2). In the United States,data on sedentary lifestyles disseminated in2003 by the Centers for Disease Control andPrevention (CDC) (3) showed that the preva-lence of physical inactivity between 2000 and2001 in this country was 27%; in that period,the percentage of those who met physical ac-tivity and health recommendations increasedfrom 26.2% to 45.4%.

In the Region of the Americas, the preva-lence of this risk factor has not been clearlyestablished because, until recently, thereexisted no single and universally acceptedinstrument for evaluating physical activitylevels that would have made it possible toobtain regional figures of reference. How-ever, data from different countries in theAmericas show that more than 50% of the

population is irregularly active; in otherwords, this group does not engage in physi-cal activity at the minimum recommendedfrequency of five days a week, 30 minutesper day (4). In some countries in the Region,the prevalence of sedentary lifestyles isnearly 60%. In Chile (5), according to theFirst National Survey on Quality of Life andHealth of 2000, the percentage that engagesin fewer than 30 minutes of physical activitythree times per week (regarded as sedentaryby this criterion) was a noteworthy 91% ofthe population.

Some of the studies analyzed by Jacoby,Bull, and Neiman (6) in Brazil, Chile, andPeru clearly show that more than two-thirdsof the population of these countries do notmeet the recommendations for the frequencyof physical activity needed to obtain healthbenefits. Results from studies conducted inBogotá, Colombia, place the rate of physicalinactivity at 79% of the population, and only5.25% of individuals regularly engage inphysical activity (7). These studies also indi-cate that women practice physical activitiesless frequently than men and that physical

AGITA SÃO PAULO: ENCOURAGING PHYSICAL ACTIVITY

AS A WAY OF LIFE IN BRAZIL

Sandra Mahecha Matsudo1 and Victor Rodrigues Matsudo2

141

1Scientific Advisor, Agita São Paulo Program, Centerfor Physical Fitness Laboratory Studies (CELAFISCS),São Caetano do Sul, São Paulo, Brazil.

2General Coordinator, Agita São Paulo Program, andCELAFISCS Scientific Coordinator.

activity decreases as chronological age in-creases (8). Another significant result is thefact that physical inactivity differs accordingto socioeconomic level. People at the lowestsocioeconomic levels present the greatestrisk of being physically inactive (9). There-fore, older adults, women, and individuals atlower socioeconomic and education levelsare at greater risk of being physically inactiveand, by extension, of developing noncom-municable diseases.

However, it should be pointed out that theproblem of sedentary lifestyles is not exclu-sive to developing countries. Indeed, a recentstudy conducted by Vaz de Almeida (10)found that the risk for physical inactivitywas greater in countries such as Portugal(9.15), Belgium (4.6), Italy (4.25), and Greece(4.21), and that the countries with the mostphysically active populations in Europe wereAustria, Finland, and Sweden. According tothis same study, the proportion of adultswho engage in three hours or less of recre-ational physical activity is 57% in the UnitedStates and 83% in Portugal.

Scientific information from the last fewdecades clearly demonstrates the beneficialrelationship between physical activity andhealth. Epidemiological data show thatphysical activity plays an important role inthe prevention, control, treatment, and reha-bilitation of the principal noncommunicablediseases, such as obesity in adults (11, 12)and in children and adolescents (13), hyper-tension (14), diabetes (15), stroke (16), cardio-vascular disease (17, 18), myocardial infarc-tion (19), osteoporosis and hip fracture (20),and cancer (21), in addition to the reductionof inflammatory markers for noncommuni-cable diseases (22) and of mortality from anycause (23, 24). The positive effects derivedfrom regular physical activity may be catego-rized as follows:

(1) Physiological/biological: weight andbody fat control and loss, preservationof lean muscle mass, blood pressurecontrol, improvement of blood lipid

profiles, blood glucose control, in-crease in cardiovascular and respira-tory capacity, and either maintenanceof or decreased loss of bone mass (1).

(2) Psychosocial: increase in self-esteemand self-image; reduction of depres-sion, stress, and insomnia; reduction in consumption of medicines; andgreater socialization (25).

(3) Cognitive: better results on attention,memory, and reaction time tests andoverall cognitive performance (26);and decreased risk of Parkinson’s dis-ease (27), dementia (28), senile demen-tia, and Alzheimer’s disease (29).

(4) Industry and employment: reductionin labor turnover; improvement of in-stitutional image; and reduction ofmedical care costs, job absenteeism,and work-associated stress (30).

(5) School: improvement in academic per-formance and in relationships withparents and teachers; reduction in ab-senteeism and of behavioral disorderrisks; prevention of juvenile delin-quency, alcoholism, and substanceabuse; and increase in sense of respon-sibility (31, 32).

In Brazil, the first data on physical inactiv-ity in the municipality of São Paulo showeda prevalence of sedentary lifestyles of some60% in men and 80% in women (33). Datafollowing the national census of 1996 and1997, as analyzed by Monteiro and col-leagues (9), showed that barely 13% of thepopulation engaged in at least 30 minutes ofphysical activity in their leisure time on oneor more days weekly, and that only 3.3% car-ried out the minimum daily recommendedamount of at least 30 minutes five times perweek.

Another important point with regard tophysical activity and its impact on publichealth is the cost of sedentary lifestyles tohealth plans. Garrett and colleagues (34) esti-mated that nearly 12% of total medical ex-penditures related to depression and anxiety,

142 Agita São Paulo: Encouraging Physical Activity as a Way of Life in Brazil

and 31% of expenditures related to coloncancer, osteoporosis, coronary disease, andstroke, are attributable to physical inactivity.The costs these diseases represented to oneU.S. medical insurance company of over 1.5million members were US$ 35.3 million forcardiovascular diseases (the most costly),with the overall estimated cost of physicalinactivity totaling US$ 83.6 million; that is,US$ 56 per member.

The Center for Physical Fitness Labora-tory Studies (CELAFISCS), which receivesadvisory services from the CDC, calculatedin 2002 the direct cost of physical inactivityto the public health care system of the stateof São Paulo. The initial data indicated thatthe cost associated with physical inactivitybetween 2001 and 2002 was approximatelyUS$ 37 million. In light of this finding, aswell as others regarding the high prevalenceof noncommunicable diseases—with cardio-vascular diseases being the leading cause of morbidity and mortality—the Ministry ofHealth sought to create an incentive programfor the regular practice of physical activity asa way of maintaining, improving, recover-ing, and achieving the highest possible levelof health for the residents of São Paulo.

The purpose of this chapter is to describethe experience of a pioneering program topromote physical activity in Latin America,Agita São Paulo, considered by some expertsin this field (6) to be one of the most exem-plary initiatives developed to date for thepromotion of active lifestyles in the Regionof the Americas.

First, this chapter details the emergence ofthe program, its structure and objectives, andthe messages it has utilized, and then de-scribes the new and innovative strategy pro-posed to combat sedentary lifestyles throughthe adoption of the so-called mobile ecologi-cal model (35), which takes into account indi-vidual and environmental factors in the pro-motion of physical activity. This chapterdescribes the educational materials devel-oped by the program as well as a series ofmega-events used to mobilize the population

and raise collective awareness regarding theimportance to overall health and well-beingof engaging in regular physical activity. Italso includes a summary (Table 3) of the bestpractices selected by governmental entities,civil society, and private enterprises to pro-mote physical activity. As will be seen, the in-herent flexibility that characterizes the ma-jority of the components of Agita São Pauloensures their adaptability to a number ofother communities throughout the Regionand around the world. Finally, the chapterconcludes with the presentation of a series ofindicators regarding the impact of Agita SãoPaulo on the population’s physical activitylevels and on its knowledge of the healthbenefits accrued from observing a more ac-tive lifestyle. It also describes the formationof international networks to promote physi-cal activity, such as the Physical Activity Net-work of the Americas (PANA) and AgitaMundo, which seek to spread the momen-tum and spirit of Agita São Paulo and otherprograms like it beyond state, national, andcontinental borders.

CREATION AND STRUCTURE OF THE AGITA SÃO PAULO PROGRAM

In 1995, the leadership of CELAFISCS, aninstitution widely recognized within and out-side Brazil for more than two decades of con-tributions in the field of sports and physicalfitness, set out to discover new ways to pro-mote physical activity. Taking into accountthe most recent paradigms of health promo-tion and a large body of scientific evidence in-dicating a strong link between the observanceof physically active lifestyles and a reductionin the risk of morbidity and mortality fromnoncommunicable diseases—particularly car-diovascular diseases—CELAFISCS seizedupon the idea of promoting physical activityas a cornerstone in the achievement, im-provement or recovery, and maintenance ofoptimal levels of overall health and well-being among the population.

Matsudo and Matsudo 143

Existing data on the high prevalence(70%–80%) of physical inactivity in the stateof São Paulo—and particularly among thelower income sectors—called attention to theneed to implement interventions for individ-ual behavior change and to reduce the preva-lence of sedentary lifestyles. In this context,the minister of health of the state of SãoPaulo at the time asked CELAFISCS to de-velop a statewide program to promote phys-ical activity.

An initiative of this scope faced two im-portant challenges. First, only limited infor-mation was available on the promotion ofphysical activity in developed countries,and, second, the target population was enor-mous. The state of São Paulo has 34,752,225inhabitants spread across 645 municipalitiescovering an area of 248,808 km2. The capitalcity, São Paulo, has more than 10 million in-habitants (with 16,446,000 inhabitants livingin the metropolitan area) and constitutes oneof the world’s largest urban concentrations.

The program planning process lasted twoyears and included consultations with thePan American Health Organization (PAHO),the CDC, the Department of Health Educa-tion of the United Kingdom, the Cooper Insti-tute and Cooper Aerobics Center (Dallas,Texas), and a variety of other programs topromote physical activity from Australia, En-gland, and Finland. CELAFISCS prepared theprogram’s logical matrix, which outlined thescientific basis for the need to promote phys-ical activity among the population, as well asthe program’s objectives, beneficiaries, over-all strategy, actions, expected results, andmeans of evaluation. Following the prepara-tory phase, Agita São Paulo was launched inDecember 1996. The initiative had the sup-port of various state governments, non-governmental organizations, and the privatesector, and was officially established by thestate’s governor in February 1997.

The name of the program was selectedafter two years of consideration and with theassistance of marketing consultants. Agita is aPortuguese word that means more than just

to move the body; it also suggests energizingthe mind and seeking energy, movement, andmotion during one’s leisure time. Indeed, theprogram calls on its target audience to de-velop a mindset prioritizing the pursuit of ac-tive lifestyles to improve their overall healthand sense of well-being. The program’s logoconsists of a clock in which the placement ofits hands serves as a reminder of the need toundertake 30 minutes daily of moderately in-tense physical activity. The clock is called theMeia-Horito (Little Half Hour) and was incor-porated into all the program’s promotionaland educational materials. Later on a femaleversion—the Meia-Horinha—was introduced,as well as other family members—two chil-dren and a pet puppy.

From the beginning, Agita São Paulosought to establish a unique identity distin-guishing it from other efforts to encouragethe practice of sports and physical activity inthe country. It saw in the formula of partner-ship formation the possibility of consolidat-ing its own identity and ensuring the pro-gram’s sustainability and success over time.Figure 1 presents a diagram of Agita SãoPaulo’s functional organization. CELAFISCS,the program’s central coordinating body, re-ceives partial financial support from the Min-istry of Health of the state of São Paulo, underwhich there are two committees or boards.The Executive Board consists of partneredgovernmental and nongovernmental institu-tions from civil society, while the ScientificBoard is comprised of renowned national andinternational experts whose knowledge helpsto ensure the theoretical soundness of thestrategies and evaluation techniques adoptedby the program.

Forging intellectual partnerships withother national and international initiativeswas a key strategy in the program’s develop-ment. This dynamic was further strength-ened by close linkages with governmental,nongovernmental, and private sector agen-cies, who could then all work together on asingle program with a common objective. Inaddition, a select group of Brazilian and non-


Brazilian professionals with extensive exper-tise in the field of physical activity and itspromotion were invited to meet with the or-ganizers of Agita São Paulo and to becomemembers of an international scientific board.

The Executive Board, overseeing the workof more than 300 partnered institutions, wasgiven responsibility for analyzing the organi-zation, execution, planning, and perfor-mance of the gamut of initiatives underwayto disseminate Agita São Paulo’s message.Various social sectors are represented on thisBoard, including education, health, sports,industry, trade, and services (36). Programactions are geared principally toward thethree population groups at greatest risk ofphysical inactivity: schoolchildren (childrenand adolescents), workers (young economi-cally active men and women), and olderadults (those over 60 years of age).

Regular meetings of the Executive Boardguarantee the continuity of program activi-ties and are held on the first Tuesday of every

month (except in January), always at thesame time (from 2:00 p.m. to 4:00 p.m.), andalways in the same place (the Ministry ofHealth). Since 1997, between 45 and 60 repre-sentatives from the partner institutions havetaken part in these meetings. During themeetings, actions and strategies to promotephysical activity are presented and discussed,and activity schedules are exchanged to en-courage the participation of and strengthenopportunities for linkages among the pro-gram partners. The Executive Board is alsoresponsible for publishing Agita News, amonthly newsletter highlighting the activi-ties of all the Board’s partners carried out inthe state capital of São Paulo and in other mu-nicipalities of São Paulo, as well as at the na-tional and international levels (representedby the Physical Activity Network of theAmericas [PANA] and Agita Mundo, to be dis-cussed at the end of this chapter). Agita Newsis delivered in person to the representativesparticipating in the monthly meeting and is


Responsible institution

Coordinating institution

Program for promotion of physical activity

Intervention target groups

Schoolchildren Workers

Scientific Board

National International

Executive Board

Institutional partners(nongovernmental)

Institutional partners(governmental)

Older adults

FIGURE 1. Organizational structure of scientific and executive-level partnerships.

sent by e–mail to the program’s partner insti-tutions and to the national scientific advisers.It is also available to all interested parties onthe program’s Web site (www.agitasp.org.br).

With regard to program structure, itshould be noted that the intersectoral bal-ance between the Executive and ScientificBoards, and the intrasectoral balance, in par-ticular, have yielded very positive results.For example, when backing was obtainedfrom the Industrial Federation, it was clearthat support should also be solicited from theChamber of Commerce, and when supportfrom the Lions Club was garnered, backingfrom the Rotary Club was also obtained. Thesame strategy was used in academic circlesand consisted of encouraging federal, state,and private universities to become involvedin the initiative.

Another innovative strategy was tostrengthen existing programs by providingeach community with sufficient autonomy todevelop initiatives within the framework ofits own unique social and cultural environ-ment. In this way, all of Agita São Paulo’s nu-merous entities shared a common objectiveand developed a solid sense of purpose, de-spite the diversity of actions in which eachwas involved. Table 1 summarizes the factorsthat were key to the successful promotion ofphysical activity, based on a qualitativeanalysis carried out by the program partnerswith special advisory support from PAHO.

The organizers of Agita São Paulo realizedearly on that the participation and collabora-tion of medical professionals would also becrucial to the program’s success. A speciallyestablished Medical Committee concludedthat physicians were not sufficiently awareof the benefits of physical activity and there-fore did not “prescribe” it to their patients.Bearing in mind that traditional medical cul-ture is heavily inclined to prescribe medica-tions for nearly all types of health conditions,the idea of launching “Agitol, the formulafor active living,” was conceived. This mockprescription medication comes in a boxwhose appearance resembles other pharma-

ceutical products but whose contents actu-ally consist of educational material on theimportance of physical activity to overallhealth and well-being that is geared specifi-cally toward the medical community. By pro-viding suggested dosages for physical activ-ity—a single dose of 30 minutes, two of 15minutes, or three of 10 minutes—the prod-uct’s creators were able to inject a sense ofhumor into Agita São Paulo’s messages andincrease their popularity among health pro-fessionals while at the same time raising thisgroup’s awareness concerning the dangers ofa sedentary lifestyle. All in all, Agitol pro-vided a classical health promotion approachutilizing the strategy of disease preventionthrough behavior change.

OBJECTIVES AND MESSAGES ON THEPROMOTION OF PHYSICAL ACTIVITY

Essentially one objective, consisting oftwo parts, was established at the beginningof the Agita São Paulo Program: (1) to in-crease the population’s knowledge about the


TABLE 1. Key ingredients contributing to the suc-cess of Agita São Paulo.ê Promotion of the inclusion principle among the

governmental and private sectors and civil societyê Establishment of intellectual and institutional

partnershipsê Intersectoral and intrasectoral balanceê Mutual reinforcement and strengthening of agendas

among partner institutionsê One single objective lending itself to a diversity of

actionsê Collaboration with and high visibility in the mass

media ê Clear messages that are easy to understand and re-

member promoting strategies that are practical andfeasible to achieve optimum levels of physical activity

ê Flexibility in adaptation of interventions to localsociocultural realities

ê Promotion of the concept of behavior change as aprocess involving the progression through a series ofstages and culminating in the achievement of a moreactive and healthier lifestyle

ê Opportunities for social interaction, enjoyment, andmutual support among population segments at high-est risk

biological, psychological, and social benefitsto health of physical activity and (2) to raisethe population’s level of moderate physicalactivity. The program’s goal was to (1) in-crease the degree of knowledge about thebenefits of physical activity by 50% and to in-crease physical activity by close to 20%within a period of 10 years (2% annually).

Various behavior change models wereused as the basis for designing the program’sintervention strategies. The first of these, theTranstheoretical Model (37), conceives be-havior change as a process that involves aprogression through a series of stages, begin-ning with pre-contemplation and movingthrough the contemplation, preparation, ac-tion, and maintenance stages. Adoption ofthis theoretical construct allowed the AgitaSão Paulo Program to develop carefullycrafted messages targeted to individuals andgroups at each of these stages and to providethe necessary incentive and support to helpthem to move forward to the next stage. Theprogram stipulated that the proposedchanges in attitude and behavior should takeinto account the different stages along thedevelopmental continuum and aim to pro-mote an increase in physical activity to atleast the next-higher level (37). In otherwords, the objective of the gamut of inter-ventions designed was to have sedentary in-dividuals become at least irregularly active,those who were irregularly active to becomeat least regularly active, those who were reg-ularly active to become even more active,and to ensure that the segment of the popu-lation which was already highly active main-tained this optimum level without the risk ofincurring injuries.

The quintessential message adopted byAgita São Paulo—that adults undertake atleast 30 minutes of moderate intensity phys-ical activity on most, if not all, days of theweek—was first developed in 1995 by theCDC and American College of Sports Medi-cine (ACSM) and was based on numerousphysiological, epidemiological, and clinicalstudies confirming the health benefits ac-

crued from this duration and intensity levelof physical activity (38) (Figure 2).

This body of evidence has furthermoredemonstrated that the physical activity rec-ommendation may be completed in one con-tinuous session lasting at least 30 minutes orachieved cumulatively through multiple ses-sions of at least 10 to 15 minutes each. Dailyactivities where activity can be accumulatedinclude recreational hobbies (playing soccer,football, baseball, basketball, racquetball,etc.; running; walking; bicycling; dancing;swimming), domestic chores in the home(pushing a baby stroller, walking the dog,washing the car, vacuuming, cleaning win-dows, cutting the grass), and activities thatmay be incorporated into the working day(walking or bicycling to and from the work-place, getting off at an earlier bus or subwaystop, climbing stairs instead of using the ele-vator, going to the gym during lunchtime).

Various high-profile scientific organiza-tions back this 30-minute recommendation,including—in addition to the CDC andACSM—the World Health Organization(WHO) and the American Heart Association(39). The recommendation has been adoptedby various large-scale health promotion pro-grams in countries outside the Region of theAmericas, including Australia and GreatBritain. In the intervening decade since therecommendation was first developed, it hasbeen reevaluated and its validity upheld in a cumulative body of scientific studies, the


Moderate

At least 30 minutes daily

Physical activityrecommendation

At least fivetimes a week

Continuous(one-30)

or cumulative(10+10+10/15+15)

FIGURE 2. Agita São Paulo physical activity recommendation.

more recent of which emphasize that the ac-tivity frequency should be at least five days aweek (40).

The concept of moderate physical activityis particularly relevant for the cultural con-text of São Paulo. Indeed, the modern, fasturban pace that characterizes life in the met-ropolitan area has led many residents to re-port that a lack of time is a major barrier todeveloping an active lifestyle (41, 42). Thus,the idea of engaging in moderate physical ac-tivity in brief sessions is probably a more ap-pealing alternative than single 30-minute pe-riods of intense physical activity. Anotherfactor perhaps influencing this tendency isthe warm and tropical climate that is foundin many parts of Brazil.

THE “MOBILE” ECOLOGICALINTERVENTION MODEL

One of the most innovative components ofAgita São Paulo, which has garnered the pro-gram well-deserved national and interna-tional recognition, is the promotion of behav-ioral change to increase the population’sphysical activity level. The “mobile” ecologi-cal intervention model utilizes as its basis aseries of interacting determinants of physicalactivity, as proposed in the ecological modelof Sallis and Owen in 1997. According to thisproposal (43, 44), the intrapersonal and so-cial and physical environmental factors forma three-dimensional, dynamic model, similarto that of a mobile. Intrapersonal factors in-clude biological, affective, and demographicaspects (gender and age), knowledge, andbehavior, which interact simultaneouslywith those of the social environment (cul-tural and social milieu, availability of sup-portive behaviors, public policies governingresources and incentives) and the physicalenvironment (natural environment, includ-ing climate and geography; constructed en-vironment, including the architecture ofhomes and work sites; public transportationinfrastructure, availability of recreational

sources), thereby positing that behaviors areinfluenced by multiple levels of factors inconstant interaction (Figure 3). This modelmakes it possible to develop behavioralchange interventions, based on an identifica-tion of the specific variables involved and onan understanding of their relationship to oneanother and to the target population.

DEVELOPMENT OF PROMOTIONALPRINT MATERIALS AND PRODUCTS

The health benefits derived from an activelifestyle have been highlighted in all of theorientation manuals and guidelines preparedin relation to the Agita São Paulo Program(39, 45), but since these are long-term benefitswhich are accrued, in some cases, only grad-ually, they are not always immediately per-ceived by the population. Thus, both thephysical and mental health benefits are em-phasized in the program’s promotional mate-rials (Table 2), taking into account that em-phasis on the latter seems to be more effectivewhen seeking behavioral change becausepeople’s perception of increased mental well-being sometimes occurs more spontaneously.This strategy has been particularly effectivein promoting the importance of physical ac-tivity in schools and the work environment,where the benefits may be demonstratedboth on an individual and collective level.

The program employs a variety of materi-als (Figure 4) to encourage increased physi-cal activity. These include:

• Pamphlets, posters, and flyers aimed atthe general public and at specific popu-lation groups (schoolchildren, workers,and older adults)

• Posters promoting mega-events (e.g.,Agita Galera, Agita Mundo, Agita OlderAdult)

• Posters for specific campaigns (e.g.,dengue prevention and control) or re-lated to special commemorative events,anniversaries, and other celebrations


• Orientation manuals for general pro-gram implementation and activities de-velopment for public schools

• Physical activity and nutrition pyramids• “Manufacturing” and promotion of Ag-

itol, “the formula for active living”• Promotional material tied to special oc-

casions (e.g., Carnival, the summer va-cation period)

• General information books highlightingAgita São Paulo activities and best prac-tices and describing the program’s im-pact and the role of partner institutions

• Promotional give-away products (e.g.,key rings, t-shirts, baseball caps, fans,stickers, mouse pads, bookmarks, com-pact disc cases).

Much of the material just described is pro-duced with financial support from the Min-

istry of Health in as-needed quantities forspecific program activities and also to pro-vide information about events sponsored inconjunction with the Ministry. The govern-mental institutions and private entities thatparticipate in the program have been grantedpermission to freely reproduce this material,incorporating their own logos and otherwisepersonalizing it as deemed necessary, as longas the basic message remains unchanged.


Social environmentIntrapersonal

DemographicCognitive/affective

Naturalenvironment

Climate/weather

Urban/suburban

Supportivebehaviors

Social climate

Geography Information

Architecture

Entertainment

Transportation

Recreation

Cultural milieu

Biological

Behavioral

Constructedenvironment

Policiesgoverningresources

Policiesgoverningincentives

Physical environment

FIGURE 3. Mobile ecological model to promote physical activity developed by the Agita São Paulo Program showing multiple dimensions of influence on behavior.

Source: Matsudo VKR, Andrade DR, Matsudo SMM, Araújo TL, Andrade E, Oliveira LC, et al. “Construindo” saúde por meio da ativi-dade física em escolares. Revista Brasileira de Ciência e Movimento 2003;11(4):111–118.

TABLE 2. The benefits of physical activity.Physiological Psychological

Lowers blood pressure Increases self-esteemHelps control body weight Reduces depressionImproves joint mobility Helps maintain indepen-Improves blood lipid profile dence and self-sufficiencyImproves physical resistance Reduces social isolationIncreases bone density Increases well-beingIncreases muscular strength Improves self-imageImproves insulin resistance Reduces stress

MOBILIZATION OF MEGA-EVENTS

In order to increase public awareness ofthe benefits of regular physical activity, theoverall program strategy includes the orga-nization of mega-events designed to attracthigh visibility in the mass media and amongthe general population. Large-scale promo-tion and coverage is presented in all themajor media, including television, radio,newspapers, and magazines. Three mega-events are organized per year, one for everytargeted population group: Agita Galera (GetMoving Everyone) or Active CommunityDay, which is geared toward schools; ActiveWorker Day; and Active Older Adult Day.

Agita Galera: Active Community Day

Beginning in 1997, Agita Galera has beenheld on the last Friday of August of eachyear. Organization of this event requiresmajor logistical preparation involving thetraining and support of tens of thousands of

health and education professionals in the640 cities of the state of São Paulo. The par-ticipants include more than 6,000 public andprivate schools, 250,000 teachers, and 6 mil-lion students who come together to discussthe positive effects of a more active lifestyleand how to create permanent mechanismsthat promote health and physical activity inthe school environment. To facilitate thisprocess, a manual has been developed anddistributed at the primary and secondaryschool levels to teachers, health serviceproviders, and the mass media. Each year, ateleconference is broadcast via cable whoseoverriding message is that creating a culturebased on regular physical activity is notsolely the responsibility of physical edu-cation teachers, but also of their colleaguesin all academic disciplines—including thelife sciences, mathematics, history, andlanguages—to highlight as part of thecourse material the relationship of physicalactivity to their particular field of knowl-edge. Collective and individual activities of15 to 20 minutes, including dances, and art,


FIGURE 4. Educational and promotional materials: Agita São Paulo.

photography, and writing contests, are alsoincorporated into the regular class period inorder to reinforce basic messages concerningthe benefits of an active lifestyle. Commu-nity participation in Agita Galera is encour-aged through outdoor activities organizedin the streets and plazas of large and smallcities throughout the state. Often theseevents include the participation of the stateminister of health and general program co-ordinator, who are transported by helicopterfrom site to site. A 15-minute informationalvideo produced in English, Portuguese, andSpanish is available at the Agita São PauloWeb site which illustrates the principal pro-motional strategies employed by AgitaGalera organizers, a list of events, and anevaluation form enabling organizers to mea-sure the process and impact of events onschools and communities.

Active Worker Day

Educational material and activities havebeen developed to encourage increased phys-ical activity in both the public and privateworkplace. These activities include holdingconferences on health and physical activityduring accident prevention weeks and rais-ing awareness among company directors, aswell as training human resources staff, onhow to work effectively with new concepts ofphysical activity and health promotion.

In addition to the general suggestionscontained in the educational materials, thedifferent missions and perspectives of thevarious institutions have been taken into ac-count, and special efforts have been made torespond to the specific needs of differentworker groups. At the same time, the AgitaSão Paulo Program participates in eventsheld to celebrate International Workers’ Dayon each 1 May and has encouraged its part-ner institutions and others to include thetopic of physical activity in celebrations of alltypes held throughout the year.

Active Older Adult Day

Agita São Paulo has designed materials,including a pamphlet and poster, with con-tent specifically geared to the needs andgoals of the older population. Observing rec-ommended levels of physical activity is, inthis case, promoted as a strategy for main-taining functional independence. Every year,usually to coincide with the 1 October obser-vance by the United Nations of InternationalDay for Older Persons, a mega-event is or-ganized that includes a walk, dances, andgames with multigenerational appeal callingon all citizens to celebrate life. The walk usu-ally lasts no longer than 30 minutes and takesparticipants through urban green areas. Onthis day, baseball caps and sun visors, a com-memorative bag with informational material,oversized cardboard hands, and candy aredistributed as souvenirs.

World Physical Activity Day: Agita Mundo

By the year 2002, the success of the AgitaSão Paulo Program was becoming wellknown around the world. The program’sphilosophy and ripple effects influenced aWHO resolution adopted at the Fifty-fifthWorld Health Assembly that made physicalactivity the central focus of World HealthDay 2002. That same year, the governor ofthe state of São Paulo issued decree 46.664/2002, establishing 6 April as Physical ActivityDay, which continues to be commemoratedthroughout Brazil and in various other coun-tries inside and outside the Region of theAmericas under the slogan “Agita Mundo.”The occasion is marked by the disseminationof materials, such as posters, fans, and stick-ers, in three languages (English, Portuguese,and Spanish) and the organization of groupwalks and of different celebrations to pro-mote physical activities for men and womenof all socioeconomic levels, ages, and ethnicgroups. With the adoption of resolution


WHA 55.23 in May 2002, the internationalMove for Health initiative was born and isheld every year on 10 May, reinforcing thespirit and energy of Agita Mundo and WorldPhysical Activity Day.

BEST PRACTICES FOR PROMOTINGPHYSICAL ACTIVITY

One of the key ingredients behind the suc-cess of the Agita São Paulo Program has beenits strategy of dissemination through both thepublic sector (principally through the Min-istries of Health and Education) and a broadspectrum of the private sector, including civilsociety at large. As a means of disseminatingthe most effective of the strategies emanatingfrom this wide range of institutions, as part ofthe celebration of World Physical ActivityDay in 2003 and 2004, the program organizedthe First and Second Encounters on Best Prac-tices in the Promotion of Physical Activity,which yielded material for two publications.Eighty-four examples are summarized in thefirst publication and 147 in the second of ex-periences in promoting physical activity. Aselection of these is presented in Table 3.

A PHYSICAL ACTIVITY PROGRAM FOR A MEGACITY: AGITA SAMPA

During its first seven years of activities,one of Agita São Paulo’s most outstandingachievements has been the launching by themayor of metropolitan São Paulo of the AgitaSampa program (decree 45.724/2005) to en-courage the regular practice of physical ac-tivity. As part of this program’s implementa-tion, a multisectoral effort was initiatedamong all of the municipal ministries (e.g.,Health, Sports, Education, Transportation,Culture) with the goal of creating a perma-nent and universal strategy to promote phys-ical activity in a variety of contexts and envi-ronments, including parks, plazas, streets,and neighborhoods.

IMPACT OF AGITA SÃO PAULO ON LEVELS OF PHYSICAL ACTIVITY

AND PROGRAM KNOWLEDGE: THE EVALUATION COMPONENT

Periodic evaluations are conducted of theprogram’s impact utilizing a series of indica-tors and the collection of data from the targetpopulation. The elements taken into consid-eration include the following:

(1) Number of program partners (2) Number of activities and events or-

ganized annually by the programand by its partners

(3) Frequency with which the programhas participated in national and in-ternational scientific events

(4) Quantity of educational material pro-duced and disseminated

(5) Determination of target population’sdegree of general knowledge aboutphysical activity and health

(6) Identification of barriers and motiva-tions to engaging in physical activity

(7) Determination of the general popula-tion’s level of physical activity andthat of the three specific groups tar-geted by the program

(8) Determination of the economic costof specific diseases and conditions as-sociated with sedentary lifestyles

(9) Assessment of the economic impactof physical activity interventions

(10) Assessment of the impact of physicalactivity interventions on community-wide morbidity and mortality rates

Evaluations of Agita São Paulo have beencarried out on a regular basis since 1999. Theevaluations, depending on the componentbeing studied, are carried out either semian-nually or annually in localities of metropoli-tan São Paulo as well as in the interior, cen-tral, and coastal municipalities of the state.Household interviews are conducted withresidents over 15 years of age to determinethat population’s level of physical activity



TABLE 3. Agita São Paulo activities summary, selected partner institutions, 1997–2004.Specific Actions Permanent Measures

• Organization of physical activities at schools; amongthem, Agita Night for students and teachers of nightclasses

• Physical activity sessions (stretching and relaxation) atthe beginning of the day and at the beginning of someclasses

• School rumbas adopted by some schools, incorporat-ing a variety of Latin rhythms to accompany physicalactivities

• Diploma awarded to teacher whose class has the most“movement”

• Inclusion of promotion of physical activity in socialintervention programs

• Inclusion of physical activity promotion in the techni-cal training manuals for health workers providingbasic care to older adults

• Inclusion of information on Agita São Paulo on theMinistry’s Web site

• Preparation and distribution of Agita informationalmaterials and promotional items, such as t-shirts, keyrings, and stickers

• Inclusion of links to Agita São Paulo activities and toinstitutional publications on the Ministry’s Web site

• Annual celebration of the Agita Verão summer eventon state beaches and of the Agitando la Sierra event in winter

• Periodic meetings with local health units in which AgitaSão Paulo’s message and activities are disseminated

• Inclusion of physical activity component in a programspecifically targeting the health and well-being ofhealth workers

• Implementation of physical activity programs in healthunits

• Organization of walks for health and conferences pro-moting the importance of physical activity

• Periodic situational review of levels of sedentarylifestyles among health worker staff and at-large localpopulation

• Dissemination of Agita program information via localelectronic networks

• Creation of regional networks for the promotion ofphysical activity

• Inclusion of physical activity component in familyhealth programs and community groups for the treat-ment of hypertension and diabetes

• Formation of walking and tai chi chuan groups and or-ganization of activities for older adults

MINISTRY OF EDUCATION• Mobilization of 6,000 schools in the state’s public net-

work to celebrate Agita Galera • Physical Activity Day commemorated on 6 April in the

public school network by decree no. 46.664/2002• Implementation of the Agita Familia program, in

which children and their families participate in jointeducational and sociocultural weekend activities, suchas 30-minute physical activity sessions at the begin-ning or end of the day. Currently more than 400,000people and 5,306 public schools are involved in theprogram.

