National School Lunch Nutrition and Cost Profile: A Case Study of the Ghana School Feeding Programme.

Numerous governments in developing countries institute school lunch programs or school feeding programs as a strategy to address high malnutrition and low education rates among children. In 2005, the Ghanaian government launched the Ghana School Feeding Programme (GSFP). The GSFP policy does not document (1) the actual meal and associated nutrient profile received by the student, (2) the cost of the meal ingredients to the caterer who prepares the food, nor (3) the recipe derivations that may supply an enhanced nutritional profile. We address these 3 information gaps by employing a detailed case study of 4 caterers supplying a traditional tomato stew recipe in northern Ghana within GSFP-supported school lunch programs. Specifically, we explore the following propositions: (1) GSFP caterers can deliver a school lunch for under 100 pesewas (1 GH¢ or $0.21 USD) per student; (2) the meal meets the recommended daily allowance for protein; (3) soy can serve as a cost-effective ingredient to fortify the meal in terms of protein level and protein quality; and (4) significant differences exist in the macro- and micronutrient profile due to caterer discretion. We answer the above 4 propositions, and by doing so show the importance of accurately measuring the nutritional content, costs, and quantities of the actual school lunch under study. Second, among our results, we show the economy of locally produced soy flour as an ingredient that can lower costs and raise nutrition when substituting for other locally produced proteins such as ground beef and mackerel.

Position of the Academy of Nutrition and Dietetics: Child and Adolescent Federally Funded Nutrition Assistance Programs.

It is the position of the Academy of Nutrition and Dietetics that children and adolescents should have access to safe and healthy foods that promote physical, cognitive, and social growth and development. Federally funded nutrition assistance programs, such as food assistance, meal service, and nutrition education, play a vital role in ensuring that children and adolescents have access to the foods they need and in improving the overall nutrition and health environments of communities. Federally funded nutrition assistance programs help to ensure that children and adolescents receive safe, healthy foods that provide adequate energy and nutrients to meet their growth and development needs. These programs provide access to adequate food supplies to combat hunger and food insecurity; provide healthy foods to children and adolescents who have nutritional or medical risk factors, such as iron deficiency anemia; and provide nutrition education. In addition, federally funded nutrition assistance programs serve as a means to prevent or reduce obesity and other chronic diseases. It is important that permanent and full federal funding be provided for these programs, which have been consistently shown to have a positive impact on child and adolescent nutrition and health outcomes. Registered dietitian nutritionists and nutrition and dietetic technicians, registered-trained in food science, nutrition, and food systems to implement programs to monitor, evaluate, and improve the nutritional status of children and adolescents-are preeminently qualified to implement and evaluate nutrition assistance programs for children and adolescents.

Cost-effectiveness of food, supplement and environmental interventions to address malnutrition in residential aged care: a systematic review.

Background: observational studies have shown that nutritional strategies to manage malnutrition may be cost-effective in aged care; but more robust economic data is needed to support and encourage translation to practice. Therefore, the aim of this systematic review is to compare the cost-effectiveness of implementing nutrition interventions targeting malnutrition in aged care homes versus usual care. Setting: residential aged care homes. Methods: systematic literature review of studies published between January 2000 and August 2017 across 10 electronic databases. Cochrane Risk of Bias tool and GRADE were used to evaluate the quality of the studies. Results: eight included studies (3,098 studies initially screened) reported on 11 intervention groups, evaluating the effect of modifications to dining environment (n = 1), supplements (n = 5) and food-based interventions (n = 5). Interventions had a low cost of implementation (<£2.30/resident/day) and provided clinical improvement for a range of outcomes including weight, nutritional status and dietary intake. Supplements and food-based interventions further demonstrated a low cost per quality adjusted life year or unit of physical function improvement. GRADE assessment revealed the quality of the body of evidence that introducing malnutrition interventions, whether they be environmental, supplements or food-based, are cost-effective in aged care homes was low. Conclusion: this review suggests supplements and food-based nutrition interventions in the aged care setting are clinically effective, have a low cost of implementation and may be cost-effective at improving clinical outcomes associated with malnutrition. More studies using well-defined frameworks for economic analysis, stronger study designs with improved quality, along with validated malnutrition measures are needed to confirm and increase confidence with these findings.

