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Nutritional Deficiencies Among
Women and Children in Nicaragua
Dr. Matthew Blondin & Audrey Blondin
PUBH 5497: Food, Health & Politics
Instructor: Dr. Katie S. Martin
November 11, 2008
1. Introduction
Nicaragua is the largest country in Central America, and one of the
poorest countries in the Western Hemisphere. Although an end to the
civil war in 1990 brought some economic growth, great inequalities in
the distribution of wealth combined with global recession continue to
hamper economic progress. 1
The main health determinant for the Nicaraguan population is poverty.
The current population (2008) is approximately 5.78 million.2 More than
one third of the population is under age 14, including approximately
900,000 children under age 6. 2 More than half of these children (55%),
live in poverty, and 40% of the population can neither read nor write. 1
The child mortality rate is six times greater than the child mortality
rate in the United States (11 per 100 children). 3 More than 25% of the
population is under nourished. 4 This lack of proper diet results in
growth retardation, anemia resulting from iron deficiency, and vitamin A
deficiency (VAD).5 The problem is compounded by the early introduction
of food and other liquids that satiate hunger but do not nourish the
body.6
The volatile political environment in Nicaragua has hampered its
stability and prosperity. Corruption within the government and a general
lack of governmental control persist, continuing to fuel civilian unrest
and political demonstrations on a regular basis throughout the country.
Nicaragua has one of the highest degrees of income inequality in the
world, and the third lowest per capita income in the Western Hemisphere
($2,800) (2007 est.). Over 50% of Nicaraguans are either unemployed or
underemployed, and 48% of the population lives below the poverty line. 2
2. Nicaraguan Health Care System
The Ministry of Health (MINSA) is responsible for the administration of
the governmental health care system. Private sector care is located
primarily in Managua for the wealthy, who comprise less than 10% of the
population. The remaining 90% are treated in the public health care
system in Health Care Centers (“Centro de Saluds”) located throughout
the countryside. These centers face a great shortage of adequate tools
for diagnosis and treatment of disease and its related consequences. A
shortage of human resources, including doctors and nurses, contributes
to a lack of treatment of chronic diseases as well as a failure to
promote primary and well-care prevention and vaccination programs within
the community at large. 3
In the more rural parts of the country, located primary in the northern
and eastern areas, access to any type of health care is virtually
non-existent. Individuals facing any type of chronic or serious illness
are basically left to die due to the inability of the national health
care system to provide even the most basic and rudimentary of services.
In July 2008, the director of planning and development of the Health
Ministry, Alejandro Solis, announced that the hospital network in the
country was seriously deteriorated, with that in the northern part of
the country in disastrous condition. Current President Daniel Ortega has
committed to the repair and reconstruction of several of these
hospitals, as well as the construction of new polyclinics throughout the
country and a new general hospital in the capital of Managua at a cost
of $36 million.7 Given the current state of the global economy, however,
coupled with the on-going corruption and countrywide disparity between
the rich and the poor, it remains unlikely that much, if any, change or
improvement will occur within the healthcare system in the foreseeable
future.
3. Food Consumption and Childhood Health Deficiencies
The service sector represents the largest component of Nicaragua’s GDP
(2007) at 57.2%, followed by the industrial sector at 25.8% and
agriculture at 16.9%. 2 Approximately 52% of all Nicaraguans are
employed in the service industry, many making just $5 per day. Another
29% are involved in agriculture and 19% are involved in industry. 2
Nicaragua suffers from persistent trade and budget deficits that force
the country to rely on international economic assistance to meet fiscal
and debt financing obligations. The United States is Nicaragua’s largest
trading partner, providing 25% of Nicaragua’s imports and receiving
about 60% of its exports.8
Staple foods of the Nicaraguan diet include maize, rice and beans. Fish
is an important part of the diet, primarily in coastal areas. Common
vegetables and starches as part of the local diet include cassava,
plantains, onions, potatoes and tomatoes. Fruits available include
guavas, limes, mangoes, papayas, oranges, and tamarinds. 9
According to a 2006 Nicaraguan demographic and health survey, 20% of
children under age 5 exhibited stunted growth, 12% were underweight, 2%
were considered wasted, and 12% were born with low birth weight. 5 Fewer
than one third of all children are breast fed for at least six months. 5
Only half the populations have access to adequate sanitation facilities,
and over one third do not have access to safe drinking water sources. 4
The Nicaraguan population not only faces problems of growth retardation,
but also faces serious vitamin A deficiency (VAD) and anemia because of
iron deficiency in children, adolescents and adult women. 6 One out of
every three children has some degree of chronic malnutrition, and there
has been no improvement in reducing malnutrition in over a decade. If
malnutrition sets in before a child turns 2 years of age, the
consequences are irreversible. 10
4. Nutritional Deficiencies – Vitamin A Deficiency (VAD) and Anemia
A) Vitamin A Deficiency
Vitamin A is essential for ocular health and proper functioning of the
immune system. It is found in foods such as milk, liver, and eggs. These
foods are often not readily available to the rural poor, especially in
third world countries such as Nicaragua. Vitamin A is also found in red
and orange fruits, red palm oil and green leafy vegetables. In
developing areas of the world like Nicaragua, vitamin A is largely
consumed in fruits and vegetables, when available, and the daily per
capita intake is often insufficient to meet dietary requirements.