MINISTRY OF SOCIAL WELFARE AND DEVELOPMENT• Integration of older adults into physical activity pro-

grams administered by Ministry staff

MINISTRY OF THE ENVIRONMENT• Adaptation of Agita São Paulo logo and clock for use

in Ministry materials• Construction of an indoor walking trail at Ministry

headquarters• Implementation of gym program for Ministry staff • Inclusion of the verb “agitar” in names of conferences

and other institutional events

MINISTRY OF JUSTICE• Health fair in the city of São Paulo to commemorate

World Physical Activity Day

REGIONAL HEALTH DIRECTORATES AND CENTERS• Organization of activities related to Agita events:

– Agita Galera: health professionals take part inschool activities

– Celebration of World Physical Activity Day – Agita Older Adult: organization of dance and walk-

ing groups and seminars and talks for health profes-sionals on the importance of physical activity

MUNICIPALITIES AND CITIES• Organization of events to celebrate Agita Galera, in-

cluding Agita in the Plaza, Agita in the Parks, andAgita in the Neighborhoods

(Continued)


Table 3. Agita São Paulo activities summary, selected partner institutions, 1997–2004. (Continued)Specific Actions Permanent Measures

• Physical activity work-outs to begin the school andwork day in public and private schools and Agita par-ticipating institutions

• Continuing health education activities, incorporatingthe concept of physical activity to combat specific dis-eases (e.g., gymnastics against dengue, basketballagainst tuberculosis)

• Formation of walking groups among family healthteams and others in basic health units

• Joint intersectoral activities developed by the Min-istries of Health, Education, and Sports to promotephysical activity

• Placement of informational material on physical activ-ity on all mobile health caravans

• Organization of dance groups for people withhypertension

• Implementation of technical protocols for behavioralchange with regard to physical activity

• Implementation of guided physical activity programs • Designation of streets specially set aside for the enjoy-

ment of recreational activities• Creation of community walking trails• Creation of the “Walking Truck”: a truck with sound

equipment that travels through neighborhoods and en-courages people to participate in walking activities

• Monthly outdoor day devoted to physical activity withparticipation by various community groups

• Observance of Quality of Life and Health Days • Placement of articles promoting physical activity and

the importance of active lifestyles in association journals• Participation in Agita in the Plaza events• Formation within juvenile diabetes associations of

physical activity groups

• Dissemination of information on physical activity onthe institutions’ Web sites

• Placement of posters and distribution of informationfor students and professors

• Dissemination of information on a variety of physicalactivity topics in internal publications and on weeklyschedule of institutional activities

• Development of physical activity programs targeted touniversity staff members

• Publication and presentation of scientific research onphysical activity

• Dissemination of Agita São Paulo message in corpo-rate communications media

• Placement of Agita program information in strategiclocations throughout the company (e.g., health unit,restrooms, employees’ cafeteria, staff lounges, waitingrooms, central lobby)

MUNICIPALITIES AND CITIES (Continued)• Participation in World Physical Activity Day • Organization of physical activities in conjunction with

the Agita Carnaval event and World Health Day• Construction of bicycle paths and sponsoring of biking

trips • Inclusion of the concept of physical activity in com-

munity events and exhibits, including health fairs andspecific disease prevention and control activities,among them dengue fever

• Talks on the importance of physical activity targetinghealth professionals, community health promoters,students of all ages, and older adults

• Preparation of signs and posters promoting the impor-tance of an active lifestyle and healthy diet

• Printing and distribution of Agita São Paulo educa-tional material in shopping malls, other commercialestablishments, churches, government centers

• Placement of signs about physical activity in all basichealth units

• Incorporation of a 30-minutes-of-physical-activity-daily message on the respective letterheads and in allofficial documents of the Ministries of Sports andHealth

• Formation of Internet discussion groups on physicalactivity

• Inclusion of a physical activity message in the salaryreceipts of civil servants and printed on all municipalelectricity bills

• Organization of special events, such as “24 hours ofwalking” in São Paulo municipalities

ASSOCIATIONS• Organization of activities in conjunction with the

Agita Galera, Agita Mundo, Agita Verão, and AgitaOlder Adult mega-events

UNIVERSITIES• Organization of activities in conjunction with the

Agita Galera, Agita Mundo, Agita Verão, and AgitaOlder Adult mega-events

• Convocation of scientific events related to the study ofphysical activity

• Inclusion of physical activity promotion in the missionof public and private academic foundations devotedto improving conditions of institutionalized minorsand delinquent adolescents

PRIVATE BUSINESS SECTOR• Organization of walk-in-the-park programs and other

types of walks for staff members and families tied intospecial commemorative occasions

• Promotion of and participation in World Physical Ac-tivity Day, World Health Day, Agita Galera, and otherAgita mega-events

(Continued)

and knowledge about the program and itsmessage. An internationally tested and na-tionally adapted questionnaire is used toassess physical activity levels (46). Thisquestionnaire, known as the InternationalPhysical Activity Questionnaire, or IPAQ,when used in its short version, determinesthe frequency and duration of vigorous andmoderate forms of physical activity and ofwalking. In 2000, data were obtained fromsemiannual visits to some 645 people se-lected at random, the analysis of whichshowed higher levels of physical activityamong those who were familiar with theprogram’s objectives (43.0%) than amongthose who were not (35.3%).

Data on physical activity levels analyzedbetween 1999 and 2004 on more than 3,000individuals (Figure 5) clearly show positiveprogress in the metropolitan area of SãoPaulo, where the rate of sedentary lifestylesdecreased from 15% to 11%. The percentageof people classified as irregularly active wentfrom 30% to 27% and that of active and veryactive people increased from 55% to 62%.

Data corresponding to the state of SãoPaulo, grouped according to sex and age andsocioeconomic and educational levels, andwith regard to the impact of the Agita SãoPaulo Program, showed that 55.7% had someknowledge of the program, more than 60% ofthose with higher educational levels knew


Table 3. Agita São Paulo activities summary, selected partner institutions, 1997–2004. (Continued)Specific Actions Permanent Measures

• Periodic distribution of informational material to staffmembers and family members

• Access to on-site gymnasium and/or recreationalfacilities

• Incentive-based campaigns to discourage sedentarylifestyles among staff (e.g., the accumulation of“miles” and points that can be exchanged for gifts atthe end of a given period, other forms of specialrecognition for staff members accumulating the mostphysical activity)

• Organization of walking and running teams

• Inclusion of physical activity in group therapy sessionsfor patients with mental health problems

• Placement of information on Agita São Paulo in physi-cians’ offices

• “Prescription” by doctors of Agitol to encourage in-creased physical activity among patients

• Provision of orientation sessions on physical activity inwaiting rooms and other public areas of health facilities

• Conferences and discussion groups on physical activ-ity for patients

• Provision of telephone advice on physical activity forpatients via a proactive call center

• Walking programs for groups of patients accompaniedby health professionals

• Presentation of educational videos on physical activity• Physical education and tai chi chuan classes for patients• Availability of physical trainers to work with patients• Teaching activities for physicians and medical students

to encourage them to promote the benefits of physicalactivity during interactions with their patients

• Availability of specialized courses for family healthprofessionals on topics related to physical activity

• Monthly field day featuring walks, games, and sports

PRIVATE BUSINESS SECTOR (Continued)• Inclusion of topics related to physical activity in the

observance of Accident Prevention Week• Opportunities for participation in sports activities for

staff members• Staff conferences on physical activity and administra-

tion of questionnaires to determine levels of physicalactivity

• Launching of personalized “corporate” versions ofAgitol (e.g., “Exercil Plus”)

• “Adopt a Sedentary Person” health promotioncampaign

HOSPITALS, CLINICS, AND HEALTH INSURANCECOMPANIES• Participation in the program’s mega-events (Agita

Galera, Agita Mundo, and Agita Older Adult); WorldHealth Day, World No-Tobacco Day, and MentalHealth Week; as well as commemorative events re-lated to weight and obesity control and preventionand control of hypertension

• Institutionally sponsored walking, stretching, andrelaxation programs

• Development of on-site physical activity facilities foruse by health professionals

• Development of research studies on the effects ofphysical activity in patients with asthma and lowerback pain, and on the knowledge of health profession-als concerning the benefits of physical activity

• Creation of multidisciplinary groups to promote bene-fits of physical activity to the community at large

about the program, and 37% were familiarwith the program’s objective. In analyzingthe impact of the program on the metropoli-tan area, positive progress could be seen inthe increase from 53% to 61% in the percent-age of people who said they knew the pro-gram’s name. Of that group, in 1999, 19%were familiar with the program’s message,while in 2004 that figure rose to 23%.

INTERNATIONAL NETWORKS TOPROMOTE PANA AND AGITA MUNDO

PANA

As a result of the positive impact of theAgita São Paulo Program in the state of SãoPaulo and throughout the country (44), since1998, similar initiatives in other countrieshave begun to emerge and subsequentlyhave been consolidated into an internationalnetwork to promote physical activity, whichhas become the coordinating nexus for theparticipating national networks. The Phys-ical Activity Network of the Americas(PANA) is a good example of the joint effort

by associations, partnerships, and estab-lished strategic coalitions working to combatsedentary lifestyles in the Region. PANA hasbeen consolidated into a network of net-works and seeks to encourage the practice ofphysical activity in the Americas with a min-imum of bureaucratic structure while at thesame time fostering action, inclusion, sim-plicity, and flexibility. PANA’s guiding prin-ciples are:

• to be an inclusive network that incorpo-rates both national and internationalpublic and private institutions;

• to focus on research and public healthprograms to benefit communities andwhole populations;

• to promote the sharing of experiencesand knowledge; and

• to promote an environment that im-proves human resources developmentamong health professionals working inthe area of physical activity and the pre-vention of sedentary lifestyles.

Numerous national and local programshave been promoted within the PANA frame-


FIGURE 5. Level of physical activity of population (percentages of inactive, irregularly active, active, and very active) in metropolitan São Paulo, 1999, 2000, 2002, 2003, and 2004.

70

60

50

40

30

20

10

0

1999 (n = 641) 2000 (n = 645)

2003 (n = 662)2002 (n = 627)

2004 (n = 651)

Inactive Irregularly active Active + very active

14.917.2 15.5 14.4

11.2

54.8

45.9

54.3

60.4 61.8

30.3

36.6

30.325.2 27

work. In Argentina, these include A MoverseArgentina, Argentina en Movimiento, andSalí a Moverte; in Bolivia, Muévete Bolivia;and in Colombia—which launched theColombian Physical Activity Network—Muévase Pues, Muévete Bogotá, RisaraldaActiva, Actívate Pereira, Buga en Movi-miento, Guajira Activa, Madrúgale a la Salud(Cartegena), Palpita/Vibra Quindío, CaucaActiva, Cundinamarca Activa y Positiva, Bo-yacá Activa, Colombia Activa y Saludable,Cali en Movimiento, A Moverse, and HuilaActiva y Saludable. In Costa Rica, the pro-grams include Movámonos Costa Rica; inEcuador, A Moverse Ecuador; in Mexico, theNacional Physical Activity Program; in Peru,Muévate Perú; and in Venezuela, Venezuelaen Movimiento. A sampling of these educa-tional and promotional materials is presentedin Figure 6. Based on the nature and scope ofactivities developed by each program, the na-tional networks in the different countrieshave also begun to form partnerships and de-velop joint work strategies in much the same

way as the Agita São Paulo Program has donesince its inception.

Agita Mundo

The goal of the Agita Mundo Network, asnoted earlier in this chapter, is to create an in-ternational momentum for a more activelifestyle as a crucial element in the promo-tion of overall mental and physical healthand well-being for all individuals, communi-ties, and nations. Since its inception in 2002,the Agita Mundo network has promoted re-search and the dissemination of informationon the benefits of physical activity and onstrategies to increase it, has advocated forphysical activity and health, and has sup-ported the creation of programs and localand national networks to promote physicalactivity. At the last meeting of the AgitaMundo network, held in São Paulo in Octo-ber 2004, the decision was made to create theAgita Mundo map, which includes a com-prehensive list of intervention programs,


FIGURE 6. Educational and promotional materials: The Physical Activity Network of the Americas.

Web sites on physical activity, major publica-tions, the institutions associated with the net-work, physical activity reference centers, anddata on the prevalence of sedentary lifestylesthroughout the world.

The principal documents produced by thenetwork, the São Paulo Manifest and the De-claration of São Paulo on the Promotion ofPhysical Activity, as well as the results ob-tained through the mobilization of the PANAand Agita Mundo international networks,are available in English, Portuguese, andSpanish at www.rafapana.org and are coor-dinated in São Paulo by CELAFISCS. In ad-dition, the networks receive ongoing supportfrom a variety of institutions, including theInternational Union of Health Promotionand Education, PAHO, and the CDC.

CONCLUSIONS

The Agita São Paulo Program has provento be a successful model of intervention forthe promotion of physical activity, especiallyin developing countries, and an effectivestrategy in different levels and sectors, be-cause it simultaneously encompasses the ac-tions of institutions and interest groups fromthe public and private sectors and from civilsociety, with a common objective: combatingsedentary lifestyles. The program’s positiveimpact on the community derives from itsfirmly rooted principle of inclusion, whichnurtures cultural and regional diversity, aswell as the promotion of intellectual and in-stitutional partnerships; the balance and dy-namism that characterizes its intersectoraland intrasectoral partnerships; the opportu-nities for mutual strengthening and rein-forcement of the respective missions of theindividual partner institutions; the presenta-tion of one clear and simple message that iseasy to understand and remember (i.e., 30minutes of physical activity, preferably everyday); the sound scientific basis for the pro-gram’s messages, intervention strategies,and evaluation component; the support of

the communications media in the dissemina-tion of messages and information to broadand diverse audiences; and Agita São Paulo’suniversality and adaptability to a variety ofsocial and environmental settings.

ACKNOWLEDGMENTS

The authors wish to acknowledge the on-going contribution of the program’s techni-cal and scientific advisers, Timóteo Araújo,Douglas Roque Andrade, Luis Carlos deOliveira, and Erinaldo Andrade, as well asexpress their gratitude to the minister ofhealth of the state of São Paulo and the mem-bers of CELAFISCS for their support.

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INTRODUCTION

This chapter describes the recent transfor-mation in the lives of the citizens of Bogotá,Colombia, and in the urban environmentthey share. Statistics point to substantialqualitative and quantitative improvementsin this large, bustling, cosmopolitan worldcapital. There are promising signs of in-creased physical activity, a situation thatcould provide useful input for the planningof a wide variety of public and private effortsaimed at counteracting the increase in seden-tary lifestyles, obesity, and chronic diseasesin this city. Indeed, scientific evidence showsthat these health conditions can be pre-vented2 by combating risk factors3 throughphysical activity. Regular physical activity,combined with a proper diet and restrictedtobacco and alcohol use, diminishes the like-lihood of dying from chronic disorders re-lated to overweight and obesity, such as car-diovascular disease (3), type 2 diabetesmellitus, and some types of cancer (of thecolon, prostate, ovary, and endometrium) (4).

Despite important cultural and urbanplanning changes in Colombia, the generalurban situation with regard to physical activ-ity is very similar to that of other large LatinAmerica cities: half the population, includ-ing all age groups over age 5, is overweight,

giving rise to an ever-increasing incidence ofchronic disease, even among the very young.The incidence of these modern ills is growingin Colombia at an annual average rate of10%; in some seven years, this could trans-late into more than 75% of Colombians beingoverweight. In Bogotá, most overall mortal-ity is related to chronic illnesses (21.7% ofdeaths from ischemic heart disease, 14.1%from cerebrovascular problems, and 7.2%from diabetes mellitus).4 Nevertheless, in thelast six years, bicycling and walking havedoubled—not counting recreational andsports purposes; if this trend continues, amoderate reduction in chronic disease in thefuture can be expected.

Although there is still scant scientific evi-dence of a correlation between improvedurban milieus and increased physical activ-ity, the study on the transformation of Bo-gotá described in this chapter should enrich

PROMOTING ACTIVE LIFESTYLES ANDHEALTHY URBAN SPACES: THE CULTURAL

AND SPATIAL TRANSFORMATION OFBOGOTÁ, COLOMBIA

Ricardo Montezuma1

161

1Director, Fundación Ciudad Humana, Bogotá,Colombia.

2“It is now clear that regular physical activity reducesthe risk for coronary heart disease, diabetes, colon can-cer, and several other major chronic diseases and condi-tions” (1).

3“Eighty percent of obese adults suffer from diabetes,high cholesterol levels, high blood pressure, [and] coro-nary heart disease” (2).

4Secretaría Distrital de Salud. Death certificates, 2001.Preliminary data.

the international discussion on the topic.Hence, more than providing definitive re-sults and evidence for the entire country, thischapter presents the case of Bogotá, whichinterdisciplinary teams from the PublicHealth Institute of Colombia’s National Uni-versity and the Fundación Ciudad Humanahave begun to study from a comprehensiveperspective.5 This interplay between diversetheoretical and practical approaches shouldcontribute to additional reflection on the pro-motion of physical activity in other locales inthe Region of the Americas.

Structural and functional changes in citiesand in modern urban life—such as the in-creased use of motor vehicles and of automatedtechnology—translate into habits that areconducive to a sedentary lifestyle, which, inturn, is one of the leading factors of higher lev-els of overweight and obesity among urbandwellers. Thus, the participation in Latin Amer-ica of urban planners in efforts to prevent andfight against chronic disease, while a very re-cent phenomenon, is nonetheless timely. In thepast 20 years, many researchers, especially inthe United States, have paid special attentionto the role of the urban environment or milieuin the maintenance and promotion of publichealth. This is because individual and collec-tive well-being is closely associated with a se-ries of physical, social, cultural, and economicconditions that influence the effectiveness ofefforts to lower the incidence of diseaseamong the population (5).

Factors related to urban layout and de-sign, including topography and land distri-bution and zoning (public vs. private), di-rectly and indirectly influence many forms ofbehavior that are determinants of physical

activity or inactivity. According to Schmid,Pratt, and Howze (6), changes in environ-ment are more likely to encourage increasedphysical activity than are policies that at-tempt to influence individual behavior.Urban structure can influence physical activ-ity and buttress public health efforts, or it canimpede the success of health policies aimedat discouraging a sedentary lifestyle, espe-cially in activities related to mobility andrecreation. Indeed, the qualitative and quan-titative characteristics of public traffic, aswell as public spaces for pedestrians (parks,sidewalks, jogging paths, etc.) and cyclists(bicycle paths or routes), are some of theprincipal factors that determine physical ac-tivity or inactivity. However, the correlationbetween these topics (city living, urban de-sign, physical activity, obesity, sedentarylifestyle, and public health) has barely beenaddressed by researchers of urban and pub-lic health issues in Latin America, and evenless so by municipal policymakers and tech-nical experts. And notwithstanding findingsshowing a correlation between physical ac-tivity and urban milieu discussed in thisstudy, government officials and technical ex-perts in Bogotá have not coordinated their ef-forts vis-à-vis urban and public health issues.

As will be elucidated further in the Con-clusions section of this chapter, Bogotá’s cul-tural and spatial transformation was the re-sult of an overall process that was unplannedand, to a certain extent, unintended, in thesense that the various constituent parts werenot necessarily coordinated, although theycomplemented each other. Citizen educationcampaigns, the recovery of public space, andthe construction of walkways and bike-ways—among other major achievements—contributed to persuading people to changetheir daily behavior related to physical activ-ity. In the long run, these new habits may in-crease life expectancy and improve the qual-ity of life in the city. In addition to thecampaigns and efforts between 1995 and2003, the urban transformation of the 1990smade it possible for these actions to have a

162 Promoting Active Lifestyles and Healthy Urban Spaces

5These two entities have begun a nationwide studyfunded by the Social Protection Ministry. The purpose ofthe study is to evaluate sedentary lifestyles and physicalactivity, and the (positive or negative) correlation be-tween the characteristics of city life and physical activ-ity. A subsequent study will attempt to introduce amodel for urban transportation to demonstrate the pos-sibilities for change in levels of physical activity in threeof the country’s departments, including Cundimarca, ofwhich Bogotá is the capital.

very positive influence on physical activity.Some of these transformations are related to:

• population density, which rose to an av-erage of 200 inhabitants per hectare;

• a reduction in average trip distances toapproximately 8 km;

• the increased use of mass transportation,with buses in an informal private networkaccounting for more than 70% of the dailytrips taken in motorized vehicles; and

• limited ownership and use of automo-biles: only 13% of the population ownsa private automobile, and merely 19%of trips are made in automobiles.

This chapter examines the above factorsand is divided into four sections. The firstoutlines the changes carried out in the cityand breaks these changes down into differentcategories. Hence, it analyzes the period inquestion from several vantage points—physi-cal and functional, social, economic, and po-litical—to present a point of reference fordiscussing the two major redefinitions under-gone by the city in the next two sections. Thefirst redefinition, that of citizen education, an-alyzes the transformations that have takenplace, focusing especially on the term ofMayor Antanas Mockus Sivickas and the citi-zen education campaigns carried out duringhis administration. The second redefinition,that of esthetics, space, and function, exam-ines the principal changes occurring duringthe term of Mayor Enrique Peñalosa: publicspace, mass transit, individual transportation,and nonmotorized transportation. The fourthsection presents this chapter’s conclusions,stressing the complementarity between thetwo types of redefinitions and their probablerole in increasing physical activity.

THE GENERAL TRANSFORMATION OF BOGOTÁ

Although Bogotá’s transformation is espe-cially noticeable in its spatial dimension, and

particularly in its transportation infrastruc-ture and the characteristics of its publicspaces, it has affected every facet of the city.Accordingly, before turning to the centralissue examined in this chapter—Bogotá’scultural and spatial transformation—a briefoverview of changes in the physical andfunctional, social, economic, and politicaldimensions is presented in separate sub-sections. This crosscutting examination ofevents in the Colombian capital is the princi-pal starting point for understanding the ori-gin and scope of changes of a general natureas well as those related to physical mobility,public transportation, and the behavior ofthe residents of Bogotá themselves between1995 and 2003, in which the latter changeshad to do more clearly with physical activity.To allow for a better understanding of themagnitude of the changes in the Colombiancapital, the evolution of the principal indica-tors over a decade is presented, and anoverview of the general characteristics ofpublic transportation before these transfor-mations occurred is given.

Physical and Functional Aspects

Despite the profound crisis in the privateconstruction sector,6 Bogotá has seen a consid-erable change in physical and functional issues,due to the recovery of public spaces for pedes-trians (promenades and tree-lined alamedas,among others), the construction of roads andrelated infrastructure, the building of bicyclepaths (a total of 300 km, at a cost of more thanUS$ 46 million), the recovery of parks andmedians, and, especially, the implementationof the TransMilenio system.7 This is a new

Montezuma 163

6Between about mid-1998 and 2003, Bogotá’s con-struction industry experienced an acute crisis, closelylinked to the national economic situation, disequilib-rium in the financial system, and the elimination ofUPAC (Unit of Constant Purchasing Power), a priceindex. Housing construction had come to a completestandstill by the end of this period.

7The name TransMilenio refers to the various compo-nents of Bogotá’s new mass transit system. The com-pany responsible for the system is referred to as Trans-Milenio S.A.

urban transportation system with lanes for theexclusive use of buses, fixed bus routes andstops, accordion (stretch) buses, and feeder(suburban to downtown) buses. TransMileniooperates like a subway-type mass transit sys-tem, sharply reducing travel time for some 13%of public transportation passengers.

In general, urban mobility has improved,especially during peak hours, reducing con-gestion and travel time (7). Indeed, whereasin the mid-1990s traffic moved at a speed ofwell below 10 kph during rush hour, by mid-2003 it had increased to 18 kph. The most sig-nificant functional change in transportationis the reduction by more than one-third inthe number of private vehicles driven duringrush hour and the rise in the number of tripson foot and by bicycle, from 7% to 11% and2% to 4%, respectively, between 1998 and2003 (Figure 1) (8). This has been made pos-sible to a large extent by the citizen educa-tion programs and the improvement of pub-lic spaces, the building of bicycle paths, andthe more rational use of automobiles duringrush hour, among other factors. Automobileuse was reduced through the programknown as “Pico y Placa,” which takes 40% ofprivate vehicles off public streets from Mon-day through Friday between 6 a.m. and 9 a.m. and 4 p.m. and 7 p.m.8 This change hastranslated into significant progress both inrelative and in absolute terms, because it hasbeen achieved within the context of a con-stant increase in the total number of vehiclesin the city and in the total number of dailytrips taken in motor vehicles.

Despite higher rush-hour driving speeds,9

one of the most important indicators of, andone of the most important achievementsfrom, improved urban mobility is the consid-

erable reduction in traffic accidents—from1,387 in 1995 to 585 in 2003, a decline of morethan 50% (Figure 2) (9). This improvementstems from citizen education campaigns,successful efforts to discourage people fromdriving while under the influence of alcohol,and the transfer of responsibility for trafficcontrol from the local to the national police.The decline in traffic accidents underscoresone of the most outstanding features of theformal and functional improvement in thecity: it can be said that today travel in Bogotáhas become twice as safe, which has had apositive impact on economic, social, environ-mental, and, especially, public health issues.

Social Aspects

There have also been significant socialchanges, both in form and in substance. First,all public utility services now reach morehouseholds. Between 1998 and 2003, house-holds with access to clean drinking waterrose from 93% to 100%; those with access toadequate sewage disposal, from 84% to 95%;and those with access to gas energy sourcesfrom 50% to more than 80%. Most of thesebeneficiaries live in lower income neighbor-hoods. The process of providing these ser-vices and improving living conditions inthese neighborhoods was called desmargina-lización (poverty alleviation). During themayoral term of Enrique Peñalosa (1998–2000) alone, 316 neighborhoods were incor-porated into urban improvement plans, en-suring them drinking water and electricityand bringing them street-paving projects.Furthermore, more than US$ 400 million wasinvested to benefit 650,000 low income resi-dents (10). In the late 1990s, outlays for pub-lic education were doubled, and enrollmentincreased to 140,000 (11), thereby indicatingthat 98% of school-age children were beingschooled by the end of 2003.

The social transformation of Bogotá hasgone beyond investment in household pub-lic utility services and the provision of infra-structure. The mentality of its citizenry has


8Starting in August 2001, the “Pico y Placa” programwas extended to public transportation vehicles, 20% ofwhich have been taken off the streets from Mondaythrough Saturday.

9According to a 1995 study by the Japan InternationalCooperation Agency, the average rush-hour drivingspeed was only 5 km/hour, whereas in 2003, the BogotáTransit Authority determined that it had risen to 16 km/hour.

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18

7

22

0

13 13

6

32

1

12

11

17

4

3

1

0

2

4

6

8

10

12

14

16

18

20

Private vehicle On foot TransMilenio Bicycle Taxi Motorcycle

1998 and 19992000 and 20012002 and 2003

Trip

s(%

)

FIGURE 1. Evolution of functional changes in transportation modes during rush hour in Bogotá, 1998–2003.

FIGURE 2. Reduction in deaths due to traffic accidents in Bogotá, 1991–2003.

585

697745

834878914931

1,301

1,387

1,3411,260

1,089

1,284

0

200

400

600

800

1,000

1,200

1,400

1,600

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Source: Encuesta Anual de Percepción Ciudadana del Proyecto “Bogotá, Cómo Vamos”, 2004.

also changed, and though this is hard todemonstrate with statistics, the acceptance ofmany education and awareness-raising pro-grams points to this change. In 2001 and2003, surveys were conducted to gauge theseprograms’ impact (Table 1). Although the re-sults suggest that there have been consider-able changes in this regard, the changes be-tween 1995 and 2001 were, presumably, evenmore significant, because from 1995 to 1997priority was given to programs to educatethe population and encourage behavioralchanges.

Some of the most significant achievementsin the city are related to personal security, asseen in the decline in the violent death rateby 46.6% between 1994 and 2003 (Figure 3).This is one aspect in which the city haschanged and improved the most. Neverthe-less, most of the population is not yet com-pletely aware of the improvements stem-ming from the declining violent death andcrime rates. There is a large difference be-tween statistics on and perceptions regard-ing or anecdotal evidence of insecurity. Fur-thermore, Bogotá’s mass media did notactively support policies to improve security,unlike in other countries, for example, the“Zero Tolerance” campaign in New York,through which the number of police and lawenforcement agents increased. In Bogotá, thefoundations for this progress were educa-tion, gun control, reconciliation between an-tagonistic groups, peaceful conflict resolu-tion, and citizen education, among otherefforts.

Economic Aspects

Changes have also been seen in the eco-nomic sphere, both in increased tax collec-tion and in higher public investment. Be-tween 1990 and 2003, tax receipts in Bogotátripled, and the credit rating on domesticdebt improved considerably, reaching a leveltwice as high as the rating given in precedingyears. In the same period, tax revenuesjumped from some US$ 200 million to more

than US$ 750 million. The revenue increasecame from a higher surcharge on gasoline,the implementation of a plan to fight tax eva-sion, the updating of the real estate register, asimplification of tax laws, the assessment ofa property tax for public works (known asvalorización de beneficio local), the raising ofpublic utility rates, and national funding forthe TransMilenio system (12)—for 15 years,52% of the total budget for this system willcome from the federal government. The risefrom 14% to 20%, and then to 25%,10 in thegasoline surcharge was one of the greatestsources of revenue for the investment intransportation (a street grid known as mallavial and mass transit). In addition, there weretwo anti-tax-evasion plans,11 and the district(capital) land registry was updated,12 withwhich significant supplementary resourceswere obtained. In addition to these increasesin general revenues, additional resourceswere created with the selling of part of Em-presa de Energía de Bogotá to private in-vestors, which yielded US$ 485 million.

One of the greatest achievements in themanagement of the capital’s finances hasbeen the reduction in operational costs andthe allocation of the resources saved to in-vestment. Until 1994, more than 45% of theannual budget went to operational costs,compared with 52% in 1992. Since 1995, ex-penditure on this item has continued to de-cline and accounted for just 20% in 1999. Fur-thermore, investment rose from 30% of thebudget in 1992 to 75% in 1999 (Figure 4).Sounder public finances increased residents’confidence in the city’s managerial capaci-ties, allowing additional voluntary taxes tobe collected between 2001 and 2003. As thecity council did not accept a proposal fromthe mayor to increase taxes, the mayor choseto ask citizens to voluntarily increase their


10Agreement 24 of 1997.11The first anti-evasion plan allowed US$ 30 million to

be collected in 1999 and US$ 35 million in 2000. The sec-ond plan allowed a 40% increase in the taxpayer roster.

12Agreement 24 of 1997.

annual tax payments by 10%. Some 70,000taxpayers accepted to do so and contributedmore than required of them. This shows thedegree of popular recognition and accep-tance both of the mayor and of his manage-ment of the city. To a large extent, the resi-dents who paid more did so as a way toexpress their appreciation for the city’s greattransformation and the improvements inpublic management. Hence, an additionalachievement was the municipal govern-ment’s renewed credibility in the eyes of thegeneral population.

Political Aspects

There have also been considerablechanges in the political realm, both amongelected officials and among their con-stituency. Elected officials have taken impor-tant, innovative actions in favor of the redef-inition of community participation and theuse of public space. And voters, through themayoral elections, have expressed their dis-agreement with the traditional political classand bipartisan system by casting what iscalled an “opinion vote,” which is a new

Montezuma 167

TABLE 1. Evolution of citizens’ behavior and respect for laws in Bogotá, 2001 and 2003, by percentage.Indicator 2001 2003

Those who are familiar with and abide by safety belt laws 13.30 25.70

Those who do not justify breaking laws regarding parking in no-parking zones 62.00 84.70

Those who generally respect local laws 43.00 48.80

Those who justify breaking the law when doing so is the only way to attain their objectives 24.10 17.30

Those who justify disobeying laws that are customarily ignored 8.90 6.60

Those who justify breaking the law when it is economically advantageous to do so 11.80 7.50

Those who think that it is preferable to have a weapon for personal protection 24.80 10.40

Source: Observatorio de Cultura Urbana (Observatory of Urban Culture).

FIGURE 3. Homicide rates per 100,000 inhabitants in Bogotá and outside of Bogotá over the last four decades.