The Influence of School Nutrition Programs on the Weight of Low-Income Children: A Treatment Effect Analysis.

Recent policy attempts to set high nutrition standards for the School Breakfast Program (SBP) and National School Lunch Program (NSLP) aim to improve children's health outcomes. A timely and policy-relevant task evaluates to what extent school meal programs contribute to child body mass index (BMI) outcomes to assess those school meal policies' potential impacts. This study examines children's weight progress from 1st through 8th grade, while recognizing the potential effects on those children participating in both programs compared with those children participating in only one program. We used difference-in-differences (DID) and average treatment effect on the treated (ATT) methodologies and focused on free- and reduced-price meal-eligible children to filter out income effects. The DID results show that short-term participation in only NSLP increases the probability that children will be overweight, and these results are more prominent in the South, Northeast, and rural areas. ATT results show that participation in both programs from 1st through 8th grade increases the probability that these students will be overweight. With the Community Eligibility Provision having taken effect across the nation in the 2014-2015 school year, the need to continue examining the impacts of these programs on child BMI is even greater. Copyright © 2016 John Wiley & Sons, Ltd.

Practice paper of the academy of nutrition and dietetics: principles of productivity in food and nutrition services: applications in the 21st century health care reform era.

Food and nutrition services, along with the health care organizations they serve, are becoming increasingly complex. These complexities are driven by sometimes conflicting (if not polarizing) human, department, organization, and environment factors and will require that managers shift how they think about and approach productivity in the context of the greater good of the organization and, perhaps, even society. Traditional, single-factor approaches to productivity measurements, while still valuable in the context of departmental trend analysis, are of limited value when assessing departmental performance in the context of an organization's goals and values. As health care continues to change and new models of care are introduced, food and nutrition services managers will need to consider innovative approaches to improve productivity that are consistent with their individual health care organization's vision and mission. Use of process improvement tools such as Lean and Six Sigma as strategies for evaluating and improving food and nutrition services efficiency should be considered.

Disadvantaged pre-schoolers attending day care in Salvador, Northeast Brazil have a low prevalence of anaemia and micronutrient deficiencies.

OBJECTIVE: To examine the micronutrient status of disadvantaged pre-schoolers from Northeast Brazil, following the introduction of pro-poor policies, by assessing the prevalence of anaemia and micronutrient deficiencies and the role of sociodemographic factors, genetic Hb disorders and parasitic infections. DESIGN: In a cross-sectional study, data on sociodemographic status, health, growth, genetic Hb disorders, parasites and nutrient supply from day-care meals were obtained. Fasting blood samples were collected and analysed for Hb, serum ferritin, transferrin receptor, folate, vitamin B12, retinol, Zn and Se. SETTING: Seven philanthropic day-care centres serving urban slums in Salvador, Northeast Brazil. SUBJECTS: Pre-schoolers aged 3-6 years from disadvantaged households. RESULTS: Of the 376 sampled children, 94 % were of black or mixed race; 33 % and 29 % had at least one genetic Hb disorder and intestinal parasite, respectively. Stunting and underweight were ≤5 %; 14 % were overweight. Day-care centres supplied micronutrient-dense meals and snacks each weekday. Less than 10 % of pre-schoolers had anaemia and micronutrient deficiencies. Predictors (P < 0·05) of Hb were α(3·7) thalassaemia, Se and retinol (but not ferritin). Micronutrient predictors (P < 0·05) were: elevated α1-glycoprotein for ferritin, Hb AS and BMI Z-score >1 for transferrin receptor, Zn and elevated α1-glycoprotein for retinol, sex and helminths for Se, helminths for vitamin B12, and Giardia intestinalis infection for serum folate. CONCLUSIONS: Impaired growth, anaemia and micronutrient deficiencies were uncommon among these disadvantaged pre-schoolers attending day care. A range of interventions including provision of micronutrient-dense, fortified day-care meals, deworming and vitamin A supplementation likely contributed to improved micronutrient status, suggesting expanded coverage of these programmes.

