Animal Source Foods to Improve Micronutrient Nutrition and Human Function in Developing Countries

The Need for Animal Source Foods by Kenyan Children1,2

Nimrod O. Bwibo*3 and Charlotte G. Neumanny
*Department of Pediatrics, Faculty of Medicine, University of Nairobi, Nairobi, Kenya and y Department of Community Health Sciences and Pediatrics, Schools of Public Health and Medicine, University of California Los Angeles, Los Angeles, CA
ABSTRACT Food intake and dietary patterns in Kenyan households have been studied since the 1920s. Reports on breastfeeding, nutrient intake, micronutrient deciencies and the impacts of malaria and intestinal parasites on nutritional status are reviewed. Diets are mainly cereal-based, with tubers and a variety of vegetables and fruits when available. White maize, sorghum and millet are high in phytate and ber, which inhibit the absorption of micronutrients such as zinc and iron. Communities growing cash crops have little land for food crops. Although households may own cattle, goats and poultry, commonly these are not consumed. Adults in nomadic communities consume more meat than nonpastoralists. Lakeside and oceanside communities do not consume adequate amounts of sh. Poor households have a limited capacity to grow and purchase food, therefore they have more nutrient deciencies. Early weaning to cereal porridge deprives the infant of protein and other nutrients from human milk. Other milk is consumed only in small amounts in sweetened tea. Older children eat adult diets, which are extremely bulky and hard to digest. Anemia is mainly due to iron deciency, malaria and intestinal parasites. In general, Kenyan children have inadequate intakes of energy, fat and micronutrients such as calcium, zinc, iron, riboavin and vitamins A and B-12. The multiple micronutrient deciencies may contribute to early onset of stunting and poor child development, whereas lack of calcium together with vitamin D deciency are responsible for the resurgence of rickets. There is an urgent need to increase the intake of animal source foods by Kenyan children. J. Nutr. 133: 3936S3940S, 2003. KEY WORDS:  Kenya  animal source foods  anemia  micronutrients  child feeding

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Historical perspective: 19021935 Research on food intake and nutrition in Kenya has been carried out by individuals, groups, institutions and government bodies. Information has been collected from medical documents, surveys and intensive research projects. In their historical review of research on food and nutrition, Jansen et al. (1) reported early studies showing that Kenyan diets were mainly cereal- based with few animal source foods (ASF)4. In his diary, Meinetzhhagen (19021906) recorded the results

1 Presented at the conference Animal Source Foods and Nutrition in Developing Countries held in Washington, D.C. June 2426, 2002. The conference was organized by the International Nutrition Program, UC Davis and was sponsored by Global Livestock-CRSP, UC Davis through USAID grant number PCE-G-00-98-00036-00. The supplement publication was supported by Food and Agriculture Organization, Land OLakes Inc., Heifer International, Pond Dynamics and Aquaculture-CRSP. The proceedings of this conference are published as a supplement to The Journal of Nutrition. Guest editors for this supplement publication were Montague Demment and Lindsay Allen. 2 This research was supported by the GL-CRSP through the Ofce of Agriculture of the United States Agency for International Development under Grant No. PCE-G-00-98-00036-00 to the GL-CRSP. 3 To whom correspondence should be addressed. E-mail: Thebwibos@ wananchi.com. 4 Abbreviations used: ASF, animal source foods; CBS, Central Bureau of Statistics; CRSP, Collaborative Research Support Program; CSD, Child Survival Project; VAD, Vitamin A deciency; WHO, World Health Organization.

of a food survey in Nyeri, Central Province. The main food crop produced and consumed was multicolored or yellow maize. A series of three reports and mimeographed notes (19281935) about the Digo community of the coastal region revealed that yellow maize was grown. When it was replaced by white maize, vitamin A deciency appeared in the form of night blindness. Leakey, in his study of the Kikuyu people, observed that white maize was the common cereal among the Southern Kikuyu community of Central Province (2). Maize was consumed together with beans. Households that kept cattle still consumed cereal foods. When the planting of cash crops (coffee and tea) was introduced, there was a change in diet from traditional dishes of maize and vegetables to purchased bread, rice and ready-made maize our (1). Leakey observed that although the Kikuyu kept cattle, goats and sheep, which played a very important part in their religious ceremonies and social life, little meat was consumed in the daily diet (2). In a historic account about prehistoric people (3), the early Kikuyu were observed to be vegetarians whose main foods were cereals, legumes, root crops and greens. This was conrmed by a later study of the indigenous diet (4). A similar lack of consumption of ASF was reported later by Paterson (5), who noted that although the Kikuyus produced milk, eggs and meat in addition to vegetables and fruits, these were sold rather than consumed, and diets had very little diversity (5). Gilks expressed the same concern in 1933 (6)

0022-3166/03 $3.00 2003 American Society for Nutritional Sciences.