0

10

20

30

40

50

60

70

80

90

1961

1963

1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

Colombia (outside Bogotá)Bogotá

Source: Instituto Nacional de Medicina Legal y Ciencias Forenses.

form of public expression that has opted toeschew traditional clientelistic voting pat-terns. Interestingly enough, this alternativevote has manifested a different expression ineach election. On the one hand, persons notlinked to the traditional political machineryhave been elected—such as professor An-tanas Mockus (1995–1997), Bogotá’s firstmayor of “civic or alternative” origin;13 onthe other hand, voters have rejected pop-ulism—as personified by the candidate Car-los Moreno de Caro—when, in the followingelections, they chose to embrace a politician,consultant, and university professor named

Enrique Peñalosa (1998–2000). Both Mockusand Peñalosa operated in a context thatstrongly favored major policy transforma-tions, allowing, among other things, an in-crease in the efficiency of civil servants and areduction in corruption, through an im-proved public sector procurement system.

An Overview of the Factors Leading to Change

As regards the transformation of Bogotá,this subsection looks at the factors that ex-plain the general changes, and, in particular,those related to transportation. The initialassumption is that the transformation ofBogotá was the result of a sea change in thepolitical sphere,14 which translated into a


FIGURE 4. Percentage in evolution of investment costs, debt servicing, and operational expenses, 1990–2000.

0

10

20

30

40

50

60

70

80

20001999199819971996199519941993199219911990

Perc

enta

ge

Year

Operating costsDebtInvestment

13In Colombia, a mayor of “civic or alternative” originis one who is elected by popular vote and whose politi-cal roots do not lie in either of the two large centrist par-ties, the Conservative Party and the Liberal Party. In ad-dition, such candidates come from different sectors ofthe public administration; generally they are academicsor representatives of lay or religious civic movements(e.g., leaders of unions or associations, demobilizedguerrilla movements, ethnic minorities).

14“The political dimension is not limited to a group ofmen, but rather to all groups and to all men, without ex-ception . . . and the political dimension is related to thejoint action of citizens for the attainment of commongood” (13).

redefinition of the roles of actors both at theat-large and the individual levels.

As we saw in the previous subsection, inthe political sense, this redefinition has in-cluded both voters and elected officials, withthe voting populace expressing their collec-tive will through use of the “opinion” vote,and with the officials elected in two succes-sive mayoral terms spearheading a redefini-tion of citizenry participation and the use ofpublic spaces. Moreover, these officials havestriven to defend public interests over pri-vate interests and the general good over par-tisan priorities. This political stance repre-sents an aberration in traditional Colombianpolitics, which in earlier years had produceda series of governments characterized by adistinct lack of will in defending the public’sbest interests and safeguarding the rights oftheir citizens.

The unfavorable political climate for tra-ditional politicians and the socioculturaltransformations characteristic of the 1990sled voters to opt for alternative proposals,such as the election of Antanas Mockus in1994. This shift in voter preference in Bogotáhad been presaged in other cities of the coun-try and was even replicated in national andlocal elections in many other countries andcities of Latin America. It has brought intopower a diversity of new players that in-cludes civic leaders (both lay and religious),representatives of unions and not-for-profitand business associations, and ethnic andpolitical minorities—such as members of in-digenous groups, black communities, left-wing parties, and former guerrillas—as wellas nationalists, intellectuals, populists, andentertainers (singers, actors, comedians, andsports commentators, among others).

Factors encouraging changes in trans-portation and physical mobility are closelytied to political issues. Hence, in Bogotá,change took place within the framework ofdetermining the role of the principal stake-holders: city hall, transportation companies,and the general public. City hall promotedchanges in the way people conceived of

transportation and how it should function;transportation companies accepted and fol-lowed through on making internal changesin the sector’s organization; and citizenschanged their thinking by accepting newlaws, standards, and programs related to thecreation of infrastructure projects. To betterexplain the magnitude of these changes, thenext subsection examines the characteristicsof urban mass transit in the late 1990s.

Urban Transit Prior to theTransformation

Starting in the early 1980s, when theurban area was burgeoning and there werelimited new alternatives for managing exist-ing urban transportation infrastructure, thequality of daily transportation in the cityprogressively deteriorated. Then, in the early1990s, urban transportation further wors-ened due to the massive introduction of ve-hicles, spurred by a macroeconomic policythat opened the borders and cut importtariffs.

Bogotá, as well as nearly every othermajor population center in the Region of theAmericas, found itself a victim of what be-came known as “the transportation prob-lem,” a dangerous dichotomy marked bywidespread automobile gridlock and a woe-fully inadequate system of public thorough-fares to accommodate the swelling numberof vehicles in circulation. In Bogotá, this situ-ation led to considerable changes in the city’ssocioeconomic and spatial structure until thephysical boundaries could no longer con-tinue to expand. Hence, there was a series ofpositive and negative occurrences, amongwhich the most important were:

• a higher population and housing density; • displacement of the downtown busi-

ness district toward the north of thecity;

• consolidation of several “subcenters”within the city and of one metropolitan“hypercenter”;

Montezuma 169

• radical changes in the criteria used byresidents in choosing a place to live; and

• consolidation of a once-unreliable masstransit system.

The last item in this list requires closerexamination, in view of the fact that thetransformation of Bogotá’s once-unreliabletransportation system has significantly con-tributed to increasing the amount of time res-idents spend walking. Indeed, the currentTransMilenio system, with its fixed bus stopsand the long distances that need to bewalked to reach these stops, stands in sharpcontrast to the traditional system, in whichbuses allowed passengers to disembarkwherever the latter requested. Prior to theconstruction of TransMilenio, passengers ofthe traditional system accounted for morethan 80% of daily trips in the city. The popu-lation’s unruliness was reinforced by a semi-informal organization of the traditionaltransportation system that forced drivers toseek out passengers in order to guaranteetheir income. Hence, drivers had turned thecity into a type of battlefield in what becameknown as the “centavo war.” Nevertheless, inpractice, the unreliability of collective trans-portation was due in part to the particularway the system was operated. The poor ser-vice—with the lack of set bus schedules, dis-regard for stops, irregular routes, and gener-alized overall lack of discipline—was not theresult of the “centavo war,” the lack of civility,or the drivers’ socioeconomic and culturalcharacteristics, as is frequently suggested.Rather, the “centavo war” was built into thestructure of this type of transportation sys-tem, requiring buses to be filled to capacitydespite the low profit margins this ridershipproduced.

These problems were not exclusive to Bo-gotá in the 1990s: precarious organizationand management of collective transportationare characteristics common to a number ofLatin American cities. To a large extent, thissituation is the result of a lack of political willon the part of local governments as well as

their inability to organize, control, and/ormanage municipal transportation systems,on the one hand, and, on the other, the seri-ous obstacles small, informally organizedtransportation enterprises often face inevolving into more stable entities. Over time,these latter types of companies have becomeconsolidated into a de facto transportationmanagement system. As noted by Coing andHenry (1989), “an exhaustive assessmentmakes the organization of transportation [indeveloping countries] a true ‘system,’ even ifthis system has nothing to do with our stan-dards [those of industrialized countries]. . . .Very strong social and functional regulationshide behind apparent disarray. . . . [Withinthis apparent disarray] there can be regula-tion mechanisms, almost always based onstakeholders’ roles” (14).

THE CULTURAL REDEFINITION OF BOGOTÁ

On 30 October 1994, Antanas Mockus waselected Alcalde Mayor (i.e., mayor of the en-tire metropolitan area) of Bogotá. In garner-ing a large majority of the votes—64%—hescored an impressive victory over EnriquePeñalosa, the candidate for the ColombianLiberal Party, who received 30%.15 His rise topower followed a novel and unusual elec-toral campaign, known as Ciudadano en For-mación, one of whose fundamental tenetswas named the “No P,” as in No Publicity,No Politics, No Money (plata), and No Par-ties. This campaign was decidedly the mosteccentric and least expensive16 in the historyof the city and the country.

In the District (capital) Development Planfor 1995–1997, called “Forming a City,” theMockus administration gave priority to six


15Registraduría del Estado Civil (vital records andelectoral oversight office), information from 1994 na-tional elections.

16The approximate cost of the campaign was 8 millionColombian pesos, or US$ 8,000 at the 1994 exchangerate.

topics, in the following order: citizen educa-tion, public space, the environment, socialprogress, urban productivity, and institu-tional legitimacy (15).

Citizen Education

Education of Bogotá’s citizenry becamethe linchpin of Mockus’s efforts, which fo-cused mainly on facilitating or strengtheningbehavior changes—changes in the way thecity’s inhabitants relate to one another andgain control of the places where they carryout their daily activities. Citizen educationwas defined as “the set of shared attitudes,customs, actions, and minimum rules thatgenerate a sense of belonging, facilitateurban coexistence, and lead citizens to re-spect common heritage and recognize theirrights and duties” (16). Furthermore, it “con-sists of facilitating, from a position of politi-cal authority, a greater convergence of law,morality, and culture, through the promotionof self-regulating and mutually regulatingprocesses. A familiarity with and internaliza-tion of cultural norms that are considered de-sirable and that set limits on social action inhighly heterogeneous social and cultural mi-lieus should promote socially acceptable be-havior without the threat of legal punish-ment, which is the last resort of state control.In sum, the result should be education for anew expression of social obligations, a new cit-izen morality constituted by new patterns ofcoexistence” (10).

The promotion of citizen educationplayed a leading, strategic role in the admin-istration’s actions. It was both a project and astrategy, encompassing several topics ini-tially proposed as strategies of the govern-ment’s plan. For the first time in the historyof Colombia, and perhaps in all of LatinAmerica, an administration focused its ef-forts on educating citizens and devoted a sig-nificant portion of its resources to that end,which had been part of candidate Mockus’sCiudadano en Formación and “Forming a City”electoral platform. Under this plan, more

than US$ 100 million was allocated to theCitizen Education Program for a period offour years, starting in 1995. The program wascarried out by the District Institute of Cultureand Tourism (IDCT).

The three basic strategies on which citi-zen education was based were: citizen self-regulation, modification of contexts, and insti-tutional incentives. These strategies wereaimed at bringing about harmonious relationsamong citizens through conflict resolution andthe overcoming of racial and social prejudices.

The implementation of the citizen educa-tion concept was carried out through pro-grams designed to teach Bogotá’s residentsby entertaining them and leading them toreflect on the importance of improving theireveryday behavior within the context of the city’s physical and social environment.The programs developed were numerousand highly varied in their approach. Theactions—promotional signage and othertypes of street representations and events—were symbolic, ingenious, and thought-provoking. However, very unpopular mea-sures were also adopted, in an effort toreduce violence, lower the rate of alcohol-related accidents, and reduce the number ofgunshot wound victims. One special focuswas the restriction of arms possession amongcivilians carried out through anti-gun cam-paigns. A “semi-dry” law known as the “car-rot law” or “carrot hour” was created, forc-ing nighttime establishments to close at 1:00a.m., and the production, sale, and use ofgunpowder for recreational purposes wereprohibited. Despite their initial unpopular-ity, these measures later came to be widelyrespected. According to surveys conductedafter their enactment, the anti-violence ef-forts were approved by 92% of the popula-tion; the steps to curb alcohol consumption,by 81%; and the restrictions on gunpowder,by 77%.17

Montezuma 171

17Bogotá, Centro Nacional de Consultoría. Conoci-miento y evaluación del programa “Cultura Ciudadana.” Un-published report, 1998, p. 108.

One important component of the actionswas based on entertainment and communi-cation: the idea was to teach people by en-couraging them to have fun during the learn-ing process. The main focus of the efforts wasinterpersonal communication through enter-taining street activities. Games were created,such as one using a perinola (a small top) andanother with white and red “citizen cards”:the game with the top was meant to symbol-ize participation, with anyone being able towin or lose, and the card game was intendedto signal citizen approval or rejection, similarto the cards used by soccer referees. To en-courage the population to reflect, a series of“urban theater” skits were staged usingstreet mimes and actors. In March 1995, thefirst of these skits sought to teach citizens torespect pedestrian crosswalks (called “ze-bras”), to wear safety belts, and to refrainfrom honking horns. The actors, disguised ascloistered monks, were to encourage citizensto reflect on the importance of loweringnoise levels in the city. These and other typesof skits were designed to “bring about asense of belonging in a city [traditionally]characterized by inhospitality and a weakcitizen-oriented culture.”18 After a series ofactivities utilizing an interpersonal strategyhad concluded, much more broad-based ef-forts were introduced, characterized by pro-grams and actions known as “Bogotá’sCharm,” “the Capital Card,” “the Rules ofthe Game,” “Bogotá Is to Be Won or Lost,”and “We All Chip In,” among others.

One of the actions that received the mostattention nationally and internationally wasthe utilization, starting in March 1995, ofstreet mimes to raise the population’s aware-ness of the need to use crosswalks. Theseskits were widely covered by the media,which greatly helped to publicize the efforts

and their objectives. Hence, with the tacitsupport of the media—an unexpected allythat contributed free airtime—the actions toraise the population’s awareness throughskits and symbolic representations achieveda large part of their objectives.

Thus, over time Bogotá residents came torecognize the significance of a governmentadministration’s efforts to raise awarenessabout the need to improve urban life. Al-though statistics are not very accurate indica-tors of the scope of the change in thinkinggenerated during Mockus’s first term, in the“mind of the imaginary Bogotá dweller,”there is the idea that citizen education hasbeen one of the most profound changes inthe capital’s recent history. The work carriedout in Mockus’s first period will be vividlyremembered for a long time. However, un-like other administrations, it will not be re-membered for its landmark public infra-structure projects—as has been the custom inBogotá’s history—but for the transformationin its citizenry resulting from large-scale ed-ucation initiatives.

Residents’ overall assessment of the citi-zens’ education program was extremely pos-itive. It scored 7 on a scale of 10; 61% consid-ered it the most important and concreteaction carried out by the Mockus administra-tion, and 96% felt that the program shouldcontinue. When asked to choose from a list ofproposed phrases in the same survey, 44% ofthe respondents associated the program withthe idea of “educating people to be more civ-ilized,” and 23% with the idea of “improvingthe work of the police and the authorities toreduce feelings of insecurity in the city.”19

The citizen education program was com-plemented by the founding of the Observa-tory of Urban Culture in September 1996 as avehicle to facilitate the study and monitoringof the city and its changes by “constructing amultidisciplinary structure for the observa-


19Bogotá, Centro Nacional de Consultoría. Conoci-miento y evaluación del programa “Cultura Ciudadana.” Un-published report, 1998, p. 108.

18Taken from a 1995 presentation given at the Obser-vatory of Urban Culture by the Center of Social Studies.“Memoria y evaluación del Instituto de Cultura y Tu-rismo, Programa de Cultura Ciudadana.” Bogotá, Na-tional University of Colombia, School of Human Sci-ences, IDCT. Unpublished report, 1998, pp. 102–104.

tion, research, collection, and rigorous andperiodic systematization of information onthe culture of Bogotá; and by promoting aconfluence of interests by researchers and bycity government in order to analyze andevaluate urban processes and the results ofthe actions of the various city governmentagencies in the capital.”

THE REDEFINITION OF ESTHETICS,SPACE, AND FUNCTION

In 1997, in a more hotly contested electionthan the preceding one, Enrique Peñalosa,running as an independent candidate, cap-tured 48% of the votes, defeating the “pop-ulist” candidate, Carlos Moreno de Caro,who received 31%. The District DevelopmentPlan for 1998–2000, called “For the BogotáWe Want,” stressed the following topics andprojects: poverty eradication, social integra-tion, a city on a human scale, transportation,urban planning and services, security andcoexistence, and institutional efficiency. Inaddition, the following “megaprojects” weredrafted: an integrated mass transportationsystem, street construction and maintenance,the creation of a land bank, a district parksystem, and a district library system.

The definition of these megaprojectsclearly set the priorities for the actions to be undertaken. Hence, the most notableachievements of the Peñalosa administrationwere directly related to these projects. Fur-thermore, the particular statute for themegaprojects allowed teams outside the gov-ernment to be formed, even with youngmanagers almost completely unfamiliar withurban issues or with the specific field ofwork involved, but who were responsible forconcrete tasks and strategic projects—knownas macroprojects.20 The administration’s dis-

course and actions from 1998 to 2000 werepunctuated by an overarching invitation tothe inhabitants of Bogotá to envision a newcity, to move “discussion on the city beyondthe subject of potholes and security, so thatwe will become aware that we can build any-thing we imagine” (17). The first 24 monthswere very taxing for the mayor, however, inthe sense that he experienced difficulties inconveying to his constituency what he wasthinking, proposing, and carrying out for Bo-gotá—the creation of “a city that todayseems utopian; [a city that is] reforested, thathas bicycle paths, beautiful promenades, isfull of parks; [a city] with nearly navigable,clean rivers; with lakes [and] libraries; [acity] that is clean and egalitarian” (17).

Although improving the city’s appearancewas not one of the priorities of the develop-ment plan, it was one of the mayor’s princi-pal concerns. Despite the large amount spenton advertising for actions to improve thecity’s image, such as the well-known cam-paign called “Bogotá, 2,600 Meters Closer tothe Stars,” launched in August 1998,21 themayor encountered challenges in gettingacross his message of encouraging people toimagine a new city. Indeed, Peñalosa’s pro-posal was only fully understood after theprojects had been completed. The reasons forthis were, on the one hand, the relatively fe-licitous effort to convey ideas and provideinformation on projects in progress, and, onthe other, the fact that most of Bogotá’s resi-dents had only limited points of comparison,which effectively prevented them fromimagining a different city.

In the search for an “egalitarian” city with“beautiful promenades,” public space and phy-sical mobility became the central elements. Pro-posals and actions of the Peñalosa administra-

Montezuma 173

21“The campaign seeks to convey the notion that Bo-gotá is a humane city, owned by all its residents, andthat its dwellers are proud of it. It wants to instill in res-idents a sense of belonging and appropriation. . . . Thisis the legitimization of a characteristic conceived as partof the city’s heritage, a recognizable emblem of its iden-tity vis-à-vis the country and the world” (18).

20Very few project managers were highly specializedin fields related to the projects being conducted. One ex-ception was the head of the Metro project, Dr. Darío Hi-dalgo G., a transportation expert.

tion were designed to create a friendlier andmore humane city, with public spaces allow-ing people to come together (promenades,plazas, parks, tree-lined avenues—mistakenlycalled “alamedas”22), and where these spacescould be used by all citizens regardless of so-cial class.

Enrique Peñalosa’s management has beenrecognized both nationally and internation-ally for the important innovations it intro-duced in urban transportation. This recogni-tion has been expressed in many ways.According to a December 2000 survey con-ducted by the Colombian daily El Espectador,more than 40% of the population describedhis administration as “excellent.”

Mobility and Transportation: The Redistribution of Public Space

Between 1998 and 2000, there was an au-thentic transformation in the approachesused to respond to the issues of physical mo-bility, transportation, and public space. Thenature of these approaches can be regardedas a radical break from the way these urbanissues traditionally had been addressed. In-deed, there is now widespread consensusamong the city’s dwellers that the effect ofthe Peñalosa administration’s policies re-garding mobility transcended physical proj-ects such as TransMilenio, the creation of bi-cycle paths, the recovery of green space, orprograms such as “Pico y Placa” and “With-out My Car in Bogotá.” From a practicalstandpoint, these efforts offered Bogotá’spopulace the opportunity to get from onepoint to another in the city in a new way, buton another plane, they enabled the citizens ofBogotá to reclaim their city and take back itspublic spaces for their own enjoyment andbenefit.

Peñalosa’s administration made Trans-Milenio a high priority and the centerpiecefor the transformation of mass transport in

the city between 1998 and 2000. Within theframework of the Bogotá Development Plan,nearly US$ 300 million was allocated in 1998to the bus system as the backbone of themass transit service. Most of this amountwas used for investment in roads and relatedtechnical infrastructure required for the im-plementation of an efficient transportationsystem, and it brought about a new physicaland functional structure for the organizationand operation of mass transport. The ser-vice’s planning, organization, infrastructureconstruction, coordination, and control wereplaced under the responsibility of a “district”(municipal) company named TransMilenioS.A. (10). Yet private transportation compa-nies were made responsible for the system’sactual operation; that is, for providing thebuses and hiring the drivers.

The type of physical infrastructure chosenfollowed the lead mainly of experiences inthe cities of Curitiba, Brazil, and Quito,Ecuador. The structure is an integrated sys-tem made up of a high-capacity arterial net-work and feeder networks. Along the busroutes, there are fixed stations where passen-gers can pre-pay before boarding. These aredivided into simple, intermediate, and headstations. There are also stations along thefeeder routes.

In addition to developing TransMilenio asa new concept of mass transport, thePeñalosa administration also promoted alter-native forms of transportation through suchprograms as “Pico y Placa” and “One Daywithout a Car,” both intended to counter thepredominance of private automobile use andto encourage the construction and improve-ment of promenades and bicycle paths, so asto stimulate an increase in nonmotorizedtransportational activities such as walkingand bicycling.

Public discourse and actions discouragingthe use of individualized transportationwere, in general, innovative, coherent, andon-target. Discourse on the impact of auto-mobiles on the urban environment was alsorelevant, stressing the tenuousness of de-


22In Spanish, alamedas should be used only in refer-ence to poplar groves.

pending on this form of transportation in themedium and long term. In this regard, it wasfrequently pointed out that “if we do not suc-ceed in getting people who own automobilesto utilize public mass transportation, thefunctioning of our city will become unviable,for both economic and environmental rea-sons, not to mention the collective despair[this will cause] our citizenry.”23 The Peña-losa administration steadfastly pointed outthat personal vehicles “are the most seriousproblem the city will have in the future . . .private automobiles are the worst threat toquality of life in this city” (20).

As mentioned above, people were encour-aged to use their automobiles rationallythrough peak-hour controls known as “Picoy Placa.” This consisted of a non-coercive re-striction designed to reduce rush-hour trafficso that automobile owners would not feel sodependent solely upon this form of trans-portation and to discourage the purchase ofadditional family vehicles. This measure suc-ceeded in taking more than one-third of pri-vate vehicles off the street each day.

Mayor Peñalosa’s anti-automobile andpro-sustainable-city discourse made it possi-ble to conduct a trial run of what the citywould be like without cars. On 29 February2000, Bogotá held its first “Without My Carin Bogotá” day; as with similar experiencesin many cities of Europe, the city functionedfor one working day without automobilesbeing driven. The objective of the event wasto encourage reflection that would allow cit-izens to imagine a new, more humane, andsustainable city. Despite the many misstepscharacteristic of such a large-scale trial, resi-dents generally supported the event andvoted in a referendum for it to be carried outannually.

The importance given to public space wasone of the most important contributions ofthe 1998–2000 administration. Public space,which once “belonged to no one and was not

given serious attention by city government,[and which] anyone could take for his or herexclusive use, without any consideration for[other] human beings . . . came to be the pre-eminent space in the city” (21). Althoughmuch remained to be done in terms of theo-retical studies, in practice considerablestrides were made: an Office to Defend Pub-lic Space (Defensoría de Espacio Público) wascreated24 and given the responsibility of re-covering land illegally occupied or seized.Furthermore, large public spaces were setaside for pedestrians through the establish-ment of formal and technical standards gov-erning the placement of promenades, parkbenches and fences, picnic tables, bus stops,public phones, and other fixtures; tree plant-ing and landscaping; signposts; and light-ing.25 All told, 836,143 m2 of public space wascreated (22); 1,034 park areas were takenback, improved, and maintained—approxi-mately 54% of the city’s total of protectedgreen areas. Almost 70,000 trees and 183,651garden plants were planted; and 202 km ofthoroughfares and 280 ha of parks were pro-tected. All of this was done at an approxi-mate cost of US$ 100 million.

The actions to recover, improve, andmaintain public space also led to progress inthe construction of a network set aside fornonmotorized vehicles. The Bicycle PathMaster Plan proposed the construction of 450km of paths exclusively for bicycles (calledciclorrutas): 300 km (two-thirds of the totaldistance) have been completed to date, mak-ing the network in Colombia’s capital thelargest in Latin America and one of thelargest in the developing world. The sizeableinvestment (US$ 46 million through 2001)

Montezuma 175

23Agreement 4 of 1999.

24Agreement 18, 26 August 1999.25Many executive orders were issued on the design

and construction of promenades, through the followingdocuments: Executive Order 682, 4 August 1998; Execu-tive Order 758, 4 September 1998; Executive Order 170,17 March 1999; Agreement 38, 13 December 1999; Exec-utive Order 198, 21 March 2000; Executive Order 822, 28September 2000; Executive Order 1003, 14 November2000.

has resulted in a number of impressive tech-nical and construction achievements, includ-ing the fact that the largest expanse of the bi-cycle path network was completed in lessthan three years, a very short time for suchan ambitious undertaking.

CONCLUSIONS: THECOMPLEMENTARITY BETWEEN

ISOLATED ACTIONS ANDINDEPENDENT ACTIONS

The conclusions of the author of this chap-ter regarding both the increase in physicalactivity among Bogotá’s residents, as dis-cussed in earlier parts of the chapter, and thecity’s physical and spatial transformation,described in subsequent sections, are verysimilar, not only because of conceptual simi-larities but also because of the interdepen-dence of these topics. Indeed, both changesstem to a large extent from a complementaryprocess of isolated political actions that wereindependent from one other in terms of theissues at hand as well as in terms of whenand where they were carried out. Althoughtoday Bogotá city dwellers walk and use bi-cycles more than ever before, this achieve-ment is due to effective urban transportationpolicies and not, in all fairness, to successfulpublic health efforts or the promotion of in-creased physical activity per se. This occur-rence serves to illustrate that if a public pol-icy is channeled in the right direction, itspositive effects may extend well beyond thesphere or issue that was originally targeted.This unintended interconnectedness be-tween different disciplines and aspectswithin the same geographical frameworknonetheless provides a strong and convinc-ing argument for the value-added nature ofcomprehensive and well-coordinated efforts.The experience in Bogotá demonstrates thepositive efforts to be derived from the forma-tion of teams to address both challenges re-lated to urban transportation as well as thoserelated to improving public health status,

particularly as regards sedentary lifestylesand physical activity. The question arisesthat if the world-class capital city of Colom-bia has unintentionally attained unprece-dented coordination and results in the trans-formation of its human and physicalcharacteristics, what would occur in othercities if urban planning and the design oftransportation structure were to adopt fromthe outset as the criterion for socioeconomicevaluation the benefits that this type of infra-structure would bring to the health and well-being of the population? Based on the expe-rience in Bogotá, many fields of research andreflection open up for future exploration ofthe concrete strengths to be offered by con-scious coordination between teams of urbandevelopment and public health specialists.Consequently, this chapter’s conclusionshave been divided into two parts, which de-tail, on the one hand, the factors leading tocultural and spatial change, and, on the other,the elements that may contribute to an in-crease in physical activity through changesin the way populations mobilize themselvesfrom one area of the city to another.

The Recent Transformation of Bogotá

Bogotá’s recent transformation is the resultof a long process that lasted approximately adecade, the most significant aspect of whichwas the complementarity and continuity be-tween actions that redefined the roles of citi-zens and those that redefined public esthet-ics, space, and function. However, it shouldbe noted that no “macro” or overarching planfor the transformation was followed by thetwo government administrations, nor wasthere continuity in terms of policies or partiesbetween the first and the second mayor—indeed, Antanas Mockus and Enrique Peña-losa were political opponents in the 1994 elec-tion. Still, the achievements in transportationunderscore the complementarity between thegoal of improving transportation and chang-ing the population’s behavior. Although theprojects involving concrete and asphalt have


strongly impacted the way people moveabout in the city, this achievement is also re-lated to a change in thinking regarding thecity in general and mobility in particular. Inrecent years, there has also been a structuralchange in the way transportation is thoughtof and provided, entailing both municipal au-thorities and the citizens they serve. First,there were citizen education campaigns; then,for the first time in the city’s history, masstransit was made a top priority, based on therational use of automobiles, the implementa-tion of the TransMilenio project, the takingback of public space, and the creation ofoptions for getting around not requiringmotor vehicles. Hence, the intention was tostrike a new balance in the use of publicspace. In this regard, Mayor Peñalosa took avery bold public stance by declaring that pri-vate automobiles were not a viable, long-term alternative for daily transportation in acity that wished to be efficient, equitable, andhumane.

A high degree of reflection regarding mo-bility has been attained, and significant ac-tions have been taken. Furthermore, a highlevel of coherence has been achieved be-tween theory and practice, which, in and ofitself, is an extremely rare phenomenon intoday’s society. Indeed, although many largemetropolitan areas have elected officials whoclaim to prioritize collective and nonmotor-ized transportation, in practice they do notquestion the indiscriminate use of automo-biles, perhaps due to the high political cost ofdoing so. If the majority of elected officialsfail to carry out programs that encourage therational use of private vehicles or that pro-pose to take back public space, it is mostlikely because such actions could directly af-fect their image or their possibilities of beingreelected.

The transformation of Bogotá over thepast decade has been a complex process re-quiring an inordinate reserve of politicalwill, coherence between plans and actions,an important investment in collective andnonmotorized transportation, and especially,

the participation and education of citizensand the creation of an ongoing dialogue withthem. For example, although the taking backof promenades has benefited most residents,the measure was apparently rejected at first,due to what has been called a “lack of pointsof comparison.” It has been demonstratedthat residents’ lack of points of comparisonwith other urban realities—either within thecity or outside of it—prevented them fromclearly perceiving the magnitude of the prob-lems in the infrastructure they used everyday. The case of the promenades has paral-lels with collective transportation. Despite itsprevious inadequacies, public transportationhas traditionally been evaluated positivelyand has scored relatively high in surveys inrecent years, despite the worsening of driv-ing conditions. In the case of the recovery ofpublic promenades, the beneficiaries—thevast majority of Bogotá’s citizens—did nothave a true point of comparison to assesswhat it meant to see uncongested thorough-fares and clearly marked and respectedpedestrian crosswalks, since these phenom-ena had never formed part of their sharedhistory.

Changing the way people think was oneof the most important challenges taken up by the two administrations, since it entailedbringing about a radical transformation inthe type of city and citizens that had existeduntil then. Indeed, the emerging metropolisof Bogotá had been structured much morearound the automobile than around masstransportation. Private automobiles had en-joyed privileged status during successivegovernments (both national and local) eventhough historically only a minority of resi-dents had owned one. Models of urban de-velopment centering around the indispens-ability of automobile use reflected thedistinct influence of the United States, thetraditional source of emulation by Colom-bian society’s middle and upper classes.

Yet since the late nineteenth century, theconsiderable influence of the United States,particularly in the socioeconomic and politi-

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cal spheres, when not clearly detrimental,has produced decidedly mixed results. Forexample, some urban sectors of Bogotá in-creasingly resemble cities in the UnitedStates; nevertheless, a closer look reveals thatthis similarity harbors many of the limita-tions characteristic of a Third World city:Bogotá’s northern sector has seen a consider-able expansion of infrastructure to accom-modate automobile use, while the center hasbecome increasingly overlooked from thisstandpoint. The appearance of much of thecity, and in particular the north, is closelylinked to the predominance of the automo-bile, as seen in the proliferation of streets andin the formal characteristics of private resi-dences and of consumption patterns and inthe choice of leisure-time activities. The pref-erence for the automobile is most obvious inthe structure of the city, since the most im-portant infrastructural elements to facilitatedriving benefit the north, at the expense ofthe rest of the city—particularly the south—thereby aggravating the city’s traditional so-cioeconomic and spatial segregation. Thissegregation, in turn, has led to an importantimbalance that is currently spreadingthroughout the metropolitan area.

In this sense, by vigorously limiting theuse of private automobiles and instead pro-moting collective and alternative forms ofurban transportation, Bogotá is setting aprecedent for many other cities in LatinAmerica. Hence, the achievements in physi-cal activity described in this chapter andtheir possible future impact on preventingsedentary lifestyles and chronic disease areimportant additional arguments, albeit in adifferent discipline, that enhance the analysisof Bogotá’s transformational experience.

Public Health and Physical Activity

The budding achievements in publichealth and physical activity strongly resem-ble other changes in the city, which stemmore from the convergence of isolated, com-plementary factors that originated indepen-

dently from one another rather than frompurposefully planned efforts coordinatedamong various public entities. Indeed, therewas no overall or sectoral plan regardingurban issues, transportation, or public healthto mobilize the people of Bogotá on a largescale. Although there have been sectoral ef-forts focusing on physical activity, these like-wise have been partial and somewhat mar-ginal for a city of this size. And whileprograms have been created that focus onphysical activity, they have targeted rela-tively small groups of individuals, such asthe employees of specific private or publicenterprises. Still, the “Sunday Bicycle Path,” a program that every Sunday makes morethan 100 km of streets available for nearlyone million people to walk, skate, or ridebicycles, is more than 25 years old and has become part of the city’s recreationalheritage.