Examining health care costs among MANNA clients and a comparison group.

Chronically ill populations have a strong need for quality public health nutrition services to aid in disease management and improve health outcomes. Evidence suggests that neglecting the importance of adequate nutrition in chronically ill patients has far-reaching implications on the health status of the individual and the health care costs. Research is currently lacking a focus on this topic. This pilot study done through the nonprofit organization MANNA (Metropolitan Area Neighborhood Nutrition Alliance), which serves the greater Philadelphia area, explored the health care expenditures of 65 MANNA clients over time in comparison with a similar group of Medicaid patients who did not receive MANNA services. Health care expenditures were examined before and after clients began receiving services. The study found that the mean monthly health care costs decreased for three consecutive months after initiation of MANNA services. Other health care cost-related factors, such as inpatient costs, length of stay, and number of hospital admissions also displayed a downward trend. These results help show the significance of medical nutrition therapy and home-delivered meal services on overall health care.

Indian social safety net programs as platforms for introducing wheat flour fortification: a case study of Gujarat, India.

BACKGROUND: Micronutrient deficiencies exact an enormous health burden on India. The release of the National Family Health Survey results--showing the relatively wealthy state of Gujarat having deficiency levels exceeding national averages--prompted Gujarat officials to introduce fortified wheat flour in their social safety net programs (SSNPs). OBJECTIVE: To provide a case study of the introduction of fortified wheat flour in Gujarat's Public Distribution System (PDS), Integrated Child Development Scheme (ICDS), and Mid-Day Meal (MDM) Programme to assess the coverage, costs, impact, and cost-effectiveness of the initiative. METHODS: India's 2004/05 National Sample Survey data were used to identify beneficiaries of each of Gujarat's three SSNPs and to estimate usual intake levels of vitamin A, iron, and zinc. Comparing age- and sex-specific usual intakes to Estimated Average Requirements, the proportion of the population with inadequate intakes was estimated. Postfortification intake levels and reductions in inadequate intake were estimated. The incremental cost of fortifying wheat flour and the cost-effectiveness of each program were estimated. RESULTS: When each program was assessed independently, the proportion of the population with inadequate vitamin A intakes was reduced by 34% and 74% among MDM and ICDS beneficiaries, respectively. Both programs effectively eliminated inadequate intakes of both iron and zinc. Among PDS beneficiaries, the proportion with inadequate iron intakes was reduced by 94%. CONCLUSIONS. Gujarat's substitution of fortified wheat flour for wheat grain is dramatically increasing the intake of micronutrients among its SSNP beneficiaries. The incremental cost of introducing fortification in each of the programs is low, and, according to World Health Organization criteria, each program is "highly cost-effective." The introduction of similar reforms throughout India would largely eliminate the inadequate iron intake among persons participating in any of the three SSNPs and would have a significant impact on the global prevalence rate of inadequate iron intake.

Development, acceptability, and nutritional characteristics of a low-cost, shelf-stable supplementary food product for vulnerable groups in Kenya.

BACKGROUND: Food-based approaches have been advocated as the best strategies to curb hunger and malnutrition in developing countries. The use of low-cost, locally available, nutritious foods in the development of supplementary foods has been recommended. OBJECTIVE: To develop low-cost food supplements using different traditionally processed local foods, consisting of cereals, legumes, nuts, fish, and vegetables, to meet the nutrient requirements for vulnerable groups in Kenya. METHODS: Four food supplements were developed and evaluated by taste panel procedures. The product containing amaranth grain, pigeon pea, sweet potato, groundnuts, and brown sugar was found to be the most acceptable supplement. Evaluation of nutritional composition, shelf-life, and cost analysis of the acceptable supplement was carried out to assess if it could satisfactorily provide more than 50% of the Recommended Dietary Allowances (RDAs) of the basic nutrients for vulnerable groups. RESULTS: The acceptable supplement contained 453.2 kcal energy, 12.7 g crude protein, 54.3 g soluble carbohydrates, 20.8 g crude fat, and 10.1 g crude fiber per 110 g. The micronutrient contents were 93.0 mg calcium, 172.4 mg magnesium, 2.7 mg zinc, 5.7 mg iron, 0.8 mg vitamin B1, 0.2 mg vitamin B2, 7.9 mg niacin, 100 microg folic acid, and 140 microg retinol equivalent per 110 g. The supplement also contained 21% total essential amino acid in addition to appreciable levels of palmitic, stearic, oleic, linoleic, and alpha-linolenic fatty acids. The shelf-life study showed that it could be stored in different packaging materials (polythene bags, gunny bags, and kraft paper) at 26°C without deleterious effects on its chemical composition for up to 4 months. Cost analysis of the supplement indicated that the product could be competitively sold at US$0.812/kg (KES 65.50/kg). CONCLUSIONS: Locally available indigenous foods can be used in the formulation of acceptable, low-cost, shelf-stable, nutritious supplementary foods for vulnerable groups.