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when he reported that animal protein was consumed much less than vegetable protein. He also noted a lack of iron and iodine in the diet (6). Disease incidence and the diet of people at Lake Magadi were examined by McNab in 1927 (7). He noted that the diets were lacking in fresh vegetables and meat. Although he found no cases of scurvy related to the low intake of vegetables, he occasionally encountered cases of night blindness, thus providing an early documentation of vitamin A deciency in that community (7). Animal source protein Raymond (8) described the dietary requirements of African children and noted the absence of appreciable amounts of animal protein in the diets. He recommended that ASF should be produced, made available and consumed (8). Schoeld had earlier made a strong plea for round-the-clock breastfeeding to ensure adequate intake of milk, and for cows milk to be given only when absolutely necessary (9). Household food consumption and nutrition surveys, carried out by Bohdal in 19641968 for UNICEF and World Health Organization (WHO), revealed that Kenyan diets were monotonous, cereal-based and unevenly distributed within the household. Energy intake was low and contributed mainly by carbohydrate in the form of maize, with plant proteins contributing ;12% of the total energy (10). Bohdal reported that intake of animal proteins was very low, contributing 0.510% of the total protein consumed. Meat was eaten very occasionally by subsistence farmers who owned a few animals, although most village markets had butcheries. Nomadic communities consumed more meat, but on the whole their energy intake was quite low and consumption of wild game was only occasional. In communities living around Lake Victoria, a fresh lake, 2530% of the protein supply was from sh. The quality of protein, expressed as a protein score, was below 65%. In the preharvest season, food intake was precarious in many communities and the protein score of most families fell below 50%. The intake of other essential nutrients, such as vitamin A, riboavin and vitamin C, was very low. The nutrition and health status of people in an irrigation scheme (Mwea-Tebere Irrigation Scheme) were studied by Korte in the late 1960s (11). He found that meat and eggs were consumed on average 1 and 3 times/mo, respectively (11). In 1974, Likimani emphasized that the major nutritional problem in Kenya was inadequacy of protein food. He also noted that the introduction of cash crops affected the production of food crops adversely; he stressed the need for cooperation between the Ministries of Health and Agriculture and the Wildlife department and he emphasized the need to improve protein production because the nutrition situation was deteriorating (12). Weaning practices In 1974 Blankhart surveyed the nutritional status and feeding of children ,3 y of age among families of staff at Kenyatta National Hospital (13). Exclusive breastfeeding for 6 mo was practiced by most mothers. This contrasted sharply with practices in a slum community, Mathare Valley, where children ,6 mo of age were already receiving cereal porridge with little or no milk (13). Kinoti and Mbugu studied breastfeeding and supplementation in a small urban area of Thika and found that cows milk and commercial formulas were used commonly (14). Children were weaned onto cows milk at the age of 34 mo. The

explanations given for this early weaning were that the child was thought to be hungry because of an inadequate supply of breast milk, that the child was crying, or that the mother had to go to work. Early weaning was also noted in a survey in a large coffee estate, where 60% of the mothers started supplementary feeding when their infants were aged 4 mo, and 85% were weaned by 6 mo. The supplementary foods included porridge, bananas, potatoes, cows milk and even commercial baby foods. A similar study in 1964 showed that 64% of the weaning diets contained no protein-rich foods, and milk was the only protein source consumed (15). Among those attending a health center in Western Province, Kenya in 1983, nearly all children had been weaned by 24 mo, and introduction of solid foods was started at a young age (16). Another survey among the ,5-y-old children in a suburban area of Nairobi, conrmed a decline in breastfeeding, and reported that at age 24 mo only 4% of mothers were still breastfeeding (17). Reasons given were that the child refused to nurse, the child was considered to be too old, there was no milk in the breast, the breast was sick, or the mother was pregnant (17). In contrast, Muirs study on feeding practices in East Pokot found a higher intake of ASF by infants and young children, with breastfeeding discontinued at a median age of 26.6 mo. In a small number of cases, breastfeeding was continued for 48 mo (18). Machakos studies The Machakos project in the late 1970s in Eastern Province, Kenya (a joint project of the Medical Research Center of Kenya and the Dutch government) provided much useful information (1923). Food intake and feeding habits varied by ecological zones and by season. The diet was maize-based, and included potatoes and various beans and vegetables. Poorer households had less land, produced less food, had less food storage and had little purchasing power (20). Breastfeeding was very successful and practiced for a prolonged period (1624 mo). Exclusive breastfeeding lasted 5 mo on average, but no child was weaned before the age of 1 y unless there was a pregnancy. Cows milk and occasionally goats milk were introduced when the infant was aged 14 mo. Porridge made from maize our was usually very dilute with a low energy density, and given 45 times/d in the rst 2 y of life. Thereafter, a young child was fed the family diet 4 times/ d (2427). The average daily energy intake increased from 500 kcal (2100 kj, 94% of the recommended intake in Kenya) at 02 mo, to 1100 kcal (4620 kj, 94% of the recommended intake) at 3035 mo. The lowest recorded energy intake was 7779% of the recommended intake at age 38 mo (28). The investigators recommended increasing the thickness of porridge, and adding more our, milk and sugar to increase energy density. For older children, they recommended that milk be given with ugali (2527). Again there was no mention of ASF apart from cows or goats milk. Iron intake in the rst half-year was low because milk is poor in iron. Before 18 mo, calcium