The changes in Bogotá can be defined as a succession of well-focused and well-thought-out public actions that have com-plemented one other in different ways. Al-though these policies have not beencoordinated, due to the issues they addressand due to time and space constraints, theyhave favored increased physical activity. In-deed, two mayors and three city govern-ments between 1995 and 2003 consolidatedhighly diverse actions that on the whole ledto a substantial increase in physical activity.The unifying factor in all these actions ap-pears to be the complementarity betweencampaigns focusing on changing citizens’behavior (citizen education) and the con-struction of public spaces and infrastructurefor mass transport and alternative forms ofmobility. Nevertheless, it must be recalledand emphasized that, in addition, there havebeen improvements on other fronts, such asthe considerable reduction in crime and traf-fic accident rates, increased citizen participa-tion, and higher housing density, among others. Although almost two-thirds of thehalf-hour of universally recommended dailyphysical activity is met through the time it


takes for most commuters to walk to thenearest station of the TransMilenio system,the elimination of parking on public streetshas also forced drivers to engage in addi-tional physical activity, since the distancesfrom their parked automobiles to their of-fices or other downtown destinations havelikewise increased.

However, and despite the progress seenwith regard to physical activity, ongoing re-search26 points to an important discrepancybetween what the residents of Bogotá per-ceive with respect to their physical activity orinactivity and the amount of activity inwhich they actually engage. Indeed, two-thirds (66%) of the respondents considerthemselves to be physically active, which,technically, refers to a maintenance level ofexercise. If this perception were accurate, itwould have very positive implications forthe population’s health and well-being, be-cause it would mean that the vast majorityengage in physical activities at periodic mo-ments throughout their daily lives. Never-theless, an analysis of the levels of activity atdifferent times throughout the day showsthat the citizens of Bogotá are sedentary dur-ing at least 75% of their spare time, 90% oftheir work hours, and 79% of the time theyspend commuting.

Another particularly worrisome findingproduced by this research is that the barriersor impediments to undertaking physical ac-tivity are related more to individual than tosocietal reasons or causes. Indeed, it wouldappear that people are sedentary more out ofa lack of willpower (30%) or energy or time(20%) than because of general, socioeco-nomic, and spatial issues in cities. The possi-ble lack of space or of safety are very rarelymentioned as barriers to physical activity.Another important contradiction, especially

since walking, running, and climbing stairscost nothing, is that 25% of the respondentspoint to a lack of money as the principal im-pediment to doing physical exercise.

Both the study of chronic disease and ef-forts to prevent it lead to an attempt to bringabout behavior changes, which can onlyoccur through a minimum, gradual adapta-tion to individuals’ internal or external con-ditions. The internal factors are related to ed-ucational and cultural level, socioeconomicclass, sex, age, physical activity or inactivity,and daily work routine, among others. Theexternal factors are related to physical andenvironmental, as well as sociocultural, con-ditions. Physical and environmental condi-tions encompass the availability of recre-ational, sports, and urban infrastructure;geographical and climatic characteristics;and the conditions in which mobility takesplace in a city, among others. Socioculturalconditions include collective awareness andbehavior and citizen culture; personal safety;notions or frames of reference regardingurban transportation; physical activity; andthe city itself or information available withinthe city. In this sense, the experience in Bo-gotá makes it possible to presume that, onthe one hand, the recovery of public spaceand the construction of infrastructure fornonmotorized transportation, and, on theother hand, citizen education campaigns, thereduction of the number of violent deaths,and increased respect for rules, can con-tribute, within an urban context, to behaviorchange, by discouraging sedentary lifestylesand encouraging physical activity, thus help-ing to improve citizens’ quality of life and in-crease their life expectancy.

ACKNOWLEDGMENTS

The author of this chapter wishes to ex-press his appreciation to colleagues of theFundación Ciudad Humana, and in particu-lar, sociologist Brenda Pérez, for their contri-butions to this text.

Montezuma 179

26See footnote 5 in this chapter for a description of thecomprehensive study being carried out by the PublicHealth Institute of Colombia’s National University andthe Fundación Ciudad Humana with funding from theColombian Social Protection Ministry.

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Integrated Strategies at the National Level

INTRODUCTION

The purpose of scientific research is togenerate knowledge. The primary tool of re-search, in the various areas of knowledge, isscientific method, whose application enablesthe duplication of experiments or studiesand the comparison of results in order to for-mulate plausible or likely statements regard-ing the relationships between the variables.Scientific method can be applied to the studyof an assortment of issues, and its applica-tion may be motivated by human curiosity,without the findings of the research neces-sarily having an immediate practical applica-tion, or the purpose may be problem-solvingor immediate practical application.

The National Institute of Public Health(INSP) of Mexico, an institution devoted topublic health research and nutrition, hasclearly defined its inclination towards gener-ating knowledge in order to apply it to theimprovement of the population’s health.This type of research, termed “mission-basedresearch” by Frenk (1), has been defined as“the development of a research effort thatmodifies some aspect of reality by producingknowledge and technology.” The “mission”is precisely that modification of reality.

Mission-based research in public healththerefore centers its efforts on improving the

health conditions of the population by apply-ing scientific method to the study of differentobjects and levels of analysis. The objects ofanalysis are the health conditions of the pop-ulation and the organized social response(policies, programs, and actions) for the pre-vention and control of such conditions. Thelevels of analysis include subcellular parti-cles (molecular biology), individuals (clinicalresearch), populations (epidemiological re-search), and health systems (systems re-search), using a multidisciplinary approachto generate knowledge that makes it possibleto resolve public health challenges. An im-portant area of mission-based research is theuse of scientific data for decision-making inpublic health, including the design and eval-uation of health and nutrition policies.

An erroneous conclusion that is fre-quently drawn upon addressing the conceptof mission-based research for the first time isthat it deals with applied research, whoseonly purpose is problem-solving. A distinc-tion is frequently drawn between applied re-search (often confused with mission-basedresearch) and basic research, which gener-ates universal knowledge. A key feature ofthe type of research that the INSP aspires to

IMPROVING NUTRITION IN MEXICO: THEUSE OF RESEARCH FOR DECISION-MAKINGIN NUTRITION POLICIES AND PROGRAMS

Juan A. Rivera1

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1Executive Director, Center for Research in Nutritionand Health, National Institute of Public Health, MexicoCity, Mexico.

conduct is the attempt to generate funda-mental knowledge; that is, research that hasan effect on the conceptual structure or theperspective of a specific field of knowledge,and, at the same time, endeavors to be use-ful. This type of research, called “strategic”research, has been described by Stokes (2),who proposes that the traditional conceptthat standardizes research as a continuum ina single dimension, with pure research andapplied research on either end, is inade-quate. He also proposes that research shouldbe conceived on a bidimensional plane, withone of its pillars represented by the searchfor the generation of fundamental knowl-edge and the other represented by the searchfor research usefulness. Strategic research islocated in the quadrant that represents boththe search for fundamental knowledge andits usefulness. A historical example of thistype of research is the sort conducted by Pas-teur, who combined both interests.

The Center for Research in Nutrition andHealth (CINyS) of the INSP, in keeping withthe philosophy of strategic mission-based re-search, seeks to develop a research agendathat aims to prevent and control poor nutri-tion in Mexico, through the generation ofknowledge and technology intended to im-prove the effectiveness of the organized so-cial response to the problems of poor nutri-tion. This chapter presents pieces of evidenceon the use of scientific research findings inMexico to generate actions aimed at prevent-ing and controlling the population’s poornutrition and to design nutrition programswith a high potential for bringing about pos-itive effects; data on the use of evaluations tofuel decision-making in existing programsand policies are also presented.

The CINyS, inspired by the philosophy ofmission-based strategic research, has set up aformat that serves as a guide for defining theCenter’s research agenda. Stages of mission-based research have been identified for eachof the various problems related to poor nutri-tion or to the challenge faced by health systemsin promoting adequate nutrition or preventing

or controlling poor nutrition. These stages usu-ally occur sequentially, but can also functioniteratively; that is, upon reaching a higher stageit is sometimes necessary to return to a previ-ous stage in order to answer the new researchquestions that have emerged.

The research sequence around the prob-lems of poor nutrition (Figure 1) starts with(1) a study of the conditions (extent and dis-tribution of the population’s poor nutritionproblems and their determinants) and re-sponses (food, nutrition, and health policiesand programs with a potential impact onpoor nutrition), and continues with (2) stud-ies on the functional consequences or on thehealth of the population suffering from poornutrition, in order to determine the impor-tance of the problems, followed by (3) stud-ies on the etiology of the problems and onthe biological or social mechanisms that ex-plain them. The next stages consist of (4) thedesign and testing of small-scale actions orinterventions, (5) controlled clinical trials forstudying the efficacy of the interventions oractions, and (6) effectiveness studies or theevaluation of actions or programs, includingprocess and cost-effectiveness evaluations.Figure 1 concludes with the design of poli-cies and programs and their evaluation inorder to provide feedback for the decision-making process. The results of the evaluationare useful for identifying operational or de-sign problems, which leads to new researchquestions that, when answered, fuel thecycle of mission-based research at somepoint in the Figure. In this final process, therewill be close interaction between the respec-tive researchers and the civil servants whowill be in charge of designing and managingnutrition and public health policies.

Reviewing the literature during the differ-ent stages is essential in order to identify theexisting knowledge and the principal voids,as well as to determine the research needs;these are contrasted with the capabilities andcomparative advantages of the CINyS inorder to therefore define the lines of researchand research projects to which the Center can

184 The Use of Research for Decision-making in Nutrition Policies and Programs

contribute effectively. This process is usefulfor both determining CINyS’ staff trainingand recruitment needs, and for forgingstrategic partnerships with other researchgroups in order to generate an effective criti-cal mass that makes it possible to respond tothe challenges of mission-based research.

The following is a chronicle of the way inwhich, through the application of this for-mat, research findings have been used fordesigning policies and programs geared tothe prevention of poor nutrition in Mexico.Several of the results that are useful in tack-ling malnutrition have also contributed tothe fundamental knowledge in this field andhave been published in Mexican and foreignpeer review journals.

STUDIES ON THE EXTENT ANDDISTRIBUTION OF NUTRITION

PROBLEMS IN MEXICO (A STUDY OF THE CONDITIONS)

An important task undertaken by theCINyS has been conducting and analyzing

probabilistic national surveys that show dataon the nutritional status of the Mexican pop-ulation and its determinants. In 1993, whenthe research group that would later becomethe CINyS was set up in the INSP, the datafrom the 1988 National Nutrition Survey(NNN), conducted by the Secretariat ofHealth (SSA) (3), were analyzed, dissemi-nated, and published. Ten years later, theINSP sought financial support to carry out asecond NNN. Support provided by the SSAand other organizations enabled the secondNNN to be carried out between 1988 and1999 (referred to in subsequent references asNNN-99). The surveys led to an understand-ing of the extent and distribution of the prob-lems surrounding poor nutrition and thedetermining factors, and those data were dis-seminated both to the scientific communityand authorities responsible for the formula-tion of food, nutrition, and health policies.As will be described in more detail furtheron, through the dissemination of publica-tions and presentations targeted to key ac-tors involved in the design and managementof policies and programs, the results of the

Rivera 185

Extent and distribution of problems

Policies and programs

Functional and health consequences

Etiology of problems and mechanisms

Design and testing of small-scale actions

Public health efficacy studies

Effectiveness studies

Design of public policies

FIGURE 1. Stages of the mission-based research process.

NNN-99 set in motion various public ac-tions, policies, and programs for preventingmalnutrition.

The following is a brief summary of theNNN-99 findings, which constituted the basisfor designing the resulting nutrition policiesand programs, and represented significantinput for defining the CINyS research agenda.

The leading problems resulting from poornutrition in Mexico, according to the NNN-99, were linear growth retardation (shortstature), anemia and deficiencies of severalmicronutrients, and overweight and obesity.

Linear Growth Retardation

In Mexico, short stature continues to be asignificant public health problem amongchildren under 5 years of age, while emacia-tion no longer constitutes a major problem atnational and regional levels. Nationally,nearly one out of five children under 5(17.7%) recorded low height in 1999, whileonly 2% showed emaciation. The analysisconducted on the prevalence of low heightfor this age group revealed that this phenom-enon occurs predominantly during the firsttwo years of life. Thus, while prevalence is8% during the first year of life, it jumps to22% during the second year, an increase ofalmost three times, and it remains at 20% upto age 4. There is not a subsequent recoveryfrom short stature, as one can see uponstudying the height of school-age childrenand women of childbearing age (4).

One of the most troubling findings of theNNN-99 was the inequity in terms of the dis-tribution of malnutrition. Short stature isdistributed heterogeneously among the pop-ulation subgroups. Figure 2 shows the preva-lence of short stature for each of the four re-gions studied,2 by urban and rural areas andin indigenous children. Prevalence in rural

areas (31.6%) is nearly three times higher thanthat of urban areas (11.6%), and in the north(the most prosperous region) it is much lowerthan in the south (the poorest region). A com-parison between regions and urban and ruralareas gives rise to greater differences. For ex-ample, while the prevalence in urban areas inthe north is close to 6%, in the rural south it ismore than 40%, almost seven times higher (5).

One of the groups with the poorest livingconditions in Mexico is the indigenous pop-ulation. Nearly two-thirds of the familieswith indigenous children under age 5 are lo-cated in the two lowest deciles for living con-ditions compared to less than 15% of thefamilies with nonindigenous children. Theprevalence of short stature is approximatelythree times greater in indigenous children(44.3%) compared to nonindigenous children(14.5%), and the differences are reduced toaround half when adjusted for socio-economic level, yet they continue to be sig-nificantly higher in indigenous children (p < 0.05) (6).

There is a strong tendency for the preva-lence of short stature by decile of socioeco-nomic level to increase the lower the socio-economic level is. The difference between theprevalence of short stature among the high-est (4.6%) and lowest deciles (47.6%) was al-most 10 times (5).

In 1988, the prevalence of short stature,low weight, and emaciation was 22.8%,14.2%, and 6.0%, respectively. The changesrecorded between surveys were 5.1 percent-age points for short stature (22.4% with re-gard to the baseline), 6.6 percentage pointsfor low weight (46.5% with regard to thebaseline), and 4 percentage points for emaci-ation (66.6% with regard to the baseline).That is, there was a satisfactory reduction inthe prevalence of emaciation, but theprogress regarding short stature was less sat-isfactory, especially when compared to thedecline recorded in South America as awhole during a similar period (5). The preva-lence of short stature in South Americadropped from 17.2% in 1990 to 9.3% in 2000;


2The NNN-99 was representative of four regions: thenorth, which mainly includes the bordering states of theUnited States; the south, which includes the pooreststates; Mexico City, including the metropolitan area; andthe central states.

that is, a decrease of 7.9 percentage points or45.9% with regard to baseline prevalence (7).It has therefore been concluded that the de-crease in prevalence of short stature recordedin Mexico from 1988 to 1999 is much lowerthan the one expected, particularly whentaking into account significant governmentspending on food assistance programs dur-ing that period, which will be discussed indetail further on.

Anemia and Micronutrient Deficiencies

More than one out of four children underage 5 (27.2%) were anemic, and 25% to 50%of the children had deficiencies of one ormore micronutrients (Figures 3 and 4). Theprevalence of iron, zinc, and vitamin A defi-ciencies was 52%, 33%, and 27%, respec-tively. Furthermore, more than 25% of thechildren presented serum concentrations ofascorbic acid, which indicates a low daily in-take of vitamin C from food (Figure 4).

Anemia and some micronutrient deficien-cies appear predominantly at an early age.The prevalence of anemia reaches a peak in

the second year of life, when it affects almosthalf of the children, and declines to nearly17% at 4 years of age (Figure 3). Iron defi-ciency affects nearly two-thirds of all chil-dren ages 1 to 2 and less than 50% of childrenages 3 to 4 (Figure 4). In contrast to shortstature, the differences in the prevalence ofanemia are not perceptibly different by re-gion and between urban and rural areas, butare higher in indigenous children (35.8%) vis-à-vis nonindigenous children (26.1%) (5, 6).

The prevalence of anemia in children ages5 to 11 was 20.1% (Figure 3), and the mostprevalent micronutrient deficiencies in thisage group were iron (36%), vitamin C (30%),vitamin A and zinc (around 20%), and folicacid (nearly 10%) (Figure 4) (8–10). The na-tional prevalence of anemia was 20.8% innon-pregnant women and 27.8% in pregnantwomen (Figure 3) (11), and the micronutri-ents with the highest prevalence of defi-ciency in non-pregnant women were iron(40.5%) and vitamin C (39.3%), followed byzinc (25.3%), while deficiencies in vitamin Aand folic acid were around 5% (Figure 4) (9, 10).

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FIGURE 2. Inequity in the distribution of poor nutrition (short stature) in Mexico.

Source: Rivera J, Sepúlveda-Amor J. Conclusions from the Mexican National Nutrition Survey 1999: translating results into nutrition pol-icy. Salud Pública Mex 2003;45(Suppl 4):S565–S575.

6.1

13.1

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17.414.5 13.1

17.5

41.5

29.2

44.0

11.6

31.6

17.7

0

5

10

15

20

25

30

35

40

45

North

UrbanRuralAll areas

Centralregion

MexicoCity

South Indigenous National

Prev

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Overweight and Obesity

Overweight and obesity have become anational epidemic in Mexico, particularly inadults, and already represent a concern inchildren. The national prevalence of over-weight (z-score of weight-for-height > +2) in

children under 5 is 5.3% (Figure 5) withgreater percentages in the north (7.2%), com-pared with the other regions (4% and 5%),and in urban areas (5.9%) vis-à-vis rural ones(4.6%). The prevalence in 1988 was 4.2% (Fig-ure 5); as a result, the increase over 11 yearswas 1.1 percentage points (4).


FIGURE 3. Prevalence (%) of anemia in children and women, Mexico, 1999.

a6 to 11 months.Source: Rivera J, Sepúlveda-Amor J. Conclusions from the Mexican National Nutrition Survey 1999: translating results into nutrition pol-

icy. Salud Pública Mex 2003;45(Suppl 4):S565–S575.

13.0

48.8

32.1

21.5

16.620.1 20.8

27.8

0

10

20

30

40

50

0a 1 2 3 4 5 to 11 12 to 49 PregnancyChildren Women

FIGURE 4. Prevalence (%) of deficiency of selected micronutrients, Mexico, 1999.

aNot pregnant.Source: Rivera J, Sepúlveda-Amor J. Conclusions from the Mexican National Nutrition Survey 1999: translating results into nutrition pol-

icy. Salud Pública Mex 2003;45(Suppl 4):S565–S575.

0

10

20

30

40

50

60

70

Zinc Vitamin A Vitamin C Folic acid Iron

0.5 to 2 yrs.3 to 4 yrs.5 to 11 yrs.Womena

The combination prevalence of over-weight and obesity (12) in children ages 5 to11 is 19.5% (13) (Figure 5). The regions withthe highest prevalence were Mexico City(26.6%) and the north (25.6%), followed bythe central region (18.0%) and the south(14.3%). The prevalence was much higher inurban areas (22.9%) than in rural areas(11.7%). The combination prevalence of over-weight and obesity in women aged 18 to 49(Figure 5) was 59.6% nationally (35.2% over-weight and 24.4% obesity), with the highestprevalence in the north (65.3%), followed byMexico City (59.1%), the central region(58.6%), and the south (55.3%).

The prevalence of overweight and obesityin women underwent an unusually signifi-cant increase over the 11 years between sur-veys. In 1988, the national prevalence ofoverweight and obesity was 24.0% and 9.4%,respectively (Figure 5), with an increase of11.2 percentage points for overweight (an in-crease of 46.7% with respect to the baseline)and 15 percentage points for obesity (an in-

crease of 160% with regard to the baseline)(14). The examples shown for using researchfor policy and program design and decision-making refer to problems pertaining to mal-nutrition and not to overweight and obesity.

STUDIES ON THE ORGANIZED SOCIALRESPONSE: NUTRITION POLICIES

AND PROGRAMS IN MEXICO

Mexico has a long history of carrying outpolicies and programs aimed at improvingthe nutrition of vulnerable groups. Despitethis, malnutrition continues to be one of thecountry’s most important public health chal-lenges. Several CINyS publications analyze,from a historical perspective, the main strate-gies, programs, and policies that have beenimplemented in Mexico, by examining theirdesign and implementation, as well as someof the results obtained (15, 16). Throughthese analyses, it becomes evident that thecountry has made considerable investmentsin food assistance programs. For example, in1993 the Mexican Government spent morethan US$ 2 million a day on food assistanceprograms, including consumption subsidyprograms. This figure is greater than theminimum food assistance expenditure rec-ommended by various organizations inorder to improve the population’s nutrition.However, as shown in the previous section,the prevalence of malnutrition, anemia, andmicronutrient deficiencies is elevated, andthe speed of reducing the prevalence of shortstature, an indicator of chronic malnutrition,turned out to be slower than expected duringthe 1990s, despite sizeable investments infood assistance programs.

These observations led to an examinationof various aspects of the food assistance pro-vided by the Government in 1988, in accor-dance with data from the survey conductedthat year, including the extent and distribu-tion of this assistance, in comparison withthe nutritional needs of the population. Thatresearch produced very valuable findings

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FIGURE 5. Prevalence (%) of overweight andobesity in childrena and women in Mexico,

according to results of 1988 and 1999 surveys.

aIn 1988, children aged 5 to 11 years were not studied.bz-score of weight-for-height > +2.Source: Rivera J, Sepúlveda-Amor J. Conclusions from the Mex-

ican National Nutrition Survey 1999: translating results into nutri-tion policy. Salud Pública Mex 2003;45(Suppl 4):S565–S575.

4.2

33.4

5.3

19.5

59.6

0

10

20

30

40

50

60

7019881999

Children aged0 to 4 yrs.b

Children aged5 to 11 yrs.

Women aged18 to 49 yrs.

that were used by the CINyS to influence thedesign of nutrition policies during the 1990s.

It was concluded that among the reasonsexplaining the low effectiveness of nutritionprograms in Mexico was the fact that theywere not targeted to the population groupsthat needed them the most. Figure 6 illus-trates the distribution of short stature chil-dren in 1988 and the percentage of benefici-ary families of the various food assistanceprograms by region. Of the almost 2 millionchildren with short stature, nearly 45% werein the southern region of the country, thepoorest one, while less than 9% of the chil-dren with chronic malnutrition were locatedin Mexico City. Yet 51% of the families withchildren under age 5 benefiting from food as-sistance resided in Mexico City, and only15% lived in the south, the region with thehighest rates of prevalence (Figure 6).

It was also found that the probability ofreceiving food assistance (Figure 7) was 0.47for families in rural areas vis-à-vis those inurban areas (using as a reference a probabil-ity of 1 for the latter), 0.24 for indigenousfamilies vis-à-vis nonindigenous families,0.42 for the tercile with low living conditionsvis-à-vis the tercile with high living condi-

tions, 0.87 for families with children underage 2 vis-à-vis families with children ages 2to 4, and 0.65 for families with short staturechildren vis-à-vis families without shortstature children (Figure 7) (17).

Apart from the emphasis placed on urbanareas and the lack of targeting regions withthe highest prevalence of malnutrition, itwas found that among poor families, indige-nous groups, and children under age 2, dis-tributed or subsidized food was not ade-quate for feeding children ages 6 to 24months; there was no coordination betweenthe programs, which led to the duplication ofefforts and benefits; and the educationalcomponent was weak. These results werevery useful in modifying the bases of the nu-trition policies and programs at the end ofthe 1990s, as will be seen further on.

STUDIES ON THE FUNCTIONALCONSEQUENCES OF THE PROBLEMS

OF POOR NUTRITION ON THEPOPULATION’S HEALTH

The CINyS has collaborated closely withthe Institute of Nutrition of Central America


FIGURE 6. Distribution of children with short stature and from beneficiary populations of food assistance programs, by region, 1988.

7.8

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and Panama (INCAP) and with Dr. ReynaldoMartorell and his group of researchers, cur-rently at Emory University. Within theframework of this collaboration, CINyS re-searchers have participated in various analy-ses on the functional effects of malnutritionduring gestation and the first years of life(the formative period), which have shownthat the presence of malnutrition during thatformative period produces adverse effectsnot only during childhood but indeedthroughout the individual’s lifetime.

Studies conducted in collaboration withINCAP point out that malnutrition duringgestation and the first two or three years oflife is associated with growth retardation andpsychomotor development (18, 19) and hasadverse effects in the longer run. For exam-ple, during adolescence and the adult years,it is associated with a reduction of: (1) bodysize (20), (2) the capacity for physical work(21), and (3) intellectual and school perfor-mance (22). These factors clearly can alsohave an impact on the individual’s ability togenerate income (23).

The studies furthermore demonstrate thatmalnutrition during the first years of life haseffects on reproductive variables. For exam-ple, women with a history of moderate mal-nutrition during childhood have childrenwith lower birthweights than women whowere better nourished during that period oflife (24). Low birthweight increases the riskof morbidity and mortality, which meansthat the nutrition of girls during their earlydevelopmental years can affect the healthand survival of the following generation.

In short, collaborative research with theEmory University group and INCAP illus-trates that malnutrition in the early stages oflife not only depletes one’s health and de-creases chances for survival during child-hood, but also leads to adverse effects on thedevelopment of human capital and on healthduring the adult years, and additionally hasan impact on the health of the following gen-eration. These data, by showing the func-tional consequences of the problems relatedto malnutrition, were very useful in provid-ing a context for the problems prevalent

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FIGURE 7. Rate of probability (95% CI) of participation in food assistance programs of households with children under 5.

1

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in Mexico and thus in convincing decision-making authorities of the need for apply-ing actions geared toward preventingmalnutrition.

STUDIES ON THE ETIOLOGY OF THE PROBLEMS AND THE BIOLOGICAL

OR SOCIAL MECHANISMS THATEXPLAIN THEM

Once the main problems of malnutritionin the population and their importance havebeen determined, as well as the problems theCINyS has the capacity and comparative ad-vantages to address, it is possible to identifythe priority problems for research purposes.Then it becomes necessary to garner infor-mation on the etiology and the biological andsocial mechanisms that explain the epidemi-ology of the problem in order to undertakepreventive or corrective actions. It is criticalto review the literature at this stage for thepurpose of identifying any possible gaps inthe knowledge that need to be addressedthrough research, taking into account capac-ities and comparative advantages.

Following is a brief description of some ofthe contributions made by the CINyS duringthis stage of knowledge generation that havebeen useful for decision-making in publichealth.

Studies conducted in collaboration withINCAP have shown that zinc supplementa-tion in children with zinc-deficient diets haspositive effects on growth (25), on reducingbouts of diarrhea (26), and on increasingphysical activity (27). This finding illustratedthe need for including zinc in interventionsin order to prevent stunting.

CINyS researchers have also conductedstudies on the bioavailability of differentchemical forms of iron and zinc in variousfortified foods, with a view to designing ormodifying strategies for preventing bothiron and zinc deficiencies, both of which con-stitute major public nutrition concerns inMexico.

One of the studies showed that reducediron, added to a food supplement designedto lessen anemia and iron deficiency, hadvery low bioavailability, while two moreforms of ferrous iron—sulfate and fumer-ate—had high bioavailability (28). These re-sults have been used by the CINyS to recom-mend substituting the type of iron added tosupplements.

Another study indicated that the absorp-tion of zinc oxide—a chemical form of low-cost zinc that is currently being used in sev-eral fortified foods distributed by variousprograms—is similar to the more expensivezinc sulfate, when added to a corn flour-based food supplement. This led to corro-borating the fact that the type of zinc used in food fortification programs in Mexico isadequate (29).

Recent research quantified the amount ofiron absorbed by adding two forms of“marked” iron (Fe57 and Fe58) to milk. Theabsorption of iron contained in milk corre-sponded to 10% of the total quantity of ironadded. This absorption value makes it possi-ble to calculate the quantity of iron assimi-lated with regard to milk consumed. Thus, achild who consumes the 400 mL of fortifiedmilk recommended by the program will beabsorbing, with the milk, 50% to 150% of theamount required to meet his/her needs foriron, depending on the child’s age.

Another relevant finding was obtainedfrom an analysis of a Guatemala study con-ducted by INCAP (30), which demonstratedthat the effects of food supplementation onthe growth of children at risk of malnutritionare elevated during the first two years of lifeand following that are almost null. For exam-ple, the size gain from 100 kcal of food sup-plement is almost 1 cm during the first yearof life, approximately 0.5 mm during the sec-ond year, and 0.4 mm during the third year,while the figure ranges from 0 to 1.5 mm peryear for children ages 3 to 7. This finding hasbeen used to argue in favor of strengtheningthe recommendation to give priority to inter-ventions targeted at the early stages of life.


DESIGNING AND TESTING SMALL-SCALE ACTIONS OR INTERVENTIONS

The CINyS has designed actions or strate-gies aimed at improving the population’s nu-trition and has tested them on a small scalein order to evaluate their feasibility and ef-fects. Two examples will be briefly describedhere.

As a part of designing fortified food sup-plements, the CINyS has conducted severalstudies of acceptance and consumption atthe community level (31). Furthermore,small-scaled strategies of educational com-munication have been developed and evalu-ated in order to improve the consumption ofa nourishing supplement distributed as partof a national program (32).

Before providing examples of efficacy andeffectiveness studies, some examples of theuse of scientific research findings to influ-ence decision-making for nutrition policiesand programs are presented in the followingsection.

USE OF RESEARCH FINDINGS TO MOTIVATE PUBLIC NUTRITION ACTIONS

The CINyS has used research findings topromote among decision-makers the designand application of policies and actionsgeared toward improving the nutrition of thepopulation. This section will describe someof the policies and programs whose initialmotivation was the dissemination of re-search results directed at those responsiblefor health and nutrition policies, or whosedesign fed off of that information.

In the mid-1990s, the Mexican Govern-ment began planning an ambitious programfor investing in human development inwhich the Secretariats of Finance, Education,Health, and Social Development partici-pated. This program, initially called the Pro-gram for Education, Health, and Food (Pro-gresa) and currently called Oportunidades, is

a federal poverty-fighting initiative that tar-gets low income families and their children’shealth, food, and educational needs and dis-penses monetary transfers as incentive forencouraging the development of human cap-ital. The participating families only receivethe money if they regularly visit their localhealth facilities, receive health education,and enroll their children in school and en-sure their regular attendance. Oportuni-dades began in 1997 as a national programdeveloped to cover the immediate needs ofMexico’s lowest income families and tobreak the intergenerational transmission ofpoverty. At present, it serves approximately5 million families in rural and urban areas,selected on the basis of their low socioeco-nomic level.

The group in charge of designing the pro-gram consulted the INSP concerning the po-tential effect of the project—as originallyproposed—on the nutritional status of chil-dren. The parties involved presented and ex-tensively discussed the various pieces ofevidence suggesting that gestation and thefirst years of life constitute a fundamentalformative period and offer a unique windowof opportunity to apply effective actionsaimed at improving nutrition. Also shownwere results of studies that underscore theimportance of including micronutrients, es-pecially iron and zinc, in assistance pro-grams to combat malnutrition. Proof wasalso provided that the majority of the prob-lems associated with malnutrition (shortstature, anemia, and deficiencies of somemicronutrients) show higher prevalencerates in the poorer population: in the south-ern region, among rural populations andindigenous families, and among those whobelong to the lowest rungs on the socioeco-nomic ladder (3). This finding supportedone of the pillars of the program; i.e., focus-ing actions on low income families. In addi-tion, data were provided on the inadequatedesign and orientation of food assistanceprograms in Mexico, as described earlier inthis chapter.

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CINyS researchers, when consulted bythose responsible for designing the Progresaprogram, expressed their concerns regardinga basic assumption by the program designersthat ensuring monetary transfers to low in-come families would be sufficient to improvethe population’s nutrition. The researchersparticularly expressed reservations aboutwhether the monetary transfers would sub-stantially improve the food and nutrition sta-tus of mothers and children during the vul-nerable period of gestation up until the thirdyear of life. CINyS staff submitted evidenceobtained from the Mexican population onthe inadequate practices of child feedingduring the critical period of the first twoyears of life, during which time foods rich inseveral nutrients had been excluded, andthey showed that these types of practices areconsiderably influenced by cultural and so-cial factors, in addition to economic factors,and that of these, only the latter (economic)factors would be affected by the receipt ofmoney transfers. Furthermore, the CINySrecommended adding a component that in-cluded the distribution of highly nutritionalsupplements in order to support nutritionduring the formative stage, in conjunctionwith effective nutrition education activitiesthat ensure adequate use of the supplementsand utilization of the additional income forpurchasing highly nutritional foods.

The CINyS researchers also proposed cre-ating an Expert Committee on Nutrition(CEN) comprised of various institutions de-voted to research in this field. CINyS recom-mendations were approved, and the CENreceived a mandate from the Mexican Secre-tariat of Health to develop the nutrition com-ponent of the program, which included thedistribution of micronutrient-fortified foodsto children ages 4–23 months, to low-weightchildren ages 2 to 4, and to lactating andpregnant women. The CEN was responsiblefor designing the fortified foods based on ex-isting knowledge of the nutritional status ofthe population (3, 33, 34). The supplements

were therefore specifically designed foryoung children and women. The ingredientsused in their preparation were powderedwhole milk, sugar, maltodextrins, vitamins,minerals, and flavorings, and contained thenutrients that are most deficient in Mexicanchildren’s diets (Table 1) (35). Children underage 2 and lactating and pregnant womenfrom low income families made up the targetgroup of these nutrition actions. The pro-gram also included an evaluation compo-nent as an essential part of its design (31).