New benchmarks for costs and cost-efficiency of school-based feeding programs in food-insecure areas.

BACKGROUND: School feeding is a popular intervention that has been used to support the education, health and nutrition of school children. Although the benefits of school feeding are well documented, the evidence on the costs of such programs is remarkably thin. OBJECTIVE: Address the need for systematic estimates of the cost of different school feeding modalities, and of the determinants of the considerable cost variation among countries. METHODS: WFP project data, including expenditures and number of schoolchildren covered, were collected for 78 projects in 62 countries through project reports and validated through WFP Country Office records. Yearly project costs per schoolchild were standardized over a set number of feeding days and the amount of energy provided by the average ration. Output metrics, such as tonnage, calories, and micronutrient content, were used to assess the cost-efficiency of the different delivery mechanisms. RESULTS: The standardized yearly average school feeding cost per child, not including school-level costs, was US$48. The yearly costs per child were lowest at US$23 for biscuit programs reaching school-going children and highest at US$75 for take-home rations programs reaching families of schoolgoing children. The average cost of programs combining on-site meals with extra take-home rations for children from vulnerable households was US$61. Commodity costs were on average 58% of total costs and were highest for biscuit and take-home rations programs (71% and 68%, respectively). Fortified biscuits provided the most cost-efficient option in terms of micronutrient delivery, whereas take-home rations were more cost-efficient in terms of food quantities delivered. CONCLUSIONS: Both costs and effects should be considered carefully when designing school feeding interventions. The average costs of school feeding estimated here are higher than those found in earlier studies but fall within the range of costs previously reported. Because this analysis does not include school-level costs, these findings highlight the higher nontransfer costs for programs delivering cooked meals in schools than for other school feeding modalities. The benchmarks presented here reflect the centralized WFP implementation model, which is not always relevant in terms of government school feeding programs, particularly those procuring within national boundaries using "home-grown" approaches.

Cost-effectiveness of medical nutrition therapy and therapeutically designed meals for older adults with cardiovascular disease.

BACKGROUND: Many older adults experience hyperlipidemia and hypertension, but there is little information about whether medical nutrition therapy (MNT) or therapeutic meals have independent or joint beneficial effects on older adults with these diagnoses. OBJECTIVE: To assess the cost-effectiveness of MNT and therapeutic meals for older adults with hyperlipidemia and/or hypertension. DESIGN: A 1-year prospective four-arm controlled randomized community-based clinical trial. SUBJECTS/SETTING: Participants were people ages 60 years or older residing in community settings who were medically diagnosed with either hypertension or hyperlipidemia. They were recruited through a number of venues beginning in May 2003. INTERVENTION: The 321 eligible individuals were assigned to one of four arms: (a) a literature control group, (b) a therapeutic meal group that received seven diagnosis-appropriate therapeutic meals a week, (c) an MNT group, and (d) an MNT-plus-therapeutic meal group. MAIN OUTCOME MEASURE: The outcome measure was quality-adjusted life-years (QALYs). Costs included both intervention and medical costs. STATISTICAL ANALYSES: Estimations of separate models of costs and QALYs facilitated the construction of incremental cost-effectiveness ratios. Net benefit analysis produced the probability that each intervention was cost-effective given different values for society's willingness to pay for a QALY. RESULTS: Therapeutic meals are cost-effective. Using the net benefit approach and a willingness to pay of $109,000 per QALY, the probability that the therapeutic meal delivery program is cost-effective is 95% and for MNT the probability is 90%. However, the combination of MNT and therapeutic meals did not have an independent significant effect on QALYs. CONCLUSIONS: Results inform the debate about extending Medicare funding for MNT to individuals with hypertension and hyperlipidemia. Future research should include more individuals who are not currently receiving medications for these diseases.