Inadequate intakes are further compromised by increased requirements for
vitamin A as children grow or during periods of illness, as well as
increased losses of the vitamin during common childhood infections. 11
Approximately 31% of all Nicaragua children under age 5 suffer from VAD.
6 VAD is the leading cause of preventable childhood blindness. In
addition, vitamin A-deficient children face a 23% greater risk of dying
from ailments such as measles, diarrhea, or malaria. 11
VAD was first noted in Latin America and the Caribbean in the mid-1960s.
However, with the exception of work done by the Institute of Nutrition
of Central America and the Panama/Pan America Health Organization on
sugar fortification in Central America, there was little interest in
controlling VAD because of the low frequency of clinical findings. More
recently, knowledge of implications of the effect of subclinical VAD on
child health and survival have generated increased interest in assessing
the problem and greater commitment to controlling it. 12
B) Anemia
Iron deficiency is the most common nutritional deficiency in the world
today. Because iron is important for red blood cell formation, iron
deficiency often leads to anemia, defined as having blood hemoglobin
levels <110 g/dL for children under age 5, <115 g/dL for children age
12-14 years and <120 g/dL for adult females. 13 Approximately one third
of all Nicaraguan children suffer from anemia. In addition, 16% of
reproductive-age women are anemic. While still high, this figure
represents a significant decrease from 1993, when the figure stood at
33.6%.14 (Fig. 1) 14
Anemia prevalence is greatest among pregnant women, infants, and young
children because of the high iron demands of pregnancy and growth. In
the human body, iron is present in all cells and serves as a carrier of
oxygen to the tissues from the lungs as hemoglobin, as well as a
facilitator of oxygen use and storage in the muscles as myoglobin and is
an important component in many of the body’s enzymes. The main causes of
anemia include inadequate intake and poor absorption of iron; malaria,
particularly in young children and pregnant women; hookworm infections;
diarrhea; HIV/AIDS and other infectious diseases. Genetic disorders,
including sickle cell anemia, and pregnancy-related problems, including
blood loss during labor and delivery, and closely spaced pregnancies,
also result in anemia. 14 Consequences of anemia include increased
maternal and perinatal mortality, increased numbers of preterm births
and/or low birth weight infants, impaired cognitive development in
children, and reduced adult work productivity. 14 (Fig. 2) 14
Productivity loss associated with lower physical productivity of anemic
adults in Nicaragua in blue-collar and heavy manual occupations has been
calculated at 3.8% of the country’s G.D.P. (2003).13
5. Strategies to Alleviate Deficiencies
A) VAD
Programs to control VAD enhance a child’s chances of survival, reduce
the severity of childhood illnesses, ease the strain on health care
systems and hospitals, and contribute to the well-being of children,
their families, and communities. Currently, three major strategies have
been suggested to help control VAD. The first strategy calls for a
high-dose vitamin A supplementation every 4 to 6 months for all children
between the ages of 6 and 59 months, as well as for all new mothers who
are breastfeeding. 11 As previously noted, less than one-third of all
Nicaraguan children are breastfed exclusively for more than six months,
and giving vitamin A to new mothers who are breastfeeding helps to
protect their children during the first months of life and also helps to
replenish the mother’s stores of vitamin A. 5, 11
Increased governmental food distribution efforts, as well as increased
introduction of food fortification, is the second method suggested for
long-term control of VAD. The most common types of food fortified with
vitamin A include sugar, oil, milk, margarine, infant foods and formula,
and various types of flour. 11
The third strategy suggested to alleviate VAD is an increase in dietary
diversification. 11 The main diet for the majority of Nicaraguans
consists of rice and beans, supplemented occasionally by chicken or
fish, depending, for the most part, on the individual’s proximity to the
coast. Feasible control of VAD requires increased consumption of vitamin
A-rich foods of animal origin, along with increased consumption of
fruits and vegetables. 11
The chances of individuals being able to diversity their diets, however,
is remote, at best, as many Nicaraguans work for less than $5/day, and
the government and food distribution systems are corrupt and
ineffective. Furthermore, access to any food source other than that
available at the subsistence farming level is often difficult at the
rural level throughout the majority of the country, and food production
methods often are environmentally unsustainable, thus limiting available
food resources for consumption. Additionally, people need to use their
limited incomes to cover basic necessities other than food. All of the
above help contribute to a basic lack of food security within the
country. 6
Despite these sustained levels of food insecurity, the infant mortality
rate has declined in Nicaragua over the last 20 years, and currently
stands at 25.91 deaths/1,000 live births. 2 Yet in almost one-half of
all childhood illnesses, the illness is complicated by malnutrition.