In addition to Oportunidades, other nutri-tion programs have also been designed oradapted as a result of having disseminatedthe research findings to those responsible forshaping public policies. One of them is alarge-scale program of pharmacological sup-plementation with multiple micronutrients,whose purpose is to prevent anemia and mi-cronutrient deficiencies in infants in predom-inantly indigenous communities that havethe highest prevalence of malnutrition na-tionwide (6). Inputs for program design werethe results of the NNN-99 and a study on theefficacy of micronutrient supplementation,to be discussed in this chapter’s followingsection.

Another example is a subsidized milk dis-tribution program in operation over the last30 years (16) and recently modified on thebasis of NNN-99 findings. The program cur-


TABLE 1. Content of calories and key nutrients infortified foods distributed to children by theOportunidades program. Nutrient DRIa (%)

Calories 15Protein 36Iron 100Zinc 100Vitamin A 100Vitamin E 100Vitamin C 100Folic acid 100Vitamin B12 100

aDaily recommended intake (DRI) for children aged 1 to 3years.

rently focuses on the importance of address-ing iron and zinc deficiencies by fortifyingmilk with iron, zinc, vitamin C, and other mi-cronutrients lacking in Mexican children’sdiets. This milk is currently distributed tosome 5 million children ages 1 to 12. Evalua-tion of the efficacy and effectiveness of themilk fortification program is now underway.

The ultimate purpose of the NNN-99 wasthe application of its results to improving thenutritional and health status of the Mexicanpopulation. Accordingly, the INSP devotedconsiderable efforts to the dissemination ofthe survey’s results, which were published atthe end of 2001 (4). Following this, there wasan intensive period of more than 100 presen-tations given to key individuals in charge ofdesigning and implementing food, nutrition,and health policies and programs; to the aca-demic community interested in the topic (in-cluding students); to the private sector; tolawmakers; and to the media, which con-cluded with the publication of a series of ar-ticles targeted to the scientific community (5,6, 8–11, 13, 36–39). One of the first presenta-tions of NNN-99 results was given in Janu-ary 2002 to the Secretary of Health and hisprincipal advisors. As a result of that presen-tation and subsequent follow-up meetings,various initiatives were born that have had adirect impact on the decisions pertaining tothe nutrition policies and programs put intopractice by the health sector.

In the discussion following the presenta-tion, the Secretary of Health remarked on theimportance the survey results would repre-sent for the Secretariat of Social Develop-ment (SEDESOL), in view of the fact that thisministerial entity is in charge of overseeingthe country’s poverty reduction programs,several of which include food distributioncomponents. He pledged to arrange a meet-ing with SEDESOL, which was subsequentlyheld in February 2002. At that meeting,SEDESOL learned of the survey results,showed great interest in contributing to ef-forts to reduce the prevalence of malnutri-

tion, and signaled its desire to initiate actionsin the short term. Among the concrete ac-tions recommended by INSP researchers sothat SEDESOL might effectively contributeto reducing malnutrition were changes to theCommunity Milk Supply Program (Programade abasto social de leche) entrusted to the Li-consa company. The program had extremelyhigh coverage (around 4.6 million children atthe time of the SSA-SEDESOL meeting), dis-tributed an excellent quality of milk, enjoyeda large degree of acceptance by the popula-tion, and could serve as a vehicle for Mexi-can children to receive various nutrientslacking in their diet if these nutrients couldbe added without affecting the milk’s overallquality or its acceptance by the beneficiaries.Iron, zinc, and several vitamins were high-lighted as possible nutrients that could beadded to the milk.

The Secretary of SEDESOL showed a greatdeal of enthusiasm regarding these ideas andinstructed Liconsa’s director-general to meetas soon as possible with CINyS researchersin order to evaluate the feasibility of addingmicronutrients to the company’s milk supplyand of setting up a team to design a milk for-tification project. The work carried out by theteam involved researchers from the INSPand other national and foreign institutions,as well as Liconsa technical and administra-tive personnel. The team’s efforts led to thedevelopment of a micronutrient-fortifiedmilk distribution program that was officiallylaunched in August 2002, just six monthsafter the initial meeting with SEDESOL.

The INSP recommended evaluating theprogram’s impact on the nutritional status ofthe beneficiary children and proposed thatSEDESOL focus both on its efficacy; i.e., theeffects of the program under controlled con-ditions that would ensure consumption, aswell as its effectiveness; i.e., the effect of theprogram in its day-to-day operations.

The following section describes the prelim-inary results of the evaluation of the efficacyof the fortified milk distribution program.

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CONTROLLED CLINICAL TRIALS FORTHE STUDY ON THE EFFICACY OF THE

INTERVENTIONS OR ACTIONS

Before implementing large-scale pro-grams, it is advantageous to have scientificdata on the efficacy of the programs or ac-tions; that is to say, on the effects of the inter-vention when it is carried out under idealconditions.

Two examples of efficacy studies are pre-sented. The first refers to a test on the effectsof supplementation with multiple micro-nutrients on linear growth that served as the basis for the design of a micronutrientsupplementation program geared toward thecountry’s indigenous population, which hasthe highest prevalence of malnutrition. Thesecond is a study on the efficacy of fortifiedmilk on the prevalence of anemia and thestatus of iron and zinc in children under age 2.

The study on the effects of supplementa-tion with multiple micronutrients, a random-ized, double-blinded clinical trial (40),showed that one of the causes of growth re-tardation in Mexican children is micronutri-ent deficiency. Moreover, it showed that theeffect of supplementation with multiple mi-cronutrients was restricted to children lessthan 12 months old. Children less than 12months old who received the micronutrientsupplement grew an average of 1.14 cm morethan the children who did not receive thesupplement during the first year of life (Figure 8).

The objective of the study on the efficacyof fortified milk was to determine the effectof this product, under ideal conditions, onthe prevalence of anemia, and iron and othermicronutrient deficiencies (41). Preliminaryresults are presented exclusively as to the ef-fect on anemia.

One hundred eighty children 12 to 30months old upon beginning the study wereselected. One group of children received twoglasses of fortified milk daily and the othergroup received unfortified milk for 12

months. The milk was delivered to thehomes of the study subjects, and researchpersonnel confirmed that the children con-sumed the quantity of assigned milk. Beforebeginning the supplementation, and six and12 months later, height, weight, and bloodsamples were taken. Blood samples weremeasured to determine the concentration ofhemoglobin that makes it possible to quan-tify the prevalence of anemia, while weightand height data were used to assess growth.

Preliminary results indicated that amongthe children who were 12 to 23 months old atthe beginning of the study, at six months theprevalence of anemia among those who con-sumed fortified milk decreased by almosttwice as much (26.3 percentage points) as itdid in the children who consumed unforti-fied milk (13.7 percentage points); as for thechildren 24 to 30 months old, the reductionfor those who consumed fortified milk was


1 2

0.6a

0.85a

1.1a 1.14a

0

0.2

0.4

0.6

0.8

1

1.2

Quarter

Leng

th(c

m)

3 4

FIGURE 8. Effects of micronutrient supplementation on growth of children

under 12 months, during the initial stage, by quarter of supplementation.

ap < 0.05.Note: Generalized Estimation Equation (GEE) adjusted on the

basis of initial size, initial age, sex, breast-feeding, and socioeco-nomic conditions.

Source: Rivera JA, González-Cossío T, Flores M, Romero M,Rivera M, Téllez-Rojo MM et al. Multiple micronutrient supple-mentation increases the growth of Mexican infants. Am J Clin Nutr2001;74(5):657–663.

around 50% greater (14.5 percentage points)than it was for those who consumed unforti-fied milk (9.5 percentage points). The resultsindicate that fortified milk is highly effectivein reducing the prevalence of anemia.

The study on the effectiveness of fortifiedmilk on the nutritional status of the benefici-aries has only more recently been concluded,and the results will be analyzed and pub-lished shortly.

EVALUATION OF STUDIES ON THE EFFECTIVENESS OF ACTIONS

AND PROGRAMS

Since the end of the 1990s, Mexico has un-dergone a fundamental change that has ledto a culture of public policy and programevaluations. The change began with theOportunidades program, whose first direc-tor insisted on including an evaluation com-ponent in the program design. This cultureof evaluation has continued, and today themajority of the policies and programs of theSecretariat of Health and of SEDESOL aresubject to evaluation.

The information presented here relates tothe evaluation of the effectiveness of theOportunidades program on the nutritionalstatus of the beneficiary children (42), takinginto account the nature of the program andthe benefits it provides to the target popula-tion, as were described earlier in this chapter.Those benefits include the distribution of amicronutrient-fortified food supplement thatis designed specifically to correct the nutri-tional deficiencies of children aged 4 to 23months old and low-weight children ages2 to 4 years of the families included in theprogram.

The program initially included some300,000 households. Since it was not possibleto provide immediate coverage to its targetpopulation (around 4.5 million families), theevaluation study was originally plannedwith a randomized design in which a groupof localities was assigned at random to one of

two groups: the first group would receive theprogram benefits for two years, while thesecond group would receive the benefitsonly after the two years of the study werecomplete. In practice, the design of the studyremained intact during the first year (1998–1999); that is, while one group received thebenefits of the study, the second group waskept as a control and did not receive any ben-efits. However, during the 1999–2000 period,both groups received the program benefits.This explains why the group that receivedthe program benefits for two years wascalled the intervention group, and the groupthat received the benefits only during thesecond year was called the crossover inter-vention group, since it began as a control but“crossed over” to become an interventiongroup during the second year. Although itwould have been desirable to preserve theoriginal design, it was not possible. Nonethe-less, with this design it was still possible toevaluate the effect of the program, since theintervention group received the programbenefits for two years, while the crossoverintervention group received them for onlyhalf of this period. Furthermore, the inter-vention group received the program benefitsduring the critical period of the first twoyears of life, while the crossover interventiongroup did not receive them for much of thatperiod (Figure 9). The greatest impact was tobe expected in the children less than 6months old in 1998, since those who be-

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1998(Initial) 1999

2000(Final)

Intervention

CrossoverIntervention

FIGURE 9. Design of effectiveness evaluationof the Oportunidades program.

longed to the intervention group receivedthe program benefits during the critical pe-riod of the first two years of life, while thecrossover intervention group received theprogram benefits for only one year, startingat 12 to 18 months; i.e., they did not receivethe program benefits for a significant part ofthe critical period (Figure 9). It was alsohoped that the program would have thegreatest impact on children from lower in-come families who showed the highestprevalence of malnutrition. For these rea-sons, all comparisons were made on the basisof age (< 6 months and 6–12 months at thebeginning) and socioeconomic level (< mid-dle or higher).

The less-than-12-month-old group cov-ered from the beginning of the program wasstudied for the two years of the program. Itconsisted of 595 children (336 in the interven-tion group and 259 in the crossover interven-tion group) from 347 rural localities (205Oportunidades and 142 control). The increasein height of each group was studied between

the baseline (1998) and the year 2000, strati-fied by age and socioeconomic level, througha linear regression model with random coeffi-cients adjusted in relation to the possible ef-fect of conglomerates. It was found that in thebaseline year the children of both groupswere very similar in almost all their anthro-pometrical characteristics, as well as with re-gard to age, socioeconomic level, and sex.The effect of the program (Figure 10) was sig-nificantly greater in the intervention groupvis-à-vis the crossover intervention group,but exclusively in the children less than 6months old in 1998 and with the lowestsocioeconomic level (p < 0.046). The effect onthis group was on average 1 cm (p < 0.05),which is considered biologically important.There was no effect found on the group ofchildren in the highest socioeconomic levelnor among the oldest children.

With regard to anemia, in view of the factthat its effects appear within a shorter periodof time, it was possible to evaluate the effectof the program in 1999, a period in which the


FIGURE 10. Adjusted increasea of size from 1999 to 2000 in infants aged 6 months during baseline measurement of the intervention and crossover intervention groups.

aAdjusted on the basis of age and length in 1988, using a linear model with random intercept.**p < 0.05.Source: Rivera JA, Sotrés-Álvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health and nu-

trition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA 2004;291(21):2563–2570.

n

27.0

25.326.4 26.5

16.0

18.0

20.0

22.0

24.0

26.0

28.0

30.0

Poorest Less poor

**

n = 79 n = 76 n = 55 n = 71

Crossover intervention Intervention

Appropriate growth = 29.8 cm

Incr

ease

inhe

ight

(cm

)

intervention group had received the pro-gram benefits for a year, while the crossoverintervention group had not received them. Inother words, in terms of anemia, it was pos-sible to conduct the analyses in keeping withthe study’s original design. It was found thatthe prevalence of anemia, adjusted in rela-tion to age, was significantly higher in thecrossover intervention group (which was atrue control during the first year) than in theintervention group (Figure 11). The effectwas of 10.6 percentage points, almost a 20%impact with regard to the crossover interven-tion group.

In studying the consumption of the sup-plement by the beneficiary children, it wasfound that some 50% to 60% of the childrenin the intervention group regularly con-sumed the supplement, in keeping with the1999 evaluation. It was also discovered thataround 10% of the crossover intervention

group regularly received the supplement,even though this group was not expected toconsume the supplement during that period(Figure 12). As is customary in programswith broad coverage, there is a certain degreeof diversion of the benefits to families not in-cluded in the program. This was possiblesince the supplements were distributed athealth centers where families from commu-nities that were not program beneficiariescame from time to time. In any event, sincethe crossover intervention group receivedthe benefits for a year, and a small percent-age of them even received them during thefirst year, the effects discovered under thestudy are clearly an underestimation of thosethat would have been found had there beena true control group.

The effectiveness study concluded thatthe program had an important impact on thelinear growth of the group of children withthe greatest nutritional vulnerability (< 6months old and low socioeconomic level)and who were exposed to the program fortwo years, and that it was also able to de-crease the prevalence of anemia in the chil-dren exposed to the program for a year.

The results of this effectiveness study on aprogram currently covering roughly 5 mil-lion households were of great importance inreaffirming the program’s success and inpresenting evidence in support of its conti-nuity. Other results of the evaluation havebeen useful in providing feedback for theprogram and proposing changes to its de-sign. Following are two examples of how theevaluation results have been applied to mod-ify the program design.

HOW THE RESULTS OF THEOPORTUNIDADES EFFECTIVENESS

EVALUATION HAVE BEEN APPLIED TOMODIFY THE PROGRAM DESIGN

One of the findings of the evaluation ofthe Oportunidades program’s effectiveness(42) was that a significant percentage (40%–

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FIGURE 11. Prevalence of anemiaa in 1999 in the intervention and crossover

intervention groups.

aAdjusted on the basis of age, using a GEE model.*p < 0.05.Source: Rivera JA, Sotrés-Álvarez D, Habicht JP, Shamah T, Vi-

llalpando S. Impact of the Mexican program for education, healthand nutrition (Progresa) on rates of growth and anemia in infantsand young children: a randomized effectiveness study. JAMA2004;291(21):2563–2570.

10.6 p.p.

(19.3%)

54.9*

44.3

0

10

20

30

40

50

60

Crossoverintervention

Intervention

Perc

enta

ge

50%) of the children for whom the fortifiedsupplement was designed did not regularlyconsume the supplement (Figure 12). Uponstudying the reasons for this low consump-tion, it was found that while the programwas well accepted, low consumption mightbe attributed to the lack of timely availabilityof the supplement at the health centers aswell as inadequate promotion of the supple-ment’s consumption: only one out of 35 ses-sions was devoted to disseminating informa-tion on how to prepare the supplement andpromote its consumption. Also, a very tradi-tional educational approach was used underinadequate conditions: the talks were fre-quently held outside of the health centerswhere the women were standing and caringfor their children under the hot sun. In sum-mary, despite the many health and nutritionachievements of Oportunidades, its educa-tional component remained weak and unsat-isfactory.

A project was therefore developed, using acutting-edge methodology for applying aneducational communication component, in-cluding formative research and social market-ing (43, 44). The project was carried out in

rural areas in two states: Veracruz and Chia-pas, in both indigenous and nonindigenouscommunities. A communications strategy thatincluded both mass and interpersonal mediawas designed and applied for four months.

A study of the preliminary results of thisproject indicates that it has had positive ef-fects on various indicators of regular supple-ment consumption (32). This experience iscurrently being conveyed to the Secretariatof Health, which is implementing an edu-cational communications strategy in fourstates, to be followed by a national strategy.

Another result of the evaluation of Opor-tunidades’ effectiveness that led to modify-ing its program design was that it had hadless of an impact on reducing anemia thanexpected and that it had not been successfulin altering the status of iron in the childrenwho had consumed the supplements (42).CINyS was informed that the type of ironadded to the supplements was reduced iron,which is absorbed substantially less thanother forms of iron (45). As a result, severalstudies were conducted on the bioavailabil-ity and acceptance of supplements fortifiedwith two other forms of iron (ferrous sulfate


FIGURE 12. Proportion of children whose mothers reported regular consumption (4 days a week) of baby food distributed by the Oportunidades program to the

intervention and crossover intervention groups in 1999.a

aAdjusted on the basis of age.Source: Rivera JA, Sotrés-Álvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health and nu-

trition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA 2004;291(21):2563–2570.

10.7 7.9 8.611.6

62.0

54.051.7

59.9

0

10

20

30

40

50

60

70Crossover intervention Intervention

n = 31 n = 45 n = 35 n = 49 n = 23 n = 51 n = 46 n = 61Poorest Less poor Poorest Less poor

< 6 months in 1998 6–12 months in 1998

Perc

enta

ge

and ferrous fumerate) that showed adequatelevels of bioavailability and acceptance (28,46). This information has been provided tothe Secretariat of Health with a recommen-dation to replace the reduced iron with oneof the other two fortifiers.

The results of the effectiveness evaluationtherefore provided valuable feedback for theprogram’s coordinators and indicated neededchanges in the design, thereby providing anexample of the iterative, cyclical nature ofmission-based research.

CONCLUSION

Strategic mission-based research (1) as-pires to generate fundamental knowledge,with an effect on universal scientific tradi-tion, which at the same time may be used tosolve the population’s health problems.

This chapter is an account of how theprinciples of strategic mission-based re-search, as applied to the design of CINyS’ re-search agenda, have generated useful knowl-edge that has had an impact on the definitionof public nutrition policies and programsand on changes to current policies and pro-grams. The chapter also presents key scien-tific data that have provided the necessaryinput for designing these new policies andprograms and for properly fine-tuning exist-ing policies and programs.

In addition, as the list of references at theend of this chapter demonstrates, the re-search findings and their interpretation havegenerated fundamental knowledge that hasbeen published in scientific peer review jour-nals, in addition to being useful for publichealth in Mexico in general.

As stated at the beginning of this chapter,mission-based research addresses various ob-jects of analysis, including health conditionsand organized social response. The research ex-amples shown encompass both of these objectsof analysis. Thus, the results of the national nu-trition survey reflect the extent and distribu-tion of poor nutrition in Mexico (the study of

the conditions), while the effectiveness evalu-ations presented refer to the analysis of poli-cies (the organized social response). Further-more, mission-based research addressesvarious levels of analysis, from subcellular par-ticles up to health systems. CINyS conductsboth clinical (studies on the bioavailability ofmicronutrients) and epidemiological or pop-ulation research (the national nutrition surveyor controlled tests) as well as research on healthsystems (evaluations of the program’s cover-age and effectiveness).

On the other hand, this chapter did not in-clude examples of subcellular particle re-search (molecular biology) simply because,to date, CINyS has not addressed this level ofanalysis; nonetheless, subcellular particleanalysis can be of great importance for thepopulation’s nutrition. For example, it canfacilitate an understanding of the biologicalmechanisms involved in the etiology of poornutrition and its consequences for health andintellectual performance, and an identifica-tion of biomarkers useful for diagnosingpoor nutrition and for selecting the popula-tions susceptible to specific deficiencies or toproblems of obesity and their effects onhealth. At the same time, it could also be use-ful for developing resolution technology, forexample, for food with nutritional or func-tional attributes aimed at reducing malnutri-tion. In short, addressing various levels ofanalysis, from subcellular particles up tohealth systems, is extremely useful for meet-ing the objectives of mission-based research.

Throughout the chapter, research experi-ences have been described that have success-fully influenced the design of and changes topublic policies. Highlighting success stories,however, does not mean that there have notbeen setbacks and failures along the way.The chapter does not describe several fruit-less efforts made with a view to influencingpublic policies; attempts that resulted infrustration and skepticism among the Cen-ter’s staff. The chapter likewise avoids a dis-cussion of the difficulties in overcoming ob-stacles and moments of disillusionment

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occasionally brought on by the same pro-cesses that eventually had an impact on pub-lic policies. It was simply determined thatinstead of addressing the hardships and dis-comforts common to any human activity thatendeavors to reach noble ends, it was impor-tant to focus on outcomes that were success-ful and to outline the processes throughwhich the objectives were met.

An especially important issue that re-mains for future endeavors is the possible re-production of similar successful mission-based research experiences in other areas. Inthis regard, INSP successfully provided tech-nical assistance to the health sector and toother governmental sectors in charge ofhealth and nutrition policies from 1993 to2005 (the author of this chapter can testify tothis since the time period coincides with hisassociation with the institution); to be pre-cise, at least one of the important factors isinstitutional in nature and is based on cur-rent norms and standards.

Other factors are less related to institution-ality and more related to people and interper-sonal relations. The majority of the successesdescribed in this chapter were made possible,to a large degree, through the participation ofstaff members who had vision and were con-vinced of the merits of informed decision-making that is founded on high-quality scien-tific research. These staff members wereresponsible for the decision-making with re-gard to food and nutrition policies. Withouttheir dedication and resolve, it likely wouldhave been much more difficult to influencepublic policy, even with institutional provi-sions and standards in place.

It was also essential to have the strong col-laboration of INSP authorities who utilizedtheir institutional investiture and broad per-sonal relations to support the develop-ment of relevant research aimed at fuelingdecision-making and the dissemination ofthe research findings among staff membersat a very high decision-making level.

Furthermore, as noted at the beginning ofthis chapter, the CINyS working group took

active responsibility for disseminating the re-search results. In addition to disseminatingstudy findings in scientific publications andacademic presentations, the results werepresented at a variety of forums to diverseaudiences, including civil servants, non-governmental organizations, the media, thelegislative branch, and business groups. Thedynamism and diligence that accompaniedthe dissemination process surely influencedthe success of the Center’s work.

Finally, it is worth noting that the Center’sresearchers have taken great efforts to main-tain a high level of quality in their researchand to bring about permanent dialogue withpolitical authorities interested in utilizing re-search for decision-making, which in turnhas forged an environment of mutual respectand understanding.

In synthesis, over the past decade, CINyShas been able to conduct effective strategicmission-based research, thanks to the combi-nation of an institutional framework thatconfers the INSP the standing of research ad-viser to Mexico’s social, health, and develop-ment sectors; an environment characterizedby civil servants with vision and dedica-tion to producing research to be used fordecision-making in public policy and institu-tional authorities committed to this type ofresearch; and the dynamism, diligence, andhigh-quality criteria of a group of researcherswho have achieved credibility and respect inthe eyes of those responsible for public nutri-tion policies.

ACKNOWLEDGMENTS

The author thanks Dr. Teresita Gonzálezde Cossío for her valuable observations onthis chapter’s final draft, the CINyS re-searchers and support personnel who partic-ipated in the research described in this textand in the publication of its results, and Dr.Jaime Sepúlveda Amor and Dr. MauricioHernández Ávila for their generous supportin developing the CINyS.


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23. Martorell R. Results and implications of the INCAPfollow-up study. J Nutr 1995;125(Suppl 4):S1127–S1138.

24. Rivera J, Flores M, Martorell R, Ramakrishnan U,Melgar P. Generational effects of supplementaryfeeding during early childhood. In: Battaglia F,Falkner F, Garza C et al. Maternal and ExtrauterineNutritional Factors: Their Influence on Fetal and InfantGrowth. Madrid: Ediciones Ergon; 1996:197–204.

25. Rivera JA, Ruel MT, Santizo MC, Lönnerdal B,Brown KH. Zinc supplementation improves thegrowth of stunted rural Guatemalan infants. J Nutr1998;128(3):556–562.

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27. Bentley ME, Caulfield LE, Ram M, Santizo MC,Hurtado E, Rivera JA, et al. Zinc supplementationaffects the activity patterns of rural Guatemalan in-fants. J Nutr 1997;127(7):1333–1338.

28. Pérez-Expósito AB, Villalpando S, Rivera JA, GriffinIJ, Abrams SA. Ferrous sulfate is more bioavail-able among preschoolers than other forms of iron in a milk-based weaning food distributed byPROGRESA, a national program in Mexico. J Nutr2005; 135(1):64–69.

29. Hotz C, DeHaene J, Villalpando S, Rivera J, Wood-house L, King JC. Comparison of fractional zincabsorption (FAZ) from ZnO, ZnO + Na2EDTA,Na2ZnEDTA, and ZnSO4, when added as fortifi-cants to a maize tortilla-based meal. In: 2004 Exper-imental Biology meeting abstracts. Abstract #129.5.Available at: http://select.biosis.org/faseb.

30. Schroeder DG, Martorell R, Rivera JA, Ruel MT,Habicht JP. Age differences in the impact of nutri-tional supplementation on growth. J Nutr 1995;125(Suppl 4): S1051–S1059.

31. Rivera JA, Rodríguez G, Shamah T, Rosado JL,Casanueva E, Maulén I, et al. Implementation, mon-itoring, and evaluation of the nutrition componentof the Mexican Social Programme (PROGRESA).Food Nutr Bull 2000;21(1):35–42.

32. Bonvecchio A, Nava F, Escalante E, Villanueva M,Safdie M, Monterrubio E, et al. Implementation of acommunication plan to improve the consumption ofa fortified supplement in Mexican children. In: 2005Experimental Biology meeting abstracts. Abstract # 833.6. Available at: http://select.biosis.org/faseb.

33. Rivera-Dommarco J, González-Cossío T, Flores M,Hernández-Ávila M, Lezana MA, Sepúlveda-AmorJ. Déficit de talla y emaciación en menores de cincoaños en distintas regiones y estratos en México.Salud Pública Mex 1995;37(2):95–107.

34. Rivera-Dommarco J, Bourges-Rodríguez H, ArroyoP, Casanueva E, Chávez Villasana A, Halhali A, et al.Deficiencia de micronutrimentos. In: De la FuenteJR, Sepúlveda-Amor J. Diez problemas relevantes desalud pública en México. México, DF: Fondo de Cul-tura Económica; 1999:15–57.

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36. González-Cossío T, Moreno-Macías H, Rivera J, Vi-llalpando S, Shamah-Levy T, Monterrubio EA, et al.

Breast-feeding practices in Mexico: results from theSecond National Nutrition Survey 1999. SaludPública Mex 2003;45(Suppl 4):S477–S489.

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40. Rivera JA, González-Cossío T, Flores M, Romero M,Rivera M, Téllez-Rojo MM, et al. Multiple micronu-trient supplementation increases the growth ofMexican infants. Am J Clin Nutr 2001;74(5):657–663.

41. Villalpando S, Shamah T, Robledo R, Rivera JA,Merlos C, Lara Y. Efficacy of iron-fortified milk inthe rates of anemia and iron status of infants andyoung children in Mexico. In: 2005 Experimental Bi-ology meeting abstracts. Abstract # 848.5. Availableat: http://select.biosis.org/faseb.

42. Rivera JA, Sotrés-Álvarez D, Habicht JP, Shamah T,Villalpando S. Impact of the Mexican program foreducation, health and nutrition (Progresa) on ratesof growth and anemia in infants and young chil-dren: a randomized effectiveness study. JAMA2004;291(21):2563–2570.

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46. Pérez-Expósito AB, Villalpando S, Rivera JA, GriffinIJ, Abrams SA. Ferrous sulfate is more availableamong preschoolers than other forms of iron in a milk-based weaning food distributed byPROGRESA, a national program in Mexico. J Nutr2005;135(1):64–69.


DEMOGRAPHIC, SOCIOECONOMIC,AND EPIDEMIOLOGICAL CHANGES

IN CHILE

Significant demographic and epidemio-logical changes have occurred in Chile in re-cent decades. In demographic terms, thepopulation under age 15 declined from39.2% of the total population in 1970 to 25.7%in 2002; in the same period, the populationover age 65 increased from 5% of the total to7.2%. The total fertility rate and the birth rateboth declined significantly, causing a fall inthe annual rate of population growth from1.8% to 1.1%. The infant mortality rate alsodropped spectacularly, going from 82.2 per1,000 live births in 1970 to 7.8 per 1,000 livebirths in 2002, while life expectancy in-creased from 60.5 years for men and 66.8years for women in 1970 to 73.2 and 79.5 in2002, respectively (1).

During the same period, Chile becamemore and more urbanized: at the beginningof the 1970s, 75% of the population lived inurban areas, and by 2000 this figure had in-creased to 86.7%. The process of urbaniza-tion has produced positive effects reflectedin several indicators, such as access to safedrinking water and sewerage services formore than 95% of the population, increasedliteracy rates, and greater access to housing

and health services. But these changes havealso meant an increase in risk factors for non-communicable chronic diseases (NCCDs),such as the adoption of diets rich in fats,sugar, and salt; sedentary habits; greater ac-cess to tobacco, alcohol, and drugs; andgreater exposure to environmental and psy-chosocial problems (2, 3).

These demographic changes and the in-crease in risk factors for chronic diseaseshave produced important transformations inthe epidemiological profile of the popula-tion, beginning in the 1970s with changes inthe proportions of death from broad groupsof causes (Table 1). Cardiovascular diseasesand tumors increased from 34.3% of alldeaths in 1970 to 52.1% in 2000, while infec-tious and perinatal diseases decreased from15.9% to 3.8% over that same period. Deathsfrom accidents and from respiratory infec-tions also decreased as proportions of totalcauses of deaths (1).

THE PUBLIC POLICY RESPONSE TOEPIDEMIOLOGICAL AND NUTRITIONAL

TRANSITION: THE CASE OF CHILE

Fernando Vio1 and Ricardo Uauy2

205

1Director, Institute of Nutrition and Food Technology(INTA), University of Chile, Santiago.

2Chair of Public Health Nutrition, London School ofHygiene and Tropical Medicine, and previous Directorof INTA.

EXPLOSIVE INCREASE IN RISKFACTORS FOR CHRONIC DISEASES

RELATED TO NUTRITION

With the process of urbanization at theend of the 1980s and beginning of the 1990s,the national diet changed spectacularly. Be-tween 1982 and 1986, Chile experienced a se-rious economic crisis that resulted in grossdomestic product falling from 14% in 1982 to2% in 1986, in increased unemployment andpoverty (4), and in a higher prevalence ofmalnutrition. But at the end of the 1980s, theeconomy revived and consumption patternschanged, with increasing consumption of fatand decreasing consumption of grains, veg-etables, and fruits (Table 2) (5). In tandemwith the high intake of food rich in energyand poor in specific nutrients, there wereother changes in lifestyle related to growingurbanization, such as increases in sedentary

habits, stress, consumption of alcohol, anduse of tobacco, all of which reached veryhigh levels. It can be said that in the 1990sNCCDs increased explosively, with alarm-ing prevalence figures indicated in a Na-tional Health Survey carried out in 2003 (6)(Table 3).

CHANGES IN THE NUTRITIONAL SITUATION

The combination of changes in eatinghabits described above and a sedentarylifestyle provide an effective trigger for an in-crease in body adiposity. The steady increasein prevalence of overweight and obesity wasgreater in low income groups that improvedtheir incomes and increased their consump-tion of energy-rich food with high contentsof fats and carbohydrates. In these groups,

206 The Public Policy Response to Epidemiological and Nutritional Transition: The Case of Chile

TABLE 1. Proportion of causes of death among total causes of death, 1970–2000, bypercentage. Broad groups of causes 1970a 1982b 1992b 2000

Cardiovascular 22.3 27.6 29.0 27.9(A80–88)a (390–459)b (I00–99)c

Malignant neoplasms 12.0 16.8 20.0 24.2(A45–59)a (140–208)b (C00–D48)c

Accidents 19.0 12.1 12.0 9.8(AN138–150 + AE138–149)a(800–999)b (V00–Y98)c

Respiratory 17.4 8.5 11.1 10.5(A89–96)a (460–519)b (J00–99)c

Digestive 6.9 8.6 6.3 7.2(A97–104)a (520–579)b (K00–93)c

Ill-defined 4.5 8.8 5.6 3.9(A137)a (780–799)b (R00–99)c

Infectious and parasitic 10.9 3.8 2.9 2.6(A1–44)a (1–139)b (A00–B99)c

Perinatal 5.0 3.5 1.9 1.2(A131–135)a (760–779)b (P00–96)c

All others 2.0 10.3 11.2 12.7

Total 100.0 100.0 100.0 100.0

aICD-8.bICD-9.cICD-10.Source: Instituto Nacional de Estadísticas. Informes Demográficos Anuales 1970, 1982, 1992, and 2000.

there was also an increase in the purchasingof television sets and other electrical appli-ances, resulting in an average of two to threehours a day being spent watching televisionduring the week and three to four hoursspent in this activity on weekends. The in-crease in numbers of hours spent watchingtelevision, as data from Santiago shows, in-creases inactivity and passivity, and exposeschildren to television commercials promot-ing the consumption of fast foods and snacksat home and the purchase of similar types offoods in the school environment (7).