The Thrifty Food Plan is not thrifty when labor cost is considered.

Recent research has shown that the typical Supplemental Food Assistance Program (SNAP) family falls short in meeting the Thrifty Food Plan (TFP) nutritional guidelines that underlie the SNAP even when they typically have sufficient monetary resources to eat a healthful diet (i.e. to follow the TFP recommendations). However, the TFP does not consider labor cost. This study uses a basic labor economics technique to value labor in a home food production scenario that is required to reach the TFP nutrition and budget targets and calculates the total cost (inclusive of labor) associated with the TFP. This TFP consistent total cost is then compared, using several metrics, with the total cost associated with actual choices made by those families sharing the same profiles as current SNAP participants. Once labor is included, we find the TFP is not very thrifty and the mean household falls short of the TFP guidelines even with adequate monetary resources.

The "Rolling Store:" an economical and environmental approach to the prevention of weight gain in African American women.

OBJECTIVE: To test the feasibility of the "Rolling Store," an innovative food-delivery intervention, along with a nutrition education program to increase the consumption of healthy foods (fruits and vegetables) to prevent weight gain in African American women. METHODS: Forty eligible African American women were enrolled in the study and randomized to intervention or control groups. A trained peer educator and a Rolling Store operator implemented the study protocol at a local community center. RESULTS: The program retention rate was 93%. Participants in the intervention group lost a mean weight of 2.0 kg, while participants in the control group gained a mean weight of 1.1 kg at six months. Overall participants showed a mean decrease in weight of -.4 kg (standard deviation 3.0 kg), but the intervention group lost significantly more weight and had a decreased body mass index at six months. In the intervention group, the average number of servings consumed per day of fruits/ fruit juice and vegetables significantly increased at six months. CONCLUSIONS: The Rolling Store, at least on the small scale on which it was implemented, is a feasible approach to producing weight loss and improvements in healthy eating when combined with an educational program in a small community center.

Process and dynamics of traditional selling wild edible mushrooms in tropical Mexico.

BACKGROUND: More than twelve temperate-inhabitant Mexican ethnic groups are considered to be mycophilic and to have extensive traditional mycological knowledge. In contrast, inhabitants of tropical lands have been studied only superficially and their mycological knowledge is less well known. In this paper, we report the results of an ethnomycological research in markets of a wide area of the Mexican tropics. Our aims were to describe the dynamics related to the traditional selling process of wild mushrooms and to determine the tendencies of informants toward mushrooms (mycophily vs. mycophoby). METHODS: We visited 25 markets of 12 different settlements in the states of Oaxaca, Tabasco and Veracruz and collected information by participant observation as well as by 291 non-structured and semi-structured interviews. RESULTS: Mushroom selling was observed in four towns in Oaxaca and in two in Tabasco. Women represented 81.82% of sellers, while indigenous people (Chinantecos, Chontales, Ch'oles and Zoques) comprised 68.18%. Mushroom commercialization took place in secondary mobile markets and only in peasant stands. Mushroom collectors gather the resource in places with secondary vegetation, farmed areas and cattle fields. Because of land tenure restrictions mushroom sellers did not normally collect mushrooms themselves. In Oaxaca, we observed economic dynamics not based on capitalism, such as exchange, reciprocity and barter. CONCLUSION: The sale of some wild edible mushrooms, the large amounts of commercialization of Schizophyllum commune, the complicated intermediary process, as well as the insertion of mushrooms into different informal economic practices are all evidence of an existent mycophily in a sector of the population of this region of the Mexican tropics. Among our informants, urban mestizo people were mycophobic, rural mestizo people were non-mycophilic and indigenous people were true mycophilic.