Long-term, low-quality food, badly balanced nutrition, and failure to
switch to weaning food because of poverty or lack of nutritional
knowledge all potentially result in chronic VAD, and general growth and
failure to thrive related issues.15
B) Anemia
The symptoms of iron deficiency anemia include weakness, fatigue and
reduced physical ability to work. Improving childhood nutrition, coupled
with iron supplementation, has been associated with modest but
significant improvements in a wide range of cognitive measures, as
children grow and develop. Interventions to reduce anemia of any
severity among women and children have been shown to reduce the risk of
death by about 20% for each 1 g/dL increase in hemoglobin count. 14
In 1993, Venezuela began a national program to fortify maize and wheat
flour with iron. After the program began, iron deficiency in a survey of
children aged 7, 11 and 15 in Caracas was reduced from 37% to 15% in two
years, and the prevalence of anemia was reduced from 19% to 10%. 13
It is unknown at this time whether a similar fortification program in
Nicaragua would be equally effective. Effectiveness varies with a number
of factors, including patterns of consumption of fortified foods, costs
associated with the food vehicle chosen for fortification and the degree
of dispersion of food processing facilities. Often, the concentration of
food processing facilities in one city or area makes it harder to obtain
fortified food outside of the existing area. 13 In addition, the
continuing lack of a functioning governmental system persists, resulting
in Nicaragua’s inability to assist its people in obtaining even the most
basic health care needs, let alone providing for increased vitamin and
mineral fortification of its limited food resources.
There are several other strategies that have also been shown to be
effective in reducing iron deficiency anemia in addition to the
fortification of commonly consumed food products. These include control
of malaria by preventative treatment programs, including outdoor and
indoor spraying, use of screens and insecticide-treated bed nets, and
reduction of water sources as a breeding ground for insects and
mosquitoes. Control of hookworms as part of a routine health care
prevention program has also been shown to be effective in reducing
anemia in women and children, as well as programs to encourage
reductions in the number of pregnancies and optimal birth spacing.14
National strategies need to be developed in Nicaragua through integrated
intervention programs to address the multiple causes of anemia. Improved
health care coordination among local, regional, national and
international agencies, networks and community groups also needs to be
developed. 14
6. Conclusion and Recommendations
In view of the challenges to implementation of rapid and large-scale
food-based interventions, supplementation is currently the primary
strategy to control VAD. Currently this remains one of the key
interventions for improving childhood and maternal anemia and the
survival of young children in Nicaragua, along with food fortification
and parasitic disease control. 11
In addition, adoption of a strategy linking supplementation to
immunization campaigns or health rallies helps to achieve high coverage
rates. Non-governmental organizations can significantly contribute to
expanding government coverage in rural areas where public health sector
coverage is spotty or non-existent. 12 Childhood feeding practices are a
crucial proximal determinant of child growth and morbidity. Because so
many children are weaned prematurely, many Nicaraguan children receive
their entire requirement of vitamin A from food and not breast milk. 16
In Nicaragua and throughout Latin America, little has been done to
quantify the association between overall feeding behaviors and childhood
health outcomes. Childhood feeding is one of the most important aspects
of child care giving that is now increasingly recognized as a key
determinant of childhood nutrition, along with food security and
availability of health services. 17
Growing environmental degradation is a problem that exacerbates poverty
among women, children and their families. Poverty and its interaction
with the environment increase already high levels of social and
environmental vulnerability, and contribute to health disparities among
women and children in Nicaragua. 10
Additional efforts need to be made to support and improve the creation
of better community water and sanitation systems. Less than half of the
Nicaraguan population has access to adequate sanitation facilities, and
one-third lack access to improved drinking water sources.1,4
Preventable illness such as diarrhea, intestinal infections,
malnutrition and respiratory ailments account for 46% of all infant
deaths in Nicaragua.18 On average, children attended school for 4.5
years, and in rural areas, less than 10% of all children complete the
primary school cycle.18 Poverty affects school participation, with many
families unable to afford the direct or hidden costs. Poverty also
results in child labor, which affects more than 167,000 children and
adolescents. 19 National strategies must be developed to call attention
to the need to invest in early childhood education as a means for
improving the efficiency of both the health and education sector, where
gains made through increased efficiency would more than offset
investments made within 10 years. 18
Additional strategies to combat nutritional deficiencies among women and
children in Nicaragua include high-level political and social advocacy,
strengthening national and municipal capacity, increased social
communication, and mobilization of selective support to basic services
and supplies. These approaches will help to combine international,
national and municipal interventions, while mobilizing and strengthening
allies and partners at all levels. 19
Community groups can also assist in nationwide efforts to improve the
health of women and children by promoting breast feeding, along with
promoting identification and early treatment of childhood diseases. In
addition, improving healthcare for pregnant mothers in the home and
community, improving personal, family and community hygiene practices,
and improving health care coordination among networks and community
groups all help to contribute to the health and well being of Nicaraguan
women and children. 20 Overall, an assessment of child nutritional
status not only provides a means of evaluating child health, but also
reflects various underlying social issues in the community.17
While some progress has been made in the prevention and treatment of
these and other nutritional deficiencies and diseases among the
Nicaraguan population, much more remains to be done to assist those most
vulnerable and most in need. Overall improvement in standards of living
and quality of life issues continue to remain an illusive goal for most
of the poorest residents of one the poorest countries in the world.
7. References
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