These factors, together with the steady de-crease in undernutrition, have increased theprevalence of obesity measured for childrenunder age 6 and pregnant women (Figures 1and 2) (8), as well as for adult men andwomen (9) and older adults (10). The mostrecent data on prevalence of overweight andobesity appears in the National Survey of

Health of 2003 (6) (Figure 3). Its results areconclusive: 61.3% of people over age 15 suf-fer from overweight or obesity, with 1.3%suffering from morbid obesity. These find-ings demonstrate that overweight and obe-sity are the most important nutritional prob-lem in Chile and one of the country’s mostimportant public health challenges. Unfortu-nately, this situation is similar to that seen inother countries of Latin America (11, 12).

POLICIES AND PROGRAMS TOADDRESS FOOD AND

NUTRITIONAL PROBLEMS

Programs Designed to Reduce theImportance of Malnutrition as a PublicHealth Problem

In the past, Chile was successful in reduc-ing malnutrition in a relatively short period oftime through implementation of sound poli-cies based on primary prevention through theNational Complementary Food Program(PNAC). This program encompassed nearlyall the vulnerable population; that is, all preg-nant and nursing women and all childrenunder the age of 6 participating in publichealth programs, and achieved a high level ofcoverage by reaching more than 1.2 millionpregnant women and children. The PNACwas complemented with a special program ofsecondary prevention for pregnant and nurs-ing mothers with undernutrition and for

Vio and Uauy 207

TABLE 2. Availability of total calories, fat, grains, fruits, and vegetables in Chile, 1980,1990, and 2000.a

1980 1990 2000 % change

Kcal/day per capita 2,664 2,519 2,870 + 7.8% of fat per capita 20.4 22.0 26.6 + 30.4G/day of vegetable fat per capita 30.9 27.5 39.4 + 27.8G/day of animal fat per capita 29.6 33.9 45.4 + 53.6Kg/year of grains per capita 159.1 143.4 142.6 – 10.4Kg/year of fruits and vegetables per capita 170.5 144.6 168.4 – 1.2

aAverages for 1979–1980, 1989–1990, and 1999–2000.Source: Food and Agriculture Organization, Hojas de Balance de Alimentos 1979, 1980, 1989, 1990, 1999, and

2000. Available at: www.fao.org/documents/show_cdr.asp?url_file=/DOCREP/006/Y5065M/Y5065M00.HTM, ac-cessed in January 2003.

TABLE 3. Risk factors in Chile, National HealthSurvey 2003.a

Men Women Total(%) (%) (%)

Obesity 19.0 25.0 22.0Overweight 43.0 33.0 38.0Hypercholesterolemia 35.1 35.6 35.6Sedentary lifestyle 88.4 91.4 89.8Smoking 48.0 37.0 42.0Cardiovascular risk 64.2 46.2 54.9

aRepresentative sample at the national level of population overage 16.

Source: Chile, Ministerio de Salud. Encuesta Nacional de Salud2003. Santiago: Ministerio de Salud; 2004.


FIGURE 1. Percentage of evolution in nutritional status of Chilean schoolchildren 6 years of age, by sex, 1987–2003.

Source: Junta Nacional de Auxilio Escolar y Becas, Institute of Nutrition and Food Technology, 2004.

0

2

4

6

8

10

12

14

16

1987 1990 1993 1996 2003

Underweight (boys)Underweight (girls)Obesity (boys)Obesity (girls)

Underweight: BMI < 5th percentile on NCHS/CDC 2000 reference.Obesity: BMI > 95th percentile on NCHS/CDC 2000 reference.

FIGURE 2. Prevalence (%) of obesity and low weight in pregnant women, Chile, 1988–2003.

Sources: Rosso P, Masdones SF. Curva patrón de incrementos ponderales para las embarazadas chilenas. Santiago: UNICEF, Ministeriode Salud; 1996, and Ministerio de Salud de Chile Web site. Available at: www.minsal.cv/ev/en/dic04/embarazadas/totales/consulta_ servicio.asp, accessed in September 2004.

10

15

20

25

30

35

1988 1990 1992 1994 1996 1998 2000 2003

Low weight Obese

children at social risk or suffering from mildmalnutrition. An intense program of ter-tiary prevention, or rehabilitation, was alsolaunched for children with severe or moder-ate malnutrition who were hospitalized inspecial centers until they were fully recov-ered. Food programs in the education sectoralso were strengthened to complement thePNAC. This included a program sponsoredby the National Kindergarten Board, coveringapproximately 62,000 children, and the SchoolFood Program (PAE), which covered some600,000 children between the ages of 6 and 14.These programs represented an annual cost ofUS$ 200 million for the country (13).

The group of initiatives just describedwere characterized by high coverage (morethan 80% of the respective target groups) andby the scaled character of the interventions,which ran the gamut from universal preven-tion measures to the fastest recovery possiblefor the seriously malnourished in order toprevent additional consequences. Thus, bycovering the full range of problems, theresults were synergistic and greater than ifeach component had been implementedseparately.

In the case of children, malnutrition, usingthe weight-for-age indicator with Sempé ref-erence values, and the maximum cutoff point

of one standard deviation, stood at 15.5% in1975. It was reduced to 8.2% in 1989 (14) andto 5% in 1993. Low weight for pregnantwomen, according to 1987 Ministry of Healthreference values (15), was reduced from 26%in 1987 to 7% in 2003 (Figure 2).

This effort was supported by a technicalconsensus that overcame political barriersand whose stability was maintained throughthe terms of various government administra-tions. There was an ongoing exchange of in-formation and cooperative work betweenacademic specialists at the universities andprofessional and technical personnel at theMinistry of Health who oversaw the pro-grams. For example, during the height of theeconomic crisis in 1982 the PNAC was re-duced by 30%. An increase in malnutrition, asmeasured through the existing nutritionalsurveillance system, was immediately ob-served. In light of this situation, academicgroups reported the situation to the technicalpersonnel at the Ministry of Health and to thecountry. The policy was immediately re-versed, and malnutrition again declined. Another example was the 1985 proposal tosubstitute rice for the milk provided topreschoolers, a step that was not imple-mented due to opposition by several groupsof professionals and academic specialists (14).

Vio and Uauy 209

FIGURE 3. Nutritional status. Chilean population age 15 and over, by sex, National Survey of Health 2003.

Source: Chile, Ministerio de Salud. Encuesta Nacional de Salud 2003. Santiago: Ministerio de Salud; 2004.

0

5

10

15

20

25

30

35

40

45

Morbid obesity Obesity Overweight

Men Women Total

Perc

enta

ge

It should be noted at this juncture thatthese interventions were made possiblethrough decades of groundwork that had es-tablished a national public health systemcharacterized by a services network of incre-mental complexity (rural posts, primary carecenters, and hospitals) which facilitated theimplementation of nutritional programs atthe local level. Public health activities alsotook place within a legal framework provid-ing for continuity, since programs cannot be modified arbitrarily to reflect politicaltrends, even if this can also be an obstaclewhen programs need to be adapted to a newepidemiological and nutritional situation inthe country.

Review and Modification of Policies andPrograms to Prevent MicronutrientDeficiencies and to Promote HealthyEating Habits

By the end of the 1980s, malnutrition hadpractically disappeared as a public health prob-lem in Chile. As a result, nutrition was notamong the priority issues on the national po-litical agenda of the early 1990s. Despite this,nutritional problems had not been resolved,and certain disorders due to micronutrient de-ficiencies persisted, such as iron deficiency ane-mia in infants and pregnant women and lowheight-for-age among the poor. Furthermore,as earlier noted, during this same period, anexplosive increase in obesity was observed. Inresponse to this situation, academic groups, to-gether with professional and technical person-nel working in nutritional programs, convokeda Food and Nutrition Forum in 1994, with thegoal of updating the national agenda regard-ing food and nutrition concerns. The Forumsucceeded in gaining the attention of the gov-ernment and making it more aware of the prob-lems that persisted in this area despite the vir-tual eradication of poor nutrition in terms ofcalorie and protein intake. The objective of en-suring adequate food and nutrition for allChileans was proposed. It was emphasized that

Chile was a country with problems of poor nu-trition due both to undernutrition and to an ex-cess and imbalance of micronutrients, whichmanifested themselves through growing ratesof chronic diseases, obesity, and inactivity, andwith these conditions, in turn, taking on greatersignificance in terms of morbidity and mortal-ity on a national scale. The poor began to ex-perience micronutrient deficiencies and higherrisks for chronic diseases of nutritional origin.A document was prepared and approved byall the technical groups active in the field ofpublic nutrition (16). The following subsectionsdescribe the priorities and orientations pro-posed in the document in order to bring foodand nutrition policies into greater harmonywith the country’s current realities.

Food Programs

It was recommended that existing programsfor supplementary feeding be evaluated withregard to: (1) their impact on growth and de-velopment in the different stages of the lifecycle; (2) the coverage achieved and their ef-fect on the coverage of other programs (for ex-ample, in the case of the PNAC, on the cover-age of primary health care actions; and ineducation, on the coverage of basic education);(3) food distributed (quality, acceptability, andequitable distribution within the family); (4) their degree of orientation toward the poorand other high-risk population segments; (5) the transfer of income toward those sectors;and (6) the cost-effectiveness relationship foreach program. A review of the existing stan-dards for each program was also recom-mended, to include criteria for eligibility, theduration of program benefits for each recipi-ent, and criteria for entry into and exit from theprograms.

Poverty and Food Safety

The Food and Nutrition Forum documentproposed the establishment of mechanismsfor detecting social and nutritional risk in


families in extreme poverty in order to pre-vent malnutrition in mothers and childrenthrough early detection of social and nutri-tional problems. Once the problems were de-tected, it was recommended that integratedmechanisms for intervention in high-riskfamilies be developed that also addressedany related economic, social, and nutritionalaspects. Intervention options in this areawere considered limited by the prevailingeconomic system. It was proposed that aslong as high levels of poverty continued toexist, it would be necessary to maintain sup-plementary feeding programs. Their contin-uation was justified not only because of thenutritional benefit they brought to their tar-get audience but also because they served asan effective means to encourage vulnerablegroups to seek preventive health check-upsand to attend preschool and school educa-tion. Furthermore, by being directed to thepoor, supplementary feeding programs wereviewed as an efficient mechanism for incometransfer and for the provision of necessarymicronutrients.

Micronutrients

In this area, the Forum proposed the fol-lowing actions: (1) the establishment, as soonas possible, of mechanisms for supplementa-tion with iron, zinc, and copper for groupswith a high prevalence of deficiencies in thesemicronutrients (pregnant women and chil-dren under 2 years of age); (2) the establish-ment of programs focusing on the detectionand treatment of goiter in areas where theprevalence of this disease remained high; (3)the launching of programs for fluoridation ofwater and fortification of food with fluorinein areas of the country deficient in this sub-stance; and (4) an evaluation of the calciumcontent in the national diet, by means of stud-ies of prevalence of osteoporosis in the femalepopulation, and calcium supplementationprograms for the groups most affected by de-ficiency of this micronutrient.

Food and Nutrition Interventions for thePrevention of NCCDs

It was proposed that a survey be con-ducted on the prevalence of obesity, un-healthy eating habits, dyslipidemia, smok-ing, alcohol consumption, and physicalactivity, by sex and age groups, to be repre-sentative of the general national population,which would then serve as a baseline for pre-ventive nutritional interventions againstNCCDs. At the same time, an analysis wasproposed of all existing information avail-able from social programs in the public sec-tor regarding overweight and obesity ininfants, preschoolers, schoolchildren, andpregnant women. It was planned to designan educational strategy incorporating con-tent on the prevention of NCCDs in (1) for-mal education, starting with preschool edu-cation and continuing throughout the entireprimary, secondary, and university educa-tion spectrum; and in (2) nonformal educa-tion, including health programs or otherrelated programs carried out through munic-ipalities, nongovernmental or grassroots or-ganizations, and other similar institutions.There was also a proposal to carry out nutri-tional programs in primary health care forthe prevention of NCCDs, actively incorpo-rating the municipalities in programs forcontrol of obesity, alcoholism, and diabetes,as well as smoking and drug addiction,which are also risk factors for NCCDs relatedto nutritional factors.

With respect to the mass media, the 1994Food and Nutrition Forum participants sug-gested that well-designed social communica-tion techniques be adopted and targeted tothe general population, as a way to counter-act the pervasive influence of campaigns carried out by the food, alcohol, and tobaccoindustries. It was agreed that technicalgroups should provide content for the socialcommunication campaigns, but that the cam-paigns themselves should be the responsibil-ity of those with specialized media commu-

Vio and Uauy 211

nications skills. Intersectoral coordination,clear messages, and continuity over timewere deemed as key ingredients in maximiz-ing the impact of the campaigns. Further-more, it was agreed that this impact shouldbe measured on a continuous basis, andquantitative goals for the reduction of riskfactors (obesity, smoking, alcohol consump-tion, diet, physical inactivity) should be es-tablished, in accordance with the findings ofthe representative baseline survey.

There was a consensus that local govern-ments should be the parties directly respon-sible for issues related to personal develop-ment and well-being and that they shouldtake responsibility for planning appropriatesports and recreational activities, as well asfor promoting physical activity among thegeneral population, as a way to encouragethe adoption of healthier lifestyles that helpprevent NCCDs. Furthermore, these pro-grams should seek to increase community in-terest and participation in the broadest scopepossible of health-related issues.

Given the high involvement of the privatesector in food production, distribution, mar-keting, and consumption, the Food and Nu-trition Forum document proposed that foodindustry representatives participate in thepreparation and implementation of nutri-tional policies aimed at preventing NCCDs,thereby seeking to create greater private sec-tor incentive for the production and com-mercialization of foods high in nutrition anda decreased focus on those with high caloricvalue (i.e., a high content of fats and refinedsugars), but without nutritional value.

Upgrading of Human Resources Education

At undergraduate and graduate schoolsspecializing in food and nutrition issues, itwas proposed that the curricula be updatedto reflect the country’s new epidemiologicalreality by incorporating, by the year 2000,course materials on healthy nutrition for theprevention of NCCDs, food quality andsafety, and other similar issues. It was further

suggested that refresher courses be orga-nized for personnel currently working in foodand nutrition programs.

Control of Food Quality and Safety

The Food and Nutrition Forum recom-mended promoting the establishment ofmechanisms for systematic, ongoing coordi-nation among all the institutions whosework involved issues related to food qualityand food safety control—the Ministries ofHealth, Economy, Agriculture, and Housing,and their affiliated agencies, as well as uni-versities and scientific societies—so as to en-courage the joint evaluation and resolutionof existing shortcomings in food protection.In addition, special emphasis was placed onthe importance of supporting a revision ofcurrent legislation and regulations, and thechanges necessary for updating these weredefined.

The Forum document—visionary for itstime—also served as the basis upon whichthe Institute of Nutrition and Food Technol-ogy (INTA) of the University of Chile rede-fined its internal policies to make them moreresponsive to the country’s new demo-graphic and epidemiological realities. Threenew programs—Chronic Diseases, Second-ary Malnutrition, and Food Quality andSafety—were created as a result of this orga-nizational review, and the importance of con-ducting research in the specific areas ofmicronutrients (iron, copper, zinc, and fluo-rine), growth size deficits, obesity, lipids, os-teoporosis, and NCCDs was stressed.

In response to the Forum’s actions andproposals, in January 1995 the Chilean Gov-ernment created the National Commissionfor Food and Nutrition, which in turn estab-lished working groups on food safety for thepoor, designed food programs, promotedfood protection regulations and the adoptionof healthy habits and lifestyles, organized ac-tivities for the prevention of NCCDs basedon nutrition, and prepared nutritional guide-lines for the population (17).


It is interesting to note that a little morethan a decade later, nearly all of the propos-als and recommendations of the Food andNutrition Forum of 1994 have been success-fully implemented. These will be discussedin the following section.

Results of the Policy and ProgramChanges: The Current Situation

Food Programs

The working group on food programs hassought to optimize the PNAC’s effectiveness,and in 1998 fortification with iron, zinc, andother micronutrients was included for milk(fortified pure milk) delivered to 80% ofChilean children under age 2, with the goalof preventing iron deficiency anemia in in-fants. This program enabled a reduction inanemia among Chilean infants from 30% in1998 to 8% by the year 2000 (18). The pro-gram’s impressive success spurred Ar-gentina and Mexico to subsequently adoptthis strategy. In addition, from the year 2000,a special milk was introduced for phenylke-tonuria and for children with low birth-weight. Also, as an obesity prevention mea-sure, the proportion of fat in milk has beenprogressively reduced.

In 2000, after an intense technical and po-litical discussion that included the participa-tion of a research commission of the ChileanCongress, the bidding conditions for the PAEwere changed, and the need to actively pro-mote healthy nutrition in all governmentalfood programs was established. Thus foodswith less saturated fats and sugars, and in-creased quantities of fruits and vegetables,dairy products, and legumes, were includedin the diet for 1.5 million preschoolers andschoolchildren. These changes in schoolmenus represented an increase in the con-sumption of fresh fruits and salads from fourto 18 times a month; the elimination of foodswith high fat and caloric content, such assausages, and of the so-called “milk drinks”

(which, in fact, contained no milk) and theirreplacement with reduced-fat milk, in orderto increase the intake of calcium; an increasein consumption of fish and vegetables totwice a week; and a reduced intake of sugarand refined carbohydrates. Thus nutritionalquality in the school diet was improved, andthe fat and caloric content was reduced.

Poverty and Food Safety

The Ministry of Planning launched apoverty eradication program called “Chile So-lidario,” incorporating all the elements high-lighted in the 1994 Forum document. Chile So-lidario targets high-risk families and utilizesinterventions that integrate economic, social,and nutritional issues and facilitate access toa gamut of State resources and subsidies. How-ever, the program’s structure, instead ofmerely providing passive assistance to the des-ignated recipients, encourages beneficiaries tobecome proactive in the improvement oftheir particular circumstances and to move be-yond their current state of poverty. Access tothe nutritional programs overseen by the Min-istries of Health (PNAC) and Education (PAE)is assured for these families, as well as educa-tional activities designed to raise awarenessconcerning healthy food and nutrition habits.

Micronutrients

In addition to the changes concerning in-clusion of iron, zinc, and copper in thePNAC, in 2000 the Ministry of Health estab-lished a legislative framework providing forthe compulsory fortification of wheat flourwith folic acid, in order to prevent neuraltube defects, the congenital malformationthat leads to results that can include thedeath of the newborn or neurological effectsthat require rehabilitation throughout life.The assessment of the impact of this inter-vention on the population showed that afteronly two years of this measure being in ef-fect, malformations were reduced by 42%(19). In addition, a national law that man-

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dates salt iodization for all salt used forhuman consumption has permitted the erad-ication of endemic goiter in the population(20). The policy of water fluoridation in thecountry was continued, and for rural sectorsa special program for milk fluoridation wascreated. A pilot study over three years(1994–1997) showed a 40%–60% reduction incaries among children between the ages of 3to 6 (21). This program is currently being ex-panded to other rural areas of the countrythrough the PNAC in the Ministry of Healthand the PAE in the Ministry of Education.With respect to calcium, nationwide studieswere conducted among schoolchildren (22),pre- and postmenopausal women, and olderadults, to determine the level of calcium de-ficiencies in the population. This led to a na-tional policy to encourage consumption ofproducts rich in calcium (23).

Prevention of NCCDs through Food and Nutrition

In order to respond to the epidemiologicaland nutritional changes that took place inChile (24, 25), it was necessary to character-ize the burden of disease on the population.For this purpose, a study was conducted in1995, based on 1993 data, that showed that75% of the burden of disease came fromNCCDs (26). This led the Ministry of Healthto shift from its traditional approach center-ing on maternal and child problems to onethat gave priority to emerging problems andresponded to the increase in risk factors re-lated to cardiovascular diseases, cancer, acci-dents, and mental health problems. Amongthe principal determinants of these problemsare deficiencies in food and nutrition, insuf-ficient physical activity, smoking, and otherpsychosocial and environmental factors.

A strategic plan to address these problemswas established and goals set for the period2000–2010. The plan, based on the NationalCouncil for Health Promotion (Vida Chile),an intersectoral entity made up of 28 govern-

mental organizations, was devised utilizinga decentralized structure in 12 regions and308 of the country’s 341 municipalities.Strategies for each determinant were imple-mented at the local level targeted to pre-schoolers and schoolchildren, as well as inworkplaces and municipality offices (27).The principal achievements of this initiativehave been the establishment of a model ofdecentralized management for health pro-motion, with projects and programs beingcarried out in a majority of the country’s mu-nicipalities, and a baseline that was definedusing a survey conducted in November–December 2000 (28) to set objectives for theyear 2010 (29) (Table 4).

Upgrading of Human Resources Education

Since 1998, training courses have beenprovided throughout the country on healthpromotion and prevention of NCCDs, firstfor managers in the health sector, then formunicipality leaders in 1999–2000 (coveringmore than 120 municipalities) (30), and thenfor community leaders in 2000–2001 (31). In


TABLE 4. Intersectoral goals for the year 2010,by percentage.

2000 2010Indicator % %

Obesity in preschool children 10 7(W/H > +2 sd NCHS reference)

Obesity in first grade 16 12(W/H > +2 sd NCHS reference)

Obesity in pregnant women 32 28(Ministry of Health reference)

Sedentary lifestyle in persons 91 84over age 15

Smoking in eighth grade 27 20

Smoking in women of childbearing age 45 40(ages 15–44)

Population in organizations 4 10

Vida Chile Plazas 0 100(one to be placed in each of the country’s municipalities)

Source: Chile, Ministerio de Salud. Objetivos sanitarios para ladécada 2000–2010. Boletín de Vigilancia en Salud Pública deChile El Vigía 2002;5(15):1–15.

the universities, distance degree courses forhealth professionals have been offered, withmore than 600 students participating in2002–2003. There are two master’s degreeprograms in health promotion, in addition tothese issues being included in undergradu-ate curricula in health, nutrition, the socialsciences, and other related fields.

Control of Food Quality and Safety

In 1997 new food health regulations werepromulgated which, although still contain-ing significant shortcomings, nonethelessrepresented progress with respect to previ-ous regulations. Since then several commis-sions continue to work on this issue, andconsiderable advances have occurred in thearea of food labeling. However, there is stillno coordinating entity for food quality andsafety regulation and for the body of relatedactions being carried out in the country bythe three ministries—Health, Agriculture,and Economy—having responsibilities inthis area. Despite Chile being a food ex-porter, the country has no modern institu-tional structure to support food production,consumption, and exports (32). During 2003,there were weekly meetings of all the gov-ernmental, private, and academic institu-tions involved with the issue, and a diagno-sis of the situation was carried out. But therewas no success in establishing a proposal fora centralized authority to coordinate, regu-late, and modernize the sector.

RELEVANT POLICY AND PROGRAM ACHIEVEMENTS

Changes in the Standard for MeasuringNutritional Status

One of the most important achievementswas the 1992 change in the standard formeasuring nutritional status, to include sys-tematic consideration of height among in-

fants and in the school population, whichhad previously prevented evaluating theproblem of children with low height andweight for their age, but with weight suffi-cient for their height. Such children wereclassified as malnourished according toweight-for-age, but using weight-for-heightas an indicator, they could be consideredobese. In addition, using the earlier criteria,children who gained little weight in a givenmonth were considered at risk, an indicatorthat was extremely sensitive but not veryspecific and that led to exaggerated estimatesof the number of children at risk. It was nec-essary to show that, given the fact thatmonthly weight gain fluctuates greatly, it ispreferable to evaluate this criterion on aquarterly basis. Although the criterion forweight gain was still reasonable for selectingchildren for the special program for risk ofmalnutrition, it was decided that childrenwho maintained a normal weight-for-heightshould not remain in the program for longerthan six months.

Preparation of Nutritional Guidelines for the Chilean Population

A broad consultative process was estab-lished, culminating in the preparation of aseries of national nutritional guidelines,along with the reorganization of food andnutrition programs (PNAC in the Ministry ofHealth and PAE in the Ministry of Educa-tion) and the updating of food health regula-tions in order to encourage the food industryto produce healthier foods (13). The prepara-tion of these guidelines was enormously use-ful, since it generated a broad debate on theneed for a healthy diet to prevent nutrition-related chronic diseases. The guidelines facil-itated a broader consideration of food safetyissues beyond specific concerns related tochemical and microbiological safety and acloser examination of the impact of diet andfood choices on health and chronic diseases.

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Education on Food and Nutrition forPreschoolers, Schoolchildren, andConsumers

The major advances in food and nutritioneducation to date have been at the preschooland primary school levels. In 2001 and 2002,an initiative supported by the Food and Agri-culture Organization of the United Nationscalled “Food and Nutrition Education in Pri-mary Schools” carried out a pilot project at 10primary schools in four regions of the coun-try and worked out the methodology andmaterials for incorporating content related tofood and nutrition into the primary curricu-lum (33, 34). This project was successful andhas currently moved into the phase of nation-wide training of schoolteachers to use theproject methodology and materials in all ofthe country’s 11,000 primary schools. Theproject is complemented by another one com-bining education in food and nutrition withphysical activity, for both preschoolers andschoolchildren (35). Finally, a program of con-sumer education was designed, using distri-bution of educational materials in supermar-kets and individual training at the place ofpurchase by students in nutrition to promotehealthier food consumption (36). These neweducational forms break the traditional moldof knowledge dissemination, make use of in-teresting graphic material, and are availablein Spanish in CD form and at the INTA Website (www.inta.cl/ consumidor).

Preparation of Active Life Guidelines for the Chilean Population

In order to combat the high prevalence ofsedentary lifestyles, physical activity guide-lines were prepared in 2001–2002, with sixmessages directed to the general public (37).A specific policy was also adopted to in-crease the number of hours and intensity ofphysical activity in preschool centers andprimary schools throughout the country, aswell as to introduce physical activity into theprimary health care structure through an

agreement between the Ministry of Healthand Chile-Deportes. In May 2003 the WorldHealth Organization (WHO) published thedocument “Diet, Nutrition, and the Preven-tion of Chronic Diseases” (38), providing sci-entific data on the importance of adequatediet and physical activity. A later year, on 22May 2004, the Fifty-seventh WHO WorldHealth Assembly approved a document fora “Global Strategy on Diet, Physical Activity,and Health” (39), which definitively en-dorses the public policies on food and phys-ical activity that are currently being imple-mented in Chile.

LESSONS LEARNED

(1) Policies may be sound and still insuf-ficient. Chile has carried out sound policies forconfronting malnutrition. Moreover, when thecountry was faced with a new demographic,epidemiological, and nutritional reality, it wasable to respond with innovative policies. How-ever, these policies have come into existence toolate and have not been sufficiently vigorous torespond to the magnitude of the challenge: anexplosive increase in risk factors in general,and, in particular, in those relating to diet, suchas the case of obesity. This has been clearlydemonstrated in successive surveys on risk fac-tors that have been carried out in the country.The 2003 National Health Survey (6), con-cluded based on a representative national sam-ple of 3,600 people, that obesity affects 23.2%of the population over age 16. Overweight af-fects 38% (43.2% of men and 32.7% of women),hypercholesterolemia 35.4%, hypertension33.7%, and smoking 42%. As a result, 55% ofthe respondents are at high or very high car-diovascular risk. In this sense, Chile’s situationis very similar to that found in developed coun-tries, where likewise, there has been no defin-itive response at the society level. Even moresignificantly, neither government authoritiesnor the public at large seems to be fully awareof the size of the problem nor of the serious-ness of its consequences.


(2) To succeed, appropriate methodologiesfor changing the population’s habits must beapplied. Changing the behavior of the popu-lation as regards diet, physical activity, theuse of tobacco, stress, and other environmen-tal aspects requires an integrated effort bythe public health sector and other areas ofthe national government. In general, theChilean public now has sufficient informa-tion about the need for and benefits of hav-ing a healthy diet, engaging in physical ac-tivity, not smoking, and controlling the mostimportant risk factors. However, that knowl-edge has not been accompanied by behav-ioral change. This change becomes perhapsmore difficult in an environment that placeshigh emphasis on consumption and is char-acterized by the unscrupulous marketing ofproducts encouraging consumers to increasetheir intake of fast foods and sugary bever-ages, their use of tobacco, and their depend-ence upon automobiles and electrical appli-ances, thereby reducing the opportunities forphysical activity.

(3) The gap in human resources trainingand education must be addressed. Significantchange is required in the training and contin-uing education of professional and technicalhuman resources in order to equip this work-force to adequately respond to the country’srapidly changing demographic, epidemio-logical, and nutritional profile. Unfortu-nately, the response capacity of academicand other public institutions responsible forimplementing policies and programs hasbeen weak and extremely slow. This explainswhy for many years in Chile high caloricfoods continued to be provided through nu-tritional programs, when the problem ofmalnutrition was already in full retreat andthere was an explosive increase of obesity, es-pecially among the poor.

(4) The lack of adequate regulations forsupporting healthy diets and active lifestylesis a weakness requiring corrective action. Thecase of Chile shows that it is possible to work

on educating and raising awareness of thegeneral public even without achieving paral-lel reinforcement from standards, regula-tions, and programs to support collective be-havioral change. For example, in Chile thereare no regulations regarding the advertisingof unhealthy foods during the hours thatchildren are most frequently watching televi-sion, nor are there laws restricting the adver-tising of cigarettes and alcohol. Likewise,there is no legislation to promote or facilitatephysical activity in the educational andworkplace settings. Regulations on healthyfood production are practically nonexistent,and the few which exist concentrate on en-suring the microbiological safety of the endproduct, ignoring the role of excess saturatedfats, sugars, and salt as determinants ofNCCDs. New regulations should include nu-tritional concepts which favor the produc-tion of foods that are not only safe but bene-ficial for health, while at the same timeestablishing limits on consumption of satu-rated fats and trans-fatty acids, free sugars,and salt; favoring foods that contain unsatu-rated fats and other healthy ingredients; andencouraging the increased consumption offruits and vegetables, as well as of legumes,whole grains, and dried fruits.

CONCLUSION

Demographic, epidemiological, and nutri-tional changes have occurred so rapidly inChile that successful maternal and child poli-cies were not modified in a timely way,changing only at the end of the 1990s. It wasnot until 1998 that a policy of health promo-tion was implemented to combat the grow-ing incidence of obesity in the Chilean popu-lation, the high levels of sedentary lifestyles,and the explosive increase in risk factors forNCCDs. Although this policy was properlyformulated, intersectoral in nature, financedby the State, decentralized to the municipal-ity level around the country, and in harmonywith WHO proposals—in particular, those

Vio and Uauy 217

expressed in the 2004 document on the“Global Strategy on Diet, Physical Activity,and Health”—in practice it remains insuffi-cient, given the magnitude of the problemand the rapidity of change. In order to meetthe current challenge, more intense social ac-tion will be required, bolstered by politicalsupport, skilled and conscientious human re-sources, and regulations that are supportiveand facilitate the establishment of the strat-egy as a priority State policy to take effectthroughout the country. The goal is to makethe healthy option, within the context ofproper diet and adequate levels of physicalactivity, also the easiest option to take. Thisrequires not only strengthening knowledgeand motivation among the general popu-lation, but also making changes at the so-cial and environmental levels that allow the healthy option to become the preferredoption.

REFERENCES

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2. Albala C, Vio F, Kain J, Uauy R. Nutrition transitionin Chile: determinants and consequences. PublicHealth Nutr 2002;5(1A):123–128.

3. Albala C, Vio F, Uauy R. The global burden of nutri-tional disease: the case of Latin America. In: Far-thing M, Mahalanabis D, eds. The Control of Food andFluid Intake in Health and Disease. Philadelphia: Lip-pincott Williams & Wilkins; 2003:87–102. (NestléNutrition Workshop Series 51).

4. Tokman V. Wages and employment in internationalrecessions: recent Latin American experience. In:Kim KS, Ruccio DF, eds. Debt and Development inLatin America. Notre Dame: University of NotreDame Press; 1985.

5. Crovetto M. Cambios en la estructura alimentaria yconsumo aparente de nutrientes de los hogares delGran Santiago 1988–1997. Rev Chil Nutr 2002;29(1):24–32.

6. Chile, Ministerio de Salud. Encuesta Nacional deSalud 2003. Santiago: Ministerio de Salud; 2004.

7. Olivares S, Albala C, García F, Jofré I. Televisionpublicity and food preferences of school-age chil-

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8. Albala C, Vio F, Kain J, Uauy R. Nutrition transitionin Latin America: the case of Chile. Nutr Rev2001;59(6):170–176.

9. Vio F, Albala C, Crovetto M. Health promotion inthe context of the epidemiological transition inChile. Rev Chil Nutr 2000;27:21–29.

10. Chile, Ministerio de Salud [Internet site]. Availableat: www.minsal.cl/ev/en/dic04/adultos_mayores/totales/consulta_servicio.asp. Accessed in Septem-ber 2003.

11. Peña M, Bacallao J, eds. Obesity and Poverty: A NewPublic Health Challenge. Washington, DC: Pan Amer-ican Health Organization; 2000. (Scientific Publica-tion 576).

12. Kain J, Vio F, Albala C. Obesity trends and determi-nants: factors in Latin America. Cad Saúde Pública2003;19(Suppl 1):S77–S86.