Costs of meals and parking for parents of hospitalised children in Australia.

BACKGROUND: The aim of this investigation was to examine the cost of parents' food and parking during a child's admission to two paediatric health facilities in a capital city in Australia and to make recommendations to alleviate the cost of admission. METHODS: A survey was undertaken of hospital facilities and food outlets, recording the type and cost of food available, opening times of the facilities and parking costs. RESULTS: Costs for food and parking for one accompanying parent can exceed A$200 per week. At one hospital no full meals were available. For parents of children admitted for long periods or those on low incomes and/or social security benefits, this would be a large proportion of their weekly income. RECOMMENDATIONS: Funding to paediatric hospitals should include meals for parents, especially breastfeeding mothers. Access to staff canteens would afford parents the opportunity to eat proper meals. Parking for parents should be free.

The association of the school food environment with dietary behaviors of young adolescents.

OBJECTIVES: We examined the association between young adolescents' dietary behaviors and school vending machines, à la carte programs, and fried potatoes' being served at school lunch. METHODS: Using a cross-sectional study design, we measured à la carte availability and the number of school stores, vending machines, and amounts of fried potatoes served to students at school lunch in 16 schools. Grade 7 students (n = 598) completed 24-hour dietary recall interviews. RESULTS: A la carte availability was inversely associated with fruit and fruit/vegetable consumption and positively associated with total and saturated fat intake. Snack vending machines were negatively correlated with fruit consumption. Fried potatoes' being served at school lunch was positively associated with vegetable and fruit/vegetable intake. CONCLUSIONS: School-based programs that aim to promote healthy eating among youths should target school-level environmental factors.

EFNEP: a nutrition education program that demonstrates cost-benefit.

OBJECTIVE: Data on the economic value of nutrition education programs, such as the Expanded Food and Nutrition Education Program (EFNEP), can help decision makers choose among alternative programs based on costs and benefits. A cost-benefit analysis of EFNEP was conducted to determine if participants' savings in food expenditures exceeded program implementation costs. DESIGN/SUBJECTS: Costs were collected over 6 months using expenditure reports and other records. Benefits were determined using prospective data from 371 women enrolled in EFNEP who completed a 24-hour food recall and behavior survey, and recorded the amount of money spent monthly on food at program entry and exit. Two treatment groups received nutrition education and one group did not receive education. One treatment group estimated food expenditures from recall and the other collected register receipts or recorded expenditures. Control group subjects reported expenditures from recall. Net present value (NPV) was calculated using mean EFNEP cost per participant subtracted from the mean change in family food expenditures per participant over a 5-year period at three discount rates. STATISTICAL ANALYSES: Analysis was designed to compare food expenditures among the two experimental groups and control group and food and nutrient intakes and survey scores between the combined experimental group and control group. RESULTS: The average EFNEP program cost perparticipant was $388, and graduating participants reported that family food expenditures decreased on average by $10 to $20 per month or $124 to $234 over a year. When benefits were projected to last 5 years, the NPV was $147 to $696 depending on the method of food expenditure estimation and the discount rate. At the same time individuals reduced food expenditures, they increased intakes of iron, vitamin C, vitamin B-6, and fiber. They added less salt when cooking and read nutrition labels more often. They also reported not running out of food at the end of the month as often. APPLICATIONS/CONCLUSIONS: Findings from this research showed that EFNEP is cost-beneficial. The magnitude of the savings in food expenditures is sensitive to the method of food expenditure reporting and assumptions about how long participants will retain the behaviors they learn.

Profile of public health nutrition personnel: challenges for population/system-focused roles and state-level monitoring.

OBJECTIVE: Our 3 objectives were to document the current public health nutrition workforce in the United States, identify top public health nutrition priorities for the next 5 years, and assess the capacity of public health nutrition personnel to address these priorities and the nutrition-related objectives of Healthy People 2000. DESIGN: A census survey was distributed to public health nutrition personnel in all state and local health agencies and nonprofit and for-profit agencies funded by official health agencies throughout the United States and US territories. Also, state and territorial nutrition directors were sent a different questionnaire. SUBJECTS: Data were collected from 49 states, the District of Columbia, and 2 territories; 7,550 public health nutrition personnel were represented. STATISTICAL ANALYSIS: Data were analyzed using EpiInfo software. Descriptive statistics are presented. RESULTS: Almost half of the respondents worked in local or county health agencies and about two thirds were involved in direct care services. Only about 40% were registered dietitians and about one fourth had a master's degree. Almost 90% of all full-time equivalent positions were funded through federal dollars; 78% of all funding was from the Special Supplemental Nutrition Program for Women, Infants, and Children. Top health concerns identified were diet/nutrition to prevent chronic disease, low breast-feeding rates, low birth weight, iron deficiency anemia, and obesity/overweight. Public health nutrition personnel will be challenged to assume population/system-focused roles and state-level monitoring of Healthy People 2000 objectives. Only 2 of the 17 nutrition objectives of Healthy People 2000 were monitored by more than 50% of the states. APPLICATIONS: If official health agencies are to shift to public health core functions, as recommended by an Institute of Medicine report, then a substantial proportion of the public health nutrition workforce must not only change how they practice but also obtain the knowledge and skills to do so. Strategies to improve workforce capacity are discussed, including continuing education interventions through professional organizations, distance and on-campus educational opportunities through approved public health nutrition programs, and advocacy for new funding streams focused on public health core functions.

Do nutrition programs make a difference? The case of Brazil.

Four Brazilian food and nutrition programs operating during some part of 1974-86 are evaluated for their effectiveness in curing or preventing infant and child malnutrition, including low birth weight when pregnant women were beneficiaries. Two programs distributed free food to identified clients: traditional commercial foods in one case and specially formulated supplements in the other. The other two programs subsidized four or more basic foodstuffs: one experiment quantitatively restricted a subsidy to identified families, and the other was unrestricted and open to all families patronizing certain shops. The programs were more effective at curing than at preventing malnutrition, and more effective at increasing weight than height. Many beneficiaries, even when initially underweight, showed no change, and some deteriorated despite the food transfer. Results were better after than during the first year of life, when deterioration is most likely. Donation programs including medical and educational components proved more effective than pure subsidies, showing that while poverty may be the chief cause of malnutrition, the problem should be seen as poor health rather than simply low food consumption. Evaluation also shows that programs were inefficient in transferring benefits, and that clients were deterred from participating by the costs of obtaining the food and its poor quality and small volume. Longer participation improved results, but more frequent participation in a given interval did not necessarily do so.

PIP: PAHO followed nutrition programs of Brazil, which have been supported almost exclusively from internal sources, since 1983 to provide technical assistance and to learn what may be applied to other countries. The PAHO program effectiveness evaluation study compared 2 ways of running nutrition programs which presumed that malnutrition was mainly caused by poverty--a subsidy of basic foods and direct distribution--between 1974-1986. 2 programs subsidized at least 4 basic foodstuffs with 1 program restricting the amount of food to identified families while the other allowed any family coming to stores in low income areas that participated in the program to take subsidized food. 2 other programs either gave free traditional commercial foods or specially formulated supplements to identified clients. The status of most well nourished or malnourished participants did not change despite intervals as long as 48 months. Moreover the nutritional status of a considerable percentage of participants deteriorated. Nevertheless moderate or severe malnourished children who started in a program tended to recover substantially, especially children 1 year old. Further the longer a client participated in a program the more likely the nutritional status would improve, yet frequent participation did not affect status. Thus the programs were more likely to cure than prevent malnutrition. Besides participants tended to not grow much, but weight status did improve. Those programs that also provided medical care and health education were more effective than those that just provided subsidies. This finding highlights how malnutrition is not just a problem of low income and low food consumption, but also a problem of poor health. The programs did not transfer benefits efficiently. In addition, the costs of securing the food, its poor quality, and insufficient volume discouraged beneficiary participation.