13. Vio F, Albala C. Nutrition policy in the Chilean tran-sition. Public Health Nutr 2000;3(1):49–55.

14. Vio F, Kain J, Gray E. Nutritional surveillance: thecase of Chile. Nutr Res 1992;12:321–335.

15. Rosso P, Mardones SF. Chart of Weight Increment dur-ing Pregnancy for Chilean Women. Santiago: UNICEF,Ministry of Health; 1996.

16. García F, Vio F. Bases para una política de alimen-tación y nutrición. Rev Chil Nutr 1994;22:150–161.

17. Castillo C, Uauy R, Atalah E, eds. Guías de ali-mentación para la población chilena. Santiago: EditorialDiario La Nación; 1997.

18. Hertrampf E, Olivares M, Pizarro F. Impact of ironfortified milk in infants: evaluation of effectiveness.Ann Nutr Metab 2001;45:357–360.

19. Hertrampf E, Cortés F, Erickson JD, Cayazzo M,Freire W, Bailey LB, et al. Consumption of folic acid-fortified bread improves folate status in women ofreproductive age in Chile. J Nutr 2003;133(10): 3166–3169.

20. Pretell EA, Delange F, Hostalek U, Corigliano S,Barreda L, Higa AM, et al. Iodine nutrition im-proves in Latin America. Thyroid 2004;14(8):590–599.

21. Mariño R, Villa A, Guerrero S. Programa de fluo-ración de la leche en Codegua, Chile: evaluación altercer año. Rev Panam Salud Pública 1999;6(2):117–121.

22. Leiva L, Burrows R, Muzzo S. Ingesta de calico enescolares de 10 a 14 años. Rev Chil Nutr 1992;20(3):207–211.

23. Muzzo S. Metabolismo óseo normal y patológico.Conclusiones y recomendaciones. Rev Med Chil1996;(Suppl 8):103–104.

24. Albala C, Vio F, Robledo A, Icaza G. La transiciónepidemiológica en Chile. Rev Med Chil 1993;121(12):1446–1455.


25. Vio F, Albala C. La transición nutricional en Chile.Rev Chil Nutr 1998;25(3):11–20.

26. Chile, Ministerio de Salud. Estudio de prioridades deinversión en salud. Estudio carga de enfermedad. Informefinal. Santiago: Ministerio de Salud; 1996.

27. Salinas J, Vio F. Promoción de la salud en Chile. RevChil Nutr 2002:29(Suppl 1):164–173.

28. Chile, Ministerio de Salud, Departamento de Epi-demiología, Departamento de Promoción de Salud.Encuesta de calidad de vida y salud. Santiago: Ministe-rio de Salud; 2000.

29. Chile, Ministerio de Salud. Objetivos sanitarios parala década 2000–2010. Boletín de Vigilancia en SaludPública de Chile El Vigía 2002;5(15):1–15.

30. Vio F, Crovetto M, Jury G, Castillo M. Programa deFormación de Recursos Humanos en Promoción deSalud: una propuesta comunal. Santiago: Universidadde Chile, Instituto de Nutrición y Tecnología de losAlimentos, Ministerio de Salud; 1999.

31. Crovetto M, Vio F, Jury G, Castillo M. Programa deFormación de Recursos Humanos en Promoción deSalud: formación de líderes comunitarios. Santiago:Universidad de Chile, Instituto de Nutrición y Tec-nología de los Alimentos, Ministerio de Salud; 2000.

32. Aguilera JM, Vio F. Cooperación universitaria in-terinstitucional: una propuesta de desarrollo de lainvestigación en alimentos en Chile. Calidad en la Ed-ucación 2003;2° semestre:51–65.

33. Olivares S, Morón C, Zacarías I, Andrade M, Vio F.Nutrition education in Chile’s basic schooling. FoodNutr Agricult 2003;33:64–69.

34. Olivares S, Kain J, Lera L, Pizarro F, Vio F, Morón C.Nutritional status, food consumption and physicalactivity among Chilean school children: a descrip-tive study. Eur J Clin Nutr 2004;58(9):1278–1285.

35. Kain J, Uauy R, Albala C, Vio F, Cerda R, Leyton B.School-based obesity prevention in Chilean primaryschool children: methodology and evaluation of acontrolled study. Int J Obes Relat Metab Disord 2004;28(4):483–493.

36. Domper A, Zacarías I, Olivares S, Hertrampf E.Evaluación de un programa de información en nu-trición al consumidor. Rev Chil Nutr 2003;30(1):43–51.

37. Vio F, Salinas J. Guías para una vida activa. Santiago:Universidad de Chile, Instituto de Nutrición y Tec-nología de los Alimentos, Ministerio de Salud; 2003.

38. World Health Organization. Diet, Nutrition and thePrevention of Chronic Diseases: Report of a JointWHO/FAO Expert Consultation, Geneva, 28 January–1 February 2002. Geneva: WHO; 2003. (WHO Techni-cal Report Series 916).

39. World Health Organization. Global Strategy on Diet,Physical Activity and Health. Geneva: WHO; 2004.

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INTRODUCTION

The headline read: “88% do not feel safe onthe streets of Lima.” With that eye-catchingopening, in November 2003, Peru’s El Comer-cio newspaper reported the results of a publicopinion poll, together with another no lessalarming finding: “53% do not even feel safein their own home” (1). “The streets belong tous,” declared an editorial appearing in PuertoRico’s El Nuevo Día one year later, which calledfor a national civic crusade “to make sure thatpeople feel safe on the streets and to take backour cities” (2).

In November 2004, Chico Buarque, a well-known Brazilian singer, referred to life in Riode Janeiro with these words: “The social dif-ferences of old were not what they are today.When I was little, I played soccer with thekids from the slums. Today’s social isolation,with people more and more afraid of vio-lence and withdrawing into their own bullet-proof world, makes that type of contact al-most impossible now” (3).

For the majority of Latin Americans, thiskind of story is very familiar, and Buarquehits the nail on the head by reminding us—especially those of us who are now goinggray—of what we’ve left behind: those timeswhen we enjoyed a sense of community,when we had freedom of movement and the

streets belonged to all of us (or almost all ofus). Will this be our unavoidable destiny?Probably not. As the saying goes, “Nothinglasts forever.” And then there’s the case of the city of Bogotá, which seems to confirmthat.

The tale of Samuel Sotomayor is illustrative.When Samuel returned to the streets of Bogotáin 2001 after 17 years in prison, he felt “wonderment: on the one hand, Bogotá hadchanged tremendously; it was more orderly,parks and green areas had sprung up in theneighborhoods, the transportation systemhad been modernized, and everywhere peoplewere coming and going, to school or to work,riding along on bicycle paths . . . a city that wasno longer a crazy, irresponsible teenager, butnow a keen young person searching anxiouslyfor his or her own destiny.”

TRANSPORTATION, URBAN DEVELOPMENT,AND PUBLIC SAFETY IN LATIN AMERICA:THEIR IMPORTANCE TO PUBLIC HEALTH

AND AN ACTIVE LIFESTYLE

Enrique R. Jacoby,1 Ricardo Montezuma,2 Marilyn Rice,3Miguel Malo,4 and Carlos Crespo5

221

1Regional Advisor on Food and Nutrition, Area ofDisease Prevention and Control, Pan American HealthOrganization, Washington, D.C., U.S.A.

2Director, Fundación Ciudad Humana, Bogotá,Colombia.

3Regional Advisor on Health Communication, Area ofSustainable Development and Environmental Health,Pan American Health Organization, Washington, D.C.

4Advisor on Health Promotion, PAHO/WHO Coun-try Office, Brasilia, Brazil.

5Professor and Director, School of Community Health,Portland State University, Portland, Oregon, U.S.A.

Samuel, a fictional character from thenovel Cobro de Sangre, by Mario Mendoza (4),tells a story with which anyone who hadbeen away from this city during the 1990scould identify. Indeed, in that period Bogotáemerged from the chaos of the streets andrampant violence to collectively embrace alife-affirming perspective and a respect forone’s neighbor that, among other things,turned public places back over to pedestri-ans and cyclists, set up parks, and created agood public transportation system. In theeight years since this experiment began, therate of deaths from violence had fallen 42%.6

From a public health perspective, the situ-ation in a majority of cities throughout theRegion of the Americas presents a series ofcommon problems, including a lack of secu-rity, violence, stress, social disintegration,and physical inactivity, all of which are rec-ognized health risk factors leading to epi-demics in cardiovascular diseases, mentalhealth problems, and obesity, which togethercause almost 60% of the deaths in the Regiontoday (5). Yet from the perspective of bothurban planners and elected political authori-ties, the diagnosis is commonly that of a sickcity, characterized by symptoms of rampantdelinquency, unsafe streets, social segrega-tion, chaotic transportation, a shrinking ofpublic spaces, and environmental pollution.Unlike the public health approach, which fo-cuses on the individual, the urban planningmindset seeks to address existing ills from acollective perspective, setting as prioritiesthe improvement of urban quality of life, se-curing a healthy environment, and providingefficient public infrastructure, such as trans-portation and appropriate urban land use,among others.

Yet even if public health authorities andurban planners take disparate and unarticu-lated approaches, it is nonetheless worth-while to question whether these viewpointsare necessarily irreconcilable, and more

specifically, if there might not be some linkbetween the environmental quality of thecity, the availability of options for publictransportation, and the status of health andphysical activity of the city’s inhabitants.These considerations are the central ques-tions that this chapter will address, and thereader will discover numerous responseswithin the two main sections of this chapter.First, the history of sedentary lifestyles indeveloped countries is addressed, followedby a description of the current situation inLatin America, which now confronts thedilemma of whether or not to take the sameroad as the nations of the Northern Hemi-sphere. The final section and the conclusionsidentify urban and transportation policiesthat could become part of public health ef-forts to promote the importance of adoptingan active lifestyle. This broader scope in thefield of urban planning policies could proveto be vital, especially now that the WorldHealth Organization (WHO) has placedamong its highest priorities the adoption ofa population-wide, prevention-based strat-egy to combat the global epidemic of non-communicable diseases (6).

The City and Public Health: A Historical Relationship

Despite their common historical roots,urban planning and public health have fol-lowed separate pathways for more than halfa century. The influential report of EdwinChadwick on the health and living conditionsof the working classes in the British Isles dur-ing the mid-nineteenth century laid the foun-dation for the public health focus by pointingout that substandard and overcrowded hous-ing and labor conditions, as well as the unhy-gienic state of the streets, were associatedwith the large-scale cholera and typhus epi-demics then ravaging the population. Influ-enced by civil engineering, his report’s pro-posals for health sector reform consisted ofadopting strict measures for the disposal ofsolid wastes and excreta, as well as for rodent

222 Transportation, Urban Development, and Public Safety in Latin America

6A detailed description of Bogotá’s transformation isfound in the Ricardo Montezuma chapter in this book.

control. Widespread propagation of thesemeasures curbed the epidemics then ram-pant, years before the microorganisms thatcaused them were identified.

Curiously, scientific progress and the the-ory of germs shifted the public health focusfrom the city to the microscope. Hence, atten-tion passed from the population’s health tothe health of the host—the affected individ-ual—and the functions of the physician be-came more prominent. The major change inpublic health in the twentieth century wasthe emphasis on individual health risks ver-sus social or environmental considerations,and the predominant strategy was aimed atidentifying individual risk factors and modi-fying them by changing personal behavior.

Nevertheless, the relationship betweenthe city and public health has once againgained importance. In the last century, thepromotion of collective health in urban me-tropolises—a relatively new specialty—helped to reconfirm the close relationship be-tween the quality of urban life and humanhealth and well-being (7). Also, within theurban context, theories such as “new urbanplanning” and “a return to the traditionalcity” have emerged, which contend that thequality of city life can be improved throughtransportation policies that promote com-muting on foot or by bicycle and discourageand/or restrict the use of personal vehicles(8). A growing body of empirical findings,descriptive observations, and social critiqueshas fueled the notion that the current rate ofuncontrolled growth in large cities and theconstant increase in motor vehicle traffic aretwo of the principal culprits in the deterior-ating quality of life and health of urbanpopulations.

Indeed, traffic accidents, poor air quality,stress, the loss of social cohesion, and physi-cal inactivity are found in almost all twenty-first century large metropolises. Echoingthese observations, in 1999 WHO publishedthe report Healthy Cities and the City PlanningProcess (9); later, in 2001, along these samelines, the U.S. Institute of Medicine pub-

lished its report on Rebuilding the Unity ofHealth and the Environment: A New Vision ofEnvironmental Health for the 21st Century (10).Despite the fact that the recommendationsincluded in these reports have merited spe-cial attention at the community and munici-pal levels in countries throughout the Regionof the Americas, they have received only alukewarm reception on sectoral and nationalpolitical agendas (11).

THE PARADIGM OF CHANGINGINDIVIDUAL BEHAVIOR

After having being applied for nearly aquarter century, the prescription of behav-ioral change at the individual level does notseem to have led, in and of itself, to signifi-cant results in terms of controlling the epi-demics of obesity and diabetes, nor in con-trolling cardiovascular diseases and certaincancers. This can be seen in the United Statesand in other high income countries and mayalso be the case in certain developing coun-tries. In the United States, for example, notonly is it currently recognized that the healthobjectives for the year 2000 were not met, butit is entirely likely that the new and ambi-tious objectives set for 2010 will similarly notbe achieved (12). Among them are eliminat-ing exposure to environmental pollution, in-creasing by 100% the number of adults whoparticipate in moderate physical activity(from 15% to 30%), and reducing the adultobesity rate from 23% to 15% (13). To date,the greatest progress made with respect tothese indicators has occurred principallyamong those groups with the highest incomeand educational levels. In Latin America,where a coherent plan to combat chronic dis-eases has yet to be implemented, those indi-viduals who follow proper guidelines foreating and undertake some degree of physi-cal activity belong to the most comfortablesocial groups (14–16). This finding and thelimitations it suggests are most likely due topoor practical implementation of the scien-

Jacoby, Montezuma, Rice, Malo, and Crespo 223

tific knowledge generated experimentally—both in the clinical and population contexts.7

In other words, under controlled conditionsmany research projects have documentedthat changes in behavior may produce posi-tive health effects, but when put into prac-tice—if this occurs—whether within thehealth services setting or at the populationlevel itself, the results nonetheless have left agreat deal to be desired (17, 18).

After carrying out an extensive and de-tailed review of social marketing campaignsaimed at encouraging proper eating habitsand increased physical activity, Alcalay andBell (19) indicate that, in controlled clinicaland personalized trials, positive effects fromcontrolling health hazards can be achieved in 10% to 20% of the cases, but it is unlikely that these effects can be achieved withpopulation-based interventions, even whenthe project’s economic resources are not alimiting factor. The authors conclude that itis necessary to rethink intervention strategiesbased on mere information disseminationand to place more emphasis on the role ofenvironmental factors and social norms.Nevertheless, it should be recognized that inaddition to this particular challenge, and es-pecially in Latin America, the general publichas limited direct access to scientific infor-mation, as well as difficulty in putting thatinformation into practice.

The only modest results obtained in termsof behavioral change may also be explainedby the fact that epidemics such as obesityand diabetes are not deemed to be a criticalsituation that demands significant socialchanges (20). Along this same line, AlfredSommer, Dean of the Johns Hopkins Univer-sity School of Public Health, recently pointedout that “it is a lot easier to avoid risky be-havior when everyone else does as well, and

when the environment doesn’t support it”(21). Christopher Caldwell, a writer with TheNew Yorker, observed that the lower rates ofsmoking achieved in the United States in thelast 40 years are attributable more to “socie-tal self-binding”—the social commitment(and political will) to combat the habit or putan end to it—rather than to access to new in-formation (22).

Public health recommendations to changelifestyle habits have focused on the individ-ual’s cognitive and behavioral processes, dis-sociating them in the majority of cases fromtheir social and cultural determinants. Thisperspective was based on such theories asreasoned action and planned behavior andthe Transtheoretical Model (23), which sharea common postulate: that people learn tosurmount risks and overcome obstacles forthe benefit of their health, but without anyfundamental modification of those risks andobstacles. The logical sequence would be: in-formed individual → change of attitude → behav-ior change.

These considerations should not lead us toconclude that educational activities, infor-mation provision, and social marketing aretotally ineffectual. On the contrary, they areessential starting points for reaching consen-sus and developing new health paradigms,as well as for recruiting the first wave of in-novative individuals willing to attempt be-havior change. However, these actions areinsufficient in and of themselves if we con-sider the vast majority of the population.Anti-smoking campaigns exemplify how in-formation was vital for that first group toinitiate changes, but it was not until after in-stituting public standards (regarding adver-tising and the sale of tobacco to minors), re-strictive measures (such as smoke-free publicplaces), and economic deterrents (highertaxes) that a substantial drop in the numberof smokers was noted in the population, atleast in those societies where such types ofactions were implemented. The use of safetybelts in automobiles is another example ofhow the combination of information, incen-


7This type of research refers to controlled clinical trialsin which the researcher randomly assigns individuals toone of two groups: one that receives the intervention (ortreatment) and another that receives a placebo andserves as an observer.

tives, and coercion succeeded in securingwidespread compliance, especially in devel-oping countries.

With regard to promoting physical activ-ity, the interventions that have been studiedto date indicate three possible results: onlyshort-term effects, little effect, or no effect atall (24). This has led some experts to con-clude that the principles of individual be-havioral change alone are an inadequateresponse to the epidemic dimension of sed-entary lifestyles and that more attentionneeds to be focused on the complexity of thisbehavior, as well as on the possibility of re-sponding to the epidemic with interdiscipli-nary actions (25).

A SEDENTARY LIFESTYLE IN THENORTHERN HEMISPHERE

The Paradox of Little Demand for the“Best Buy”

In the last quarter century, countless stud-ies have shown the usefulness of physical ac-tivity for both physical and mental health.Among the principal public health benefitsare a reduction in mortality and preventionand control of obesity, hypertension, dia-betes, and cardiovascular diseases. It has alsobeen established that physical activity de-creases stress and facilitates positive socialinteraction (26, 27). It is not an exaggeration,then, to claim that this abundance of benefitsqualifies as “today’s best buy in publichealth” (28).

The quantity and intensity of physical ac-tivity needed to obtain these benefits hasbeen well documented. The recommenda-tions, furthermore, have gone from more toless: from practicing aerobics and other typesof systematic exercise, as was advised in the1970s and 1980s, to today spending a mere 30minutes daily in moderate forms of physicalactivity, such as walking, bicycling, dancing,or going up and down stairs. These 30 min-utes a day help to ensure a healthy outcome

with a minimum investment in physical ef-fort, time, and money and also hold the po-tential for increased social interaction amonglarge and diverse groups of people who haveincorporated a gamut of physical activitiesinto their daily routine (29).

In the United States and other developedcountries, however, the scientifically provenbenefits derived from following recommen-dations on physical activity did not translateinto higher active lifestyle rates or into a re-duction of obesity rates. The Centers for Dis-ease Control and Prevention’s statistics indi-cate that physical inactivity rates remainedalmost constant (at approximately 55%) dur-ing the 1990s (30). At least with respect to theU.S. population, this finding cannot be at-tributed to a lack of available information,especially in light of the fact that there is al-most universal recognition of the benefits ofan active lifestyle. The reason for this incon-gruity, then, must lie beyond the existence ofinformation and awareness.

U.S. Suburbia, Personal Vehicles, andTechnological Innovation

Those who have studied physical activity,particularly in the United States, pay close at-tention to the possible influences exerted onhuman behavior by the urban environmentand the available means of transportation inlarge cities, particularly as these relate to phys-ical exercise. This relatively new intereststems in part from discoveries made by trans-portation experts and urban planners over thepast 30 years through their studies of “humanmobility,” which indicate that certain charac-teristics of the organization and layout of citiesinfluence people’s daily commuting prac-tices—with or without motor vehicles—as wellas the degree to which they lead a sedentarylife (31).

During the second half of the twentiethcentury, U.S. economic growth and continu-ous improvement of the middle class’s stan-dard of living led to a progressive abandon-ment of collective dwellings in traditional


urban centers and to migration to individualdwellings located on the periphery of thosecenters, thus creating low density suburbs.One of the reasons for this migration was theexpectation of recovering that lost sense ofpeace and harmony to be found only in thecountryside without having to sacrifice thebenefits and conveniences of city life. Urbangrowth’s new direction was fueled by thelarge-scale construction of expressways andturnpikes and a parallel and growing de-pendency on private automobiles.

The suburban model in the United Statesconsists of an extensive spread of single-family homes with a scattering of commer-cial centers and other activity and servicescenters, each at some distance from the oth-ers. This segregation and parceling of theland—unlike the traditional European modelconsisting of a diverse, compact city—resultsin a situation in which the majority of the in-habitants’ typical destinations are far fromone another and poorly interconnected, sothat some type of motorized transportationis needed to get from one place to another ina reasonable amount of time. Some believethat this suburban model discourages walk-ing, reduces available public spaces, de-creases human contact, and creates a de-pendency upon automobiles. At the center ofsome of the theories advanced in severalNorth American urban doctrines, such as theNew Urbanism (8, 32), is the need to reversethis trend and to improve people’s quality oflife, an idea which has attracted the attentionof public health experts interested in turningthe tide against the growing tendency to-ward physical inactivity.

The influences of mass versus individualtransportation have contributed to the for-mation of two opposite systems of urbanstructure and space utilization. For example,in the majority of European cities, the spaceallocated for mobility represents around 20%of the urbanized land surface; on the con-trary, in some U.S. cities this percentage isabove 70% (33). In Paris, space allocated for

traffic circulation represents only 23%, whilein Los Angeles it is more than 70%. The dif-ferences in these two urban mobility modelsnot only have to do with space utilization,but are also manifested in well-defined anddissimilar social characteristics, which mostlikely preceded the present urban realities. Inthe case of Paris, mass transportation hascontributed to the development of what ispublic, what is community, and what is so-cial, while in the case of Los Angeles, wheremobility in one’s own automobile is both apriority and a majority value, the principlesare much more related to what is private andindividual.

In developed countries where urban plan-ning has favored mass transportation, con-centric, dense cities have been fused—theEuropean cities.8 “The Stockholm subway isa good illustration of the densifying effectinduced by urban rail transportation: the1954 transportation plan, which proposedthe subway, was conceived around the sametime as the 1952 urbanization plan; and thesubway stations opened at the same time—or even before—completion of constructionof the new neighborhoods surrounding thestations” (34). In developing cities, there isonly the case of Curitiba, Brazil, in whichurban planning has been based on a systemof mass transportation. On the other hand, inplaces where urban planning has given pri-ority to individual transportation, the pres-ence of highways and automobiles has given


8The majority of European cities, “enormous urbanconcentrations, dense and well covered by mass transit,seem to discourage motorization or at least the use ofautomobiles.” Dupuy G, L’auto et la ville, Flammarion,Paris, Collection Dominos, 1995, p. 21. There exist othercases in the world where mass transit has played aneven more central role in urban life, but this appears tobe related to such characteristics as space availability orthe particular type of city planning. For example, inAsian cities such as Tokyo and Hong Kong, the activerole of mass transit has been influenced by the lack ofspace, and the new cities of the former Soviet Unionhave been deliberately designed on the basis of masstransit.

way to dispersed, low density agglomera-tions similar to the residential suburbs sotypically found in the United States.

There are also other factors that help to ex-plain the contemporary tendency toward asedentary lifestyle and its pervasiveness.Among these, the most obvious factor in-volves the evolving nature of the workingworld that accompanies rapid urbanization.Here we see growth in the services sector, au-tomation in the manufacturing sector, and aneconomy increasingly dominated by com-puters and computer technology. Domesticlife, as well, has been “liberated” from phys-ical labor, and the growing mechanization ofhousehold tasks is ubiquitous. Promoting in-creased physical activity appears to be notonly impractical within this context, butanachronistic, since the idea would be atcross-purposes with the sign of our times:productivity and the ability to do morethings in less time. Even our entertainmentpreferences and how we spend our free timehave changed: a predilection for walking,versus electronic games and television, hasbeen relegated to the category of “a thing ofthe past,” in much the same way as has theidea of children going to play in the “greatout-of-doors” from morning to dusk. Ac-cording to economist Darius Lakdawalla,rapid assimilation of technological innova-tions in the marketplace and in domestic lifeis alone responsible for some 60% of the in-crease in obesity in the United States (35).

How Does the Urban PhysicalEnvironment Influence Physical Activity Levels?

The previous section’s discussion is notonly logically persuasive and supported bysignificant econometric estimates, but is fur-ther bolstered by important empirical cor-roboration indicating just how certain physi-cal, functional, and cultural characteristics ofa city and its transportation system (in otherwords, the urban physical environment) im-

pact on human health through their influ-ence on physical activity, air quality, and per-sonal and traffic safety. For example, an eco-logical study conducted by Ewing andcolleagues (36) has linked suburban life inthe United States with hypertension and obe-sity. With even more refined study methods,these same authors have shown, in the city ofAtlanta, that in neighborhoods where landuse is more diversified (i.e., includes a mix ofresidences, commercial businesses, enter-tainment and recreational centers, and publicparks, for example), the obesity rates re-corded are lower than those in the type ofsuburban neighborhoods described earlier in this chapter. The authors found, further-more, that the city-obesity relationship wasaffected by the frequency with which peoplewalked (37).

In a study conducted in eight provinces inChina, where a group of adults was moni-tored between 1989 and 1997, the results atthe end of that period showed that automo-bile ownership was correlated with develop-ing obesity. Among the male subjects whohad acquired a car (14%) during the eightyears that the study lasted, an average weightincrease of 1.8 kg was observed, along withan increased risk of obesity, in comparisonwith those who had not acquired an automo-bile during that same period (38).

At a more detailed level, studies carriedout by experts in urban affairs and roadsafety—mainly in Europe and the UnitedStates—show how specific characteristics ofurban space design and transportation sys-tems influence the population’s level ofphysical activity. The most studied factor hasbeen urban density and non-motorizedtransportation; i.e., walking and bicycle-riding. It is currently recognized that higherpopulation and urban building densitiespromote the habit of walking. This effect canbe increased even more with a highly diver-sified land use plan that includes residences,businesses, entertainment sites, and schoolsall located within a relatively close distance


to one another (39). In a study by Frank, An-dresen, and Schmid, it was found that obe-sity risk decreased 12.2% in each successivequartile of mixed land use and declined by4.8% for each additional kilometer walked.They also observed that every additionalhour of using an automobile increased theobesity risk by 6% (37).

The second-most-studied aspect dealtwith transportation systems and street net-works. The traditional urban grid layout rep-resented by the typical city block provideshigh “connectivity,” in contrast with thecharacteristic curvilinear layout of U.S. resi-dential suburbs. In the traditional layout,there are any number of viable options for in-terconnecting two given geographical points(high connectivity), while in the suburbanlayout, the “streets” are not intended to con-nect pedestrian destinations, but rather, fol-low the logical flow of motor vehicle traffic.

Furthermore, low connectivity and longdistances between daily destinations, whileincreasing the functionality of the automo-bile for a U.S.-type lifestyle, at the same timehinder the appeal and profitability of publictransportation because of the long distancesthat must be traveled as a result of the dis-tinctly segregated use of public space. In theUnited States, 90% of the total number ofdaily trips are made in an automobile, and inmore dispersed urban suburbs, such as thoseof Atlanta, for example, every resident trav-els an average of 55 kilometers a day, whilein Philadelphia and San Francisco, cities withhigher population densities, the averages are27 and 34 kilometers, respectively.

The third element that characterizes acity’s physical environment and has beenextensively studied is urban space design.Factors such as degree of street cleanliness,pavement condition, the presence of naturalgreenery, and personal and traffic safety allinfluence a person’s decision to walk, al-though it has been noted that these elementshave only a modest impact, basically onrecreational walking rather than walking toand from the workplace (29).

From Scientific Evidence to Public Policies

The issue of urban design and its relation-ship with physical activity, as just presentedin a brief overview here, has generated tworesponses in the United States. On the onehand, there are those who maintain that theinfluence of transportation policies on healthis conclusive, especially with regard to traf-fic accidents, environmental pollution, andphysical inactivity (40, 41); consequently, theproponents of this response propose that at-tention be focused not on highway construc-tion, but rather on promoting investments invarious forms of commuting, whether bypublic transportation, on foot, or by bicycle.This investment—according to this group—could have a multiplier effect if it were to beaccompanied by parallel changes in city de-signs, thereby making metropolitan areasmore varied, dense, compact, and stimulat-ing to pedestrians (42, 43).

On the other hand, a group of experts re-cently brought together by the U.S. Instituteof Medicine and the Transportation ResearchBoard, after having evaluated the scientificevidence available to date, concluded thatmost of the existing information has comefrom cross-sectional studies,9 which makesthe establishment of a cause-and-effect linkmore difficult, even though the group did, atthe same time, recognize the possibility of anassociative link between a city’s physical envi-ronment and its people’s health, includingphysical activity. In light of these findings,the experts maintained that it would be pre-mature to adopt public policy decisionsbased on this accumulated data and insteadrecommended conducting new studies withbetter conceptual preparation and more rig-orous designs (44).


9This refers to studies conducted at a particular pointin time (surveys, for example) in which the final result—physical activity or obesity—is evaluated at the sametime as explanatory variables, such as the physical envi-ronment and the socio-demographic characteristics ofthe participants.

PHYSICAL ACTIVITY, WALKINGHABITS, AND MASS TRANSIT USE

IN LATIN AMERICA

Walking for Utilitarian and RecreationalPurposes

Until a few years ago, public health ex-perts depended on surveys related to thepractice of sports in order to determine thelevel of sedentary lifestyle among a givenpopulation. In Latin America, those sur-veys—usually administered by sports au-thorities—showed that only some 15% to20% of adults engaged in sports activities,usually men and individuals at a high so-cioeconomic level, and that this activitytended to decline with age (45, 46). In the ab-sence of a more refined means of study,around 80% of the population was classifiedas “inactive.”

The recent development of standardizedmethods for measuring physical activity,such as the International Physical ActivityQuestionnaire (IPAQ) (47), has improvedthose measurements. This new instrumentnow makes it possible to analyze all domainsof physical activity (i.e., domestic chores,work-related, recreational, and transporta-tion), as well as their duration and intensity.Unfortunately, the IPAQ, in its short format,does not make a distinction between the dif-ferent activity domains.

Figure 1 shows the results of surveys con-ducted in a selection of Latin American citiesthat used the short version of the IPAQ ques-tionnaire (48–52). In general, the participants(men and women combined) were classifiedas “active” if they had undertaken at least 30minutes of moderate physical activity in fiveout of the last seven days prior to the survey,or if they performed vigorous physical activ-ities10 20 minutes a day at least three times

per week. However, the different city sur-veys presented variations in their definitionof what constituted an “active” person.11 De-spite these variations, which may need to beadjusted to make the survey results fullycomparable, it may be observed that be-tween 37% and 75% of the survey partici-pants were classified as active. These ratesare two to four times greater than the resultsreported from the earlier-described sportssurveys. How can this difference be ex-plained? Is it due to the inclusion of physicalwork carried out around the home and walk-ing? And as regards walking, how much isattributable to walking for recreational pur-poses versus walking for utilitarian purposes(e.g., domestic chores, transportation on footas part of the regular workday)? The answersto these questions are relevant to the extentthat they might help define and further re-fine intervention options.

The authors of the physical activity studyconducted in Pelotas, Brazil, in 2002 (Figure 1)point out that even though recreational phys-ical inactivity was reported as being inverselyproportionate to socioeconomic levels, there isa direct correlation between socioeconomiclevel and overall inactivity level. In otherwords, overall physical activity among individ-uals in the lower socioeconomic strata wasgreater than that of groups at higher socio-economic levels. The same authors postulatethat “the results reflect the probability that oc-cupational activities are a more important com-ponent than physical recreational activity in de-veloping countries.”


10Vigorous physical activity is activity that acceleratesrespiration (and heart rate) and causes the individual tosweat more than with moderate physical activity. Inmetabolic terms, the first represents a minimum expen-

diture of 6 MET (metabolic equivalents) while the sec-ond represents from 3 to 6 MET. More information isavailable regarding these concepts at http://www.cdc.gov/nccdphp/dnpa/physical/measuring/met.htm.

11In the case of the Brazilian cities of Manaus, Belén,Rio de Janeiro, and São Paulo, the definition of “active”mentioned in the text adds a further option: the combi-nation of moderate, vigorous, or walking activities per-formed at least five days a week for at least 150 minutesweekly. In the case of the city of Pelotas, the authors ofthe study used a broader definition of “active”: peoplewho performed 150 minutes of moderate or vigor-ous physical activity, without considering the weeklyfrequency.

Given the importance of walking as a util-itarian and recreational activity, in 2003 Hal-lal and colleagues conducted a second sur-vey in Pelotas (53)—this time for the purposeof studying the pattern of recreational walk-ing in order to be able to compare these re-sults with the previous study, in which theyexamined all the walking domains: occupa-tion, transportation, and leisure. Accordingto this study, 73% of the respondents (71.8%of the men and 74.3% of the women) hadwalked to some extent during the previousweek. Among those adults who followed therecommendation to walk ≥ 150 minutes perweek in all the walking domains (regardlessof weekly frequency), the participants be-longing to the lower socioeconomic stratawalked more than those in the higher socio-economic groups (50.8% versus 38.4%). Andamong those who met the same requirementto walk ≥ 150 minutes, but this time takinginto account only recreational walks, thehigher socioeconomic groups reportedhigher rates than the poor (25.5% versus11.6%). Thus, walking for utilitarian reasonsby the poor seems to be almost four timesmore important than for groups belonging tohigher socioeconomic classes (Figure 2).

According to a survey conducted by theFES Foundation in Colombia with the IPAQquestionnaire (48), the case of Pelotas is sim-ilar to that of Bogotá: of the 36.8% of the lat-ter city’s residents—both men and women—who met the minimum requirements ofphysical activity, 60% reported that theywalk, 20% participated in regular recre-ational activities, 11% utilized a bicycle as ameans of transportation, and 9% performedmuch of their physical activity as part ofhousehold tasks and/or physically demand-ing occupational tasks.

The physical activity profiles for Pelotasand Bogotá may very well resemble those ofmany other Latin American cities, in thesense that the local economies typically arebased largely on manufacturing concernsand there is widespread use of mass trans-portation. Use of a private automobile con-

tinues to be the exclusive domain of a selectminority. But this dynamic is changing, andutilitarian physical activity will tend to de-cline as economic development increasinglyincorporates automated and computerizedproduction systems that are less dependenton physical work and the demand for pri-vate automobiles and mechanization in thehome increases.

Walking is both a form of transportationand a widespread leisure-time activitythroughout the Region of the Americaswhose practice should be encouraged andfacilitated within the context of physical ac-tivity’s contribution to optimum health andwell-being (54). This relationship draws at-tention to the nature of transportation sys-tems and mobility itself: according to ex-perts, on average, two-thirds of the urbanpopulation in developing countries moveabout by means of walking or riding a bicy-cle; i.e., for utilitarian reasons (55). Given thissituation, the reinforcement and ensured sus-tainability of these forms of mobilizationseems advisable, before motorcycles and pri-vate automobiles become the transportationoption of choice. Indeed, in many large citiesin developing countries, the motorcycle hasalready become the stepping stone to com-plete motorization for the populace; it hassucceeded in replacing taxis and buses interms of personal preference, with a corre-sponding impact on accident rates and noiseand air pollution levels.

In developed countries where the depen-dence upon private automobiles is very high,interventions aimed at promoting physicalactivity by discouraging frequent vehicularuse have yielded merely modest results, andmainly only among highly motivated indi-viduals (56). Experience indicates that an ef-ficient mass transit system and widespreadbicycle use are achieved only in the presenceof proactive government policies favoringpublic transportation and energy conserva-tion, as is the case in Germany, Japan, theNetherlands, and the Scandinavian coun-tries. In these societies, travel by foot or



FIGURE 1. Minimally active population rates (men and women) measured with the short version of the IPAQ questionnaire.

FIGURE 2. Recreational physical activity (PA) and overall physical activity rates (including recreation, transportation, work, and miscellaneous) among those who walk ≥ 150 minutes per week, by socioeconomic level, in Pelotas, Brazil.

Source: Hallal PC, Victora CG, Wells JCK, Lima RC. Physical inactivity: prevalence and associated variables in Brazilian adults. Med SciSports Exerc 2003;35(11):1894–1900.

0

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Sources: Bogotá: Gómez LF, Duperly J, Lucumi D, Venegas AS, Gamez R. Niveles de actividad física global en la población adulta de Bogotá. Prevalencia y factores asociados. Gaceta Sanitaria (in press). Buenos Aires: Bazán NE, Díaz G, Kunik H, O’Connor C, Gavini K.IPAS Tango: la aplicación del cuestionario internacional de actividad física en la Ciudad de Buenos Aires, Argentina. Buenos Aires: Go-bierno de la Ciudad de Buenos Aires, Secretaría de Educación, Instituto Superior de Deportes; 2003. Manaus, Belén, Rio de Janeiro: Brasil,Ministério da Saúde, Instituto Nacional do Câncer. Reporte, 2003. São Paulo: Matsudo SM, Matsudo VR, Araújo T, Andrade D, Andrade E,Oliveira L, et al. Nível de atividade física da população do Estado de São Paulo: análise de acordo com o gênero, idade, nível socio-econômico, distribuição geográfica e de conhecimento. Revista Brasileira Ciência e Movimento 2002;10(4):41–50. Pelotas: Hallal PC, Vic-tora CG, Wells JCK, Lima RC. Physical inactivity: prevalence and associated variables in Brazilian adults. Med Sci Sports Exerc 2003;35(11):1894–1900.

bicycle is feasible and convenient not onlybecause travel by these means within certainareas takes the same amount or less timethan the same trip would take by automo-bile, but also because automobile use impliesadditional costs (e.g., fuel, parking, licensing,taxes). In other words, walking and bicyclingfrom one point to another in the city, insteadof being viewed by residents as a stigma, areviewed positively as a viable, efficacious,and economical means of urban mobility.

Mass Transit Systems

In Latin America, a minority of the popu-lation—yet a rapidly growing one—uses theprivate automobile as a means of daily trans-portation. The average number of vehiclesper family in this region was 0.15 during the1990s (41), compared to 1.8 in the UnitedStates in 1995 (57).

Transportation studies in five Latin Amer-ican metropolitan centers have shown thatbetween 55% (São Paulo) and 83% (MexicoCity) of the total number of daily trips aremade using public transportation, with inter-

mediate levels being 66% in Buenos Aires,78% in Rio, and 82% in Lima (58). Through-out the developing world, the average num-ber of trips on public transportation repre-sents between 70% and 85% of the totalnumber of daily trips (55). In comparison,the Nationwide Personal Transportation Sys-tem survey in the United States indicatedthat 86% of the total amount of commutingby urban dwellers is via private automobile,contrasted with only 3% via mass transit sys-tems (Figure 3) (29).

The impact of public transportation useon walking habits can be explained by thefact that passengers are usually required towalk to and from the bus (or train) station,and to and from their final destinations; thus,each trip has two components: one “motor-ized” and one “non-motorized.” In Bogotá, aseries of surveys conducted by the organiza-tion Bogotá, Cómo Vamos (Bogotá: How AreWe Doing?) (2002) show that mass transitpassengers walk for 18.5 minutes a day, onaverage, which represents almost two-thirdsof the recommended 30 minutes a day ofmoderate physical activity for health pur-


Lima Rio deJaneiro

BuenosAires

São Paulo MexicoCity

U.S.A.

100

80

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40

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FIGURE 3. Percentage of total daily trips made using mass transportation systems in Latin America and the United States.

Sources: Latin America, end of the 1980s data: Figueroa O. A hundred million journeys a day: the management of transport in LatinAmerica’s mega-cities [Internet site]. Available at: http://www.unu.edu/unupress/unupbooks/uu23me/uu23me0f.htm. Accessed in Novem-ber 2004. United States, 1990 data: Frank LD, Engelke PO, Schmid TL. Health and Community Design: The Impact of the Physical Envi-ronment on Physical Activity. Washington, DC: Island Press; 2003.

poses. In other words, daily use of masstransportation for commuting purposescould serve as an effective, wide-reachingpublic health intervention.

The bus systems in Bogotá and Curitibaare examples of how public transportationand pedestrian walkways (or bike paths forcyclists) can function synergistically, espe-cially when access to public transportationstations is directly connected to pedestrian orbicycle path networks, as may be seen partic-ularly in cities with high-density buildings(59). This is precisely the idea behind theconcept of “transportation-oriented develop-ment,” which seeks to stimulate the growthof urban density and diversity alongsidemass transportation corridors. The synergybetween public transportation and walkinghabits can be made even greater if trans-portation systems are fast and efficient, anddirectly accessed by pedestrian walkwaysand bicycle paths. In other words, if con-ceived and managed with these strategicconcepts in mind, public transportation sys-tems have the capacity to become catalystsfor the development of a city’s physical envi-ronment and can help to create a more favor-able urban infrastructure for moving aroundon foot or by bicycle (60, 61).

On the other hand, the situation that pre-vails in many Latin American cities today in-volves a series of unregulated, decentralizedoptions driven by demand. In Lima andMexico City, for example, where the meansof public transportation are controlled bythousands of private enterprise providers,the ubiquitous private automobile has in-vaded major thoroughfares, connecting sidestreets, and even public spaces, thereby cre-ating inefficiencies and stimulating furtherdemand for individual forms of motorizedtransportation.

The precarious organization and manage-ment of public transportation today in LatinAmerica stem from the inability of city gov-ernments to effectively oversee and controltransportation distributional patterns andvolume, at the same time that transportation

providers from the more or less informal sec-tor have scant capacity or incentives to im-prove their own services. This latter grouphas created—whether out of financial needor convenience—a series of cooperatives,unions, committees, enterprises, and othertypes of similar arrangements in order to en-sure their continued operation and sustain-ability. In fact, the collective number and sizeof these ventures have in many cases trans-formed them into the only (albeit de facto)urban transportation service provider, fol-lowing the disappearance or weakened stateof their public sector counterparts. Despitethis, the day-to-day basic operations of theseimprovised arrangements lack the structuralsolidity and rational, broad-based scope andvision that might characterize for-profit, cen-tralized enterprises of the formal sector. InMexico City, for example, taxis represent74.7% of the overall vehicle fleet allocated topublic transportation, yet they make up only6% of the total daily trips, while the corre-sponding rates for buses and minibuses are22.2% and 73%, and the subway rates are 2%and 18% (62).

It is a fact of life that higher income levelsand enhanced purchasing power increase thedesirability of personal automobile and/ormotorcycle ownership for the relative in-dependence and convenience they offer ascompared with other forms of transporta-tion, in addition to their serving as symbolsof economic well-being and prestige (63).The goal of securing access to individualizedmeans of transportation stems not only froma function of lifestyle, but is also driven bypublic policies that fail to take into accountthe negative and costly effects of automobiletransportation—in terms of energy con-sumption, environmental damage, risk ofcollision and injury, and increased tendencytoward physical inactivity and developingobesity—resulting in an ironic situation that,in effect, only further reinforces the appealand legitimacy of personal vehicle owner-ship. Examples of this de facto subsidizing ofautomobile use include the creation of new


residential communities increasingly distantfrom large metropolitan centers, public poli-cies that favor investments in new highwayconstruction over those aimed at improvingmass transportation infrastructure, the de-velopment of incentives to boost automobileimports, and the establishment of only mod-erate gasoline taxes. In these cases, the ra-tionale of a transportation policy becomesone that is centered on moving the largestnumber of vehicles possible in the shortestamount of time with a minimum of trafficcongestion (64). In low and middle incomeeconomies, this situation often translates intoa cross-subsidization by the poor for the ben-efit of the most economically well-off, a phe-nomenon which has attracted the scrutiny ofdiverse experts questioning the long-termsustainability of today’s status quo (65).

One of the greatest problems facing theRegion of the Americas, from the perspec-tives of both transportation and publichealth experts, is the increasing number ofprivate vehicles in circulation and the deteri-oration (deregulation, decentralization, pri-vatization, and equipment aging and dis-repair) of mass transportation, a situationwhich has wrought significant social, envi-ronmental, energy, and health consequences(66, 67). The increasing number of trips madein private automobiles is still limited in LatinAmerica in comparison with the UnitedStates, but that trend is changing. For exam-ple, in Chile, which has experienced signifi-cant economic growth over the past 15 years,there is a growing predilection toward use ofprivate automobiles and living away fromthe city in distant suburbs that increasinglyresemble the U.S. model. Between 1991 and2001, the number of trips made on publicbuses in Santiago decreased from nearly 60%to 42%, while the number of trips made inautomobiles increased from 18.5% to 38%(Figure 4). The effects of this trend on envi-ronmental pollution and health have alreadybecome clear, and some measures—includ-ing restricting the volume of vehicles in si-multaneous circulation and improving fuel

and quality—have already been adopted.12

Although these measures have not solvedthe problem, there is at least some consensusbetween political authorities and publicopinion polls recognizing the relationshipbetween automobiles, transportation sys-tems, and health. Hopefully in the future,this recognition will extend to other healthproblems, such as sedentary lifestyle, stress,and quality of life of the population, creatinga favorable synergy for public health actionsin this area.

Policies for Sustainable UrbanTransportation

There is no doubt that transportation fulfillsan important function in economic develop-ment by promoting efficiencies in the labormarket, providing access to goods and services,and fostering urban growth, both nationally aswell as internationally. Hence, some 16% of theWorld Bank’s total annual loans go to this sec-tor (66). This same institution, however, pointsout important challenges threatening the sus-tainability of transportation systems, especiallyin the developing world. Among these are in-creasing motorization, emerging transportationneeds related to world trade, vehicular conges-tion, environmental pollution, limited accessby the poor to means of transportation, andusers’ expectations that road systems shouldbe safer and of better quality (68). To cope withthese challenges, a sustainable transportationpolicy has been taking shape in recent years,a key element of which is the notion that ahigher demand for transportation servicesmight very well not reflect legitimate demandsfrom passengers, but could be strongly influ-enced instead by factors such as physical dis-tances created by urban dispersion, deficientpublic transportation systems, and a false senseof the real costs of driving (41).


12Recently, Chile’s transportation authority launcheda new surface public transportation system known asTransantiago with the goal of discouraging private auto-mobile use and similarly helping to reverse the othertrends noted.

Sustainable transportation, from theWorld Bank’s perspective, consists of threecentral elements: economic sustainability, toallow for efficient use of physical resourcesand their maintenance; social sustainability,so that the benefits of transportation may beavailable to all groups within society; andenvironmental sustainability, which shouldbe taken into account in order to avoid theexternal effects of both public and privatetransportation in terms of health and the en-vironment, when making decisions aimed atimproving overall socioeconomic develop-ment. Aside from the financing and manage-ment strategies that are an intrinsic part ofthis proposal, the policy of sustainable trans-portation points to three specific actions thathave a synergistic effect from the sustainabil-ity standpoint: addressing environmentalproblems, ensuring road safety, and promot-ing alternative transportation, which in-cludes better pedestrian infrastructure andpromoting bicycle transportation.

The foregoing discussion constitutes anexcellent opportunity to establish linkages

between public health and transportation in-terventions. Many of the public health con-cerns that have been raised in response togrowing urban motorization have now beenreinforced. The fact that the current trend inroad policies is to emphasize people mobil-ity, and not vehicle mobility, has placed thehuman dimension at the very center of thedebate, along with the issue of health (partic-ularly the importance of physical activity); asa result, the well-being of the population—both city and suburban dwellers—mightvery well come to the forefront and occupy apreferential place on the public agenda. Thesocial impact of public transportation is noless important, inasmuch as it facilitates in-creased social contact and interaction. In con-trast to the isolation inherent in private auto-mobile use, mass transportation breaksdown social barriers by bringing togetherpassengers of all socioeconomic strata whotake the train, bus, or ferry on a daily basis.This exchange can create more social confi-dence and stimulate the implementation ofother types of social policies seeking to im-


FIGURE 4. Distribution of daily trips, in percentages, per type of transportation used, 1991 and 2001, Santiago, Chile.

Source: Etcheberry Celhay J. Transantiago. Work presented at the Seminario Transantiago en Marcha. Santiago, Chile, 11 November2004. Available at: http://www.transantiago.cl/seminario/315, 3, slide 3. Accessed in January 2005.

Automobile,38.1

Bus, 42.1

Other, 6.4

Taxi, 6.0

Subway, 7.4

Automobile,18.5

Bus, 59.6

Other, 9.8

Taxi, 3.5

Subway, 8.5

200110,147,247daily trips

19915,996,118daily trips

prove living conditions across a broad spec-trum of society.

ROAD SAFETY

The Impact on Health

Traffic accidents were one of the first prob-lems related to transportation issues to capturethe attention of political leaders around theworld. As early as 1974, WHO World HealthAssembly resolution 27.59 declared that traf-fic accidents constituted a major public healthproblem. Today it is estimated that every year1.2 million people lose their lives and nearly50 million are wounded in traffic accidents (69).According to WHO, in 1990, transportation-related injuries ranked ninth place among fac-tors contributing to the world disease burden,and it is estimated that if the current trend con-tinues, by 2020 traffic accidents will have risento third place. In Latin America and theCaribbean, the number of deaths attributableto traffic accidents will increase by 48%; in Asia,by 144%; while in high income countries, it will

diminish by 26%. The problem’s dynamic in-dicates that deaths on public thoroughfarestend to rise as the income level of the affectedcountries increases; when the latter is high, thetrend goes down. On the other hand, when oneconsiders the ratio of the number of deaths tothe number of motor vehicles (deaths per10,000 vehicles), as a country’s income level in-creases, there is a steady decline in these rates.The latter is explained mainly by the progres-sive application of measures at several levels:automobile design and transit managementsystems, traffic safety education, the establish-ment of speed limits, the use of safety belts, andthe prohibition against driving under the in-fluence of alcohol (Figure 5). In the majority ofpoor countries, on the other hand, implemen-tation of these life-saving measures poses anenormous challenge in and of itself.

Lack of safety on the roadways involvesother health problems as well. Nearly two-thirds of all traffic accident victims are pedes-trians, and of that group, one-third are children.In Latin America and the Caribbean, the ma-jority of victims are between 15 and 30 years ofage, and three-quarters of the victims are men,


FIGURE 5. Public roadway deaths per traffic volume and population for various income levels.

Source: International Road Federation 1993. World Road Statistics 1988–1992. In: Sustainable Transport: Priorities for Policy Reform,World Bank, 1999. Available at: http://www.worldbank.org/transport/pol_econ-docs/ 276,21, Slide 21. Accessed in January 2005.

90

80

70

60

50

40

30

20

10

0

200

180

160

140

120

100

80

60

40

20

0HighMedium highMedium lowPoor

Deaths/10,000 carsDeaths/million inhabitants

Dea

ths/

10,0

00au

tom

obile

s

Dea

ths/

mill

ion

inha

bita

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Income level

which is consistent with greater exposure bythis group. Pedestrians and cyclists are the mostvulnerable users of public thoroughfares; of thetotal number of deaths, pedestrians represent25% in Trinidad and Tobago, 40% in Mexico,and 62% in El Salvador; and cyclists represent3% in Saint Lucia and 10% in Jamaica (70). Onthe other hand, in Canada and the UnitedStates, pedestrians represent 16% and 11%, re-spectively, of traffic accident victims; nearly 90%of the victims are either drivers or passengersin vehicles.

The danger that streets and highways en-tail for pedestrians and cyclists also has anegative impact on people’s mobility andphysical activity (71). It is estimated that thisproblem could be more acute for the elderly,who, aware of their fragility, tend to avoidthe streets (72).

The economic costs of the lack of roadsafety represent approximately 1% of thegross national product in low income coun-tries and 1.5% in middle income countries. Inlow income countries, those costs translateinto US$ 65,000 million annually, which is ahigher figure than what those countries re-ceive in development assistance during thesame period (68).

New Prospects for Road Safety

In the 1970s, the introduction of the Had-don matrix—still widely in use today—rep-resented the first systematic approach to theproblem of traffic-related injuries. Thismodel suggested that accidents have threetime phases: before, during, and after the in-jury incident. Each one of these phases, inturn, can be examined within the context ofthree principal factors: the injury victim, thevehicle and its equipment, and the physical,social, and/or cultural environment (73).This perspective offered public health au-thorities and specialized personnel—particu-larly epidemiologists—the opportunity toapply basic public health principles to trafficsafety and injury prevention policies andprograms. Specifically, Haddon’s compelling

framework facilitated a new focus on me-chanical energy exchange and the humanbody’s injury threshold to this force and con-tributed to the subsequent adoption of suchmeasures as vehicle speed controls and theprohibition against driving while under theinfluence of alcohol. Thus, the traditionalthinking that placed blame for collisions ondriver behavior (e.g., failure to perceiveand/or react to danger in a timely manner)has, over time, given way to a more etiologi-cal, systemic perspective in which all forcesat play on public thoroughfares—includingthe structural design of the vehicles androads themselves—are considered as poten-tial causal factors and responsibilities aremore equally shared between transportationsystem providers and users (73).

More recently, a report by the WHO’s Re-gional Office for Europe has attempted to gobeyond the Haddon matrix by developing aroad safety concept that incorporates themacro-scale aspects which affect vehicle traf-fic risk exposure, such as land use, urban de-sign, and transportation policies. In otherwords, it proposes that road safety plans takeinto account the specific preferences and poli-cies of transportation and urban develop-ment, since these policies determine to a largeextent the scope and magnitude of roadsafety problems. Thus, an urban develop-ment policy that favors mass transit and non-motorized means of commuting facilitatesthe implementation of safety measures on allpublic thoroughfares (i.e., not just on high-ways) and helps ensure the efficiency of thesemeasures, in contrast to a scenario in whichthe dominant preference is transportation byprivate automobile (74). Without a doubt, thisoption increases the synergy between roadsafety and urban design policies, strengthen-ing their public health component.

CONCLUSIONS

This chapter seeks to call attention to theinfluence exerted by urban development de-


sign and public transportation structure andoptions on public health and the level ofphysical activity of city dwellers. Table 1 of-fers a brief summary of the positive effectsthat various urban interventions could pro-duce on physical activity.

The rapid urbanization of Latin America,as we have seen in this chapter, has, in manycases, produced a negative impact on thequality of life of inhabitants of large metro-politan areas, and has favored the adoptionof individualized modes of motorization(motorcycle or private automobile) and theuse of urban public space in a manner resem-bling the U.S. suburban model, thereby com-promising opportunities for fulfilling thecurrent recommended levels of physical ac-tivity, especially walking. There is an emerg-ing need to restrain and discourage thesetrends now and in the future, not only be-cause of their negative impact on humanhealth, but also because of their negative eco-nomic, environmental, and social effects, andthe need to improve public transportation ef-ficiency and to responsibly address the citi-zenry’s quality of life concerns. New and cre-ative approaches to urban zoning codes,including densification and mixed-use com-munities, coupled with measures to improveroad and personal safety and mass transitsystems, can provide the crucial underpin-ning for adequately responding to all of theabove challenges and at the same time helpto dispel the notion that socioeconomic de-velopment and prosperity are inextricablyrelated to and/or dependent upon the avail-ability and ownership of individualizedforms of motorized mobility.

Public policies currently enjoy a promi-nent place on the international agenda, withparticular focus on those related to sustain-able transportation systems and road safety,as well as on such public health issues ascombating a sedentary lifestyle, injury pre-vention, clean air, and quality of life of thepopulation. The convergence of these publichealth and urban planning priorities indi-cates that at least some municipal govern-

ments in the Region of the Americas areshowing increased sensitivity to the prob-lems of urban quality of life and suggeststhat the groundwork for implementing theproposals set forth in this chapter is nowbeing laid.

The health and physical activity data onurban life in Latin America presented earlierin this chapter lead to the following conclu-sions and preliminary recommendations:

• Information gathered from applications ofthe IPAQ questionnaire indicates thatwalking is an important part of everydaylife for those individuals whose physicalactivity levels are sufficiently adequate to enable them to derive health benefits.Furthermore, walking for utilitarian pur-poses is more common than recreationalwalking, particularly among low incomegroups.

• Data from transportation studies areconsistent with the above finding. In themajority of the Region’s large citieswhere there is widespread use of publictransportation and fewer private vehi-cles on the streets, there are indicationsthat a large part of people’s daily com-mutes is undertaken on foot or by bicy-cle, and not via privately owned auto-mobiles, as in the United States andother areas that have adopted the U.S.residential/suburban model.

• This suggests that public health policiesand strategies should promote the im-portance of walking and bicycle-riding,in addition to advocating for better in-frastructure and safety for individualswho participate in these activities. Dueto the potential scope of the target pop-ulation, this approach should be ac-corded preferential attention and becomplemented by similar strategiesaimed at increasing participation in avariety of other recreational activitiesrequiring physical exertion.

• Research findings need to be consoli-dated concerning the impact of inter-


ventions in the areas of urban develop-ment, mass transit, and citizen educa-tion, similar to those adopted in thecities of Bogotá, Curitiba, Quito, andothers, on physical activity levels, per-sonal health status, and optimumcost/benefit.

• Studies are needed on the costs to per-sonal health and the environment—asyet unknown—of transportation pro-grams that directly or indirectly pro-mote individualized forms of motor-ized mobility versus those whosedesign favors a combination of physicalactivity and mass transit.

In the programmatic and public policyareas, public health in Latin America is fac-ing important challenges, which can be sum-marized as follows:

• the need to forge closer ties and synergybetween the public health sector andthose responsible for urban transporta-tion systems, road safety, environmen-tal protection and municipal land man-agement, preservation of public spaces,providing incentives for non-motorizedforms of transportation, and designat-ing physical structures primarily forpedestrian and cyclist use (Table 2


TABLE 1. Impact of transportation, road safety, crime control, and public space on physical activity ofurban inhabitants. Area of Intervention Physical Activity Impact

Transportation

Public transportation

Alternative transportation

Clean air

Road Safety

Crime Control

Public Space

Structures designated specially for pedestrian use (sidewalks, crosswalks, etc.)

Parks/recreational facilities

Preservation/conservation of historical, architectural, and cultural centers

Closing streets for recreational purposes

Accounts for a large portion of non-motorized mobility (walking or bicycling) to reachmass transportation means in areas not covered by motorized means of feeder/connecting transportation

Riding a bicycle and walking are the most widespread alternative means of mobility andprovide users with the opportunity to incorporate physical activity as part of their dailyroutine.

Can be a persuasive factor in encouraging people to spend more time out-of-doors andon the street and engage in sports and other types of recreational physical activity

Promotes greater use of public thoroughfares for walking, biking, and traveling via auto-mobile to sports, exercise, and recreational centers

Promotes use of public thoroughfares for recreational or utilitarian purposes

Ensure personal protection and safety. While important for all population age groups,these structures are particularly important for older adults.

Open-air parks encourage walking and bicycling, while recreational facilities (indoor oroutdoor) stimulate physical exertion and social interaction in sports such as baseball,basketball, football, tennis, and swimming.

The presence of these centers in areas with restrictions on vehicular traffic and parkingpromotes physical activity.

Events such as bike rides, street festivals, block parties, special sports and dance compe-titions, etc., solidify community sense of identity and stimulate collective interest in par-ticipating in recreational and physical activities.

shows the impact on health and the syn-ergy potential of various public poli-cies);13 and

• supporting the efforts and sustainingthe achievements made to date in all ofthe aforementioned areas.

The community of public health profes-sionals can play an important leadership rolein promoting priority actions in all of theidentified areas by showing the magnitudeand health consequences of a sedentarylifestyle and its relationship to urban devel-opment choices, advocating public policiesthat favor physical activity and the highestpossible quality of life for all sectors of ur-ban residents, and monitoring populationchanges with regard to physical activity leveland overall health status.

ACKNOWLEDGMENTS

The authors express their gratitude toRuth Long, a masters in public health degree

candidate from The George Washington Uni-versity, Washington, D.C., for her work inconducting an electronic literature search ontransportation issues for use as backgroundmaterial in this chapter.

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CONCLUSIONS

Despite the successes of recent decades in the majority of countries in the Region ofthe Americas, large segments of the population, especially those living in poverty andmarginalization, continue to suffer from nutritional problems. In these sectors, childrenunder 3 are the most vulnerable group, and therefore, at greatest risk for the immedi-ate, medium-, and long-term consequences of inadequate nutrition.

At the same time, the rise in prevalence of overweight and obesity in many parts ofthe Region reminds us of the need to address issues related to excessive caloric intakeand sedentary lifestyles.

This book assembles the contributions of noted Latin American authors to scientificknowledge about the magnitude and nature of nutritional problems and their lifelongconsequences for individuals and also provides a strong scientific basis for the impor-tance of promoting physical activity and the adoption of active lifestyles. The variouschapters describe a series of successful experiences from the Region in both rural andurban settings and at the local and national levels that may serve as viable models foradaptation in other geographical and cultural contexts within or outside the Americas.

The articles included in this compendium were selected to encourage policymakersand health and nutrition program planners, as well as future public health and nutritionprofessionals, to seriously reflect on the critical need to avoid passive acceptance of per-sistent nutritional problems and to recognize the emerging threats to health posed by seden-tary behaviors in the Region. On the basis of a full awareness and understanding of theseissues, the public health and research community will be able to effectively promote science-based action that can yield positive, measurable results in the health of populations.

A review of the scientific evidence on the consequences of inadequate nutrition andits impact on the physical growth and mental development of individuals and popula-tions, of the capacity of that evidence to optimize potential, and of the results emanat-ing from successful programs in several countries, leads to the following conclusions:

(1) There is sufficient scientific evidence on the impact of malnutrition on the healthof individuals and populations to confirm the urgent need for effective, low-cost pro-grams to reduce its high prevalence. It should also be noted that the Region of theAmericas already possesses a critical mass of knowledge and experience that may makeit unnecessary to import programs from other parts of the world.

(2) The successful experiences described in this book are flexible enough in their de-sign to enable them to be adaptable in a variety of circumstances in locales and coun-tries nearly everywhere. In this sense, the Region has a battery of models, methodolo-gies, instruments, and processes at its disposal that have proven their effectiveness incombating malnutrition and hold great potential for successful adoption in other partsof the world.

(3) These experiences also show that to achieve the expected results, the technical ex-pertise and support of diverse disciplines are required, among them public health, med-

245

icine, nutrition, epidemiology, economics and planning, communications, and the ap-plied social sciences. Focused on a common objective, these contributions will facilitatethe development and execution of responses that are both practical and sustainable.

(4) The experiences described in this book show us that regardless of the approachadopted by the program proposals, all of these have required the collaboration of abroad segment of interests—the government; local, national, and international organi-zations; the business community; and civil society—in the design and implementationof activities.

(5) One of the elements essential to the success of any initiative is the full empower-ment of all the institutions involved and civil society in terms of program objectives andtheir active (versus merely passive) participation.

(6) Successful completion of each stage of the programs (identification of needs andproblems, planning, execution, monitoring, and evaluation) requires skilled, experi-enced professionals familiar with the appropriate tools, methodologies, and instrumentscalled for in each instance, as emphasized in the chapters by Rea and Araújo, and Daryand Mora and their respective colleagues, among others.

(7) To demonstrate their achievements, programs should conduct process and im-pact assessments that prove the effectiveness of the interventions at the individual andpopulation levels, identifying from the outset the particular results they seek to obtain.

(8) The key to the feasibility of the proposed interventions is the commitment of gov-ernments and the international community, translated into the allocation of sufficientand appropriate financial and human resources.

The above conclusions, particularly as they relate to the need for an integrated, mul-tidisciplinary approach and a solid scientific foundation, are equally applicable to theother focus of this book—the promotion of increased physical activity and the obser-vance of active lifestyles at all socioeconomic levels of the population. Several addi-tional points with respect to this still-emerging public health issue need to be made:

(1) Sedentary lifestyles are a major risk factor contributing to the global burden ofnoncommunicable diseases. In 2004, the World Health Organization, through itsendorsement of a Global Strategy on Diet, Physical Activity, and Health, signaled itsresolve to prioritize among its Member States the adoption of a population-wide,prevention-based response to this epidemic.

(2) In light of mass urbanization trends over recent decades, researchers—aware thatthe ability to secure health and well-being is closely associated with a series of physi-cal, social, cultural, and economic variables—have sharpened their focus on the role ofthe urban environment in determining individual and collective health status.

(3) The evidence emanating from these studies suggests that it is unrealistic to expecthealthier behaviors to be achieved and maintained at the individual level if these effortsare not facilitated and strengthened by supportive policies and plans fueled by sus-tained political commitment.

(4) As the chapters by Matsudo and Matsudo, Montezuma, and Jacoby and col-leagues point out, concrete examples—including the large metropolises of São Paulo,Brazil, and Bogotá, Colombia—are already yielding promising results to support theidea that major behavioral and environmental risk factors are indeed amenable to mod-ification through the implementation of essential and concerted action between the var-ious sectors we have cited throughout this book.

246 Conclusions

The authors and I bring this book to our readers with the desire that each of its con-tributions will become the object of an in-depth analysis that examines both the pro-grams and their scientific underpinnings, and that these motivate decision-makers inthe international community to bring to fruition the necessary interventions to addressnutritional inequities and risk factors associated with noncommunicable diseases.

Wilma B. Freire

Conclusions 247

Nutritionand an

Active Life

From Knowledge to Action



Nutrition and an Active Life: From Knowledge to Action is ananthology by leading public health experts from the Pan AmericanHealth Organization and the international development community.The book’s selections focus on how research in nutrition and thepromotion of active lifestyles can provide vital input for the creationof public policy and planning and for the design, implementation,monitoring, and evaluation of programs.

You and I, in one way or another, stand to directly benefit fromthis science and its effective application. The knowledge gainedfrom the research presented here has the power to transform thelives of mothers and children, the economically active population,older adults, and all age groups whose sedentary lifestyle placesthem at greater risk of developing life-threatening chronic diseases.

Nutrition and an Active Life: From Knowledge to Action is animportant contribution that should be of particular interest to prac-titioners, researchers, and decision-makers in the fields of healthpromotion, community education, nutrition, maternal and childhealth, physical activity, policy development in public health andurban planning, social communications, and other related areas.

525 Twenty-third Street, N.W. Washington, D.C. 20037 U.S.A.www.paho.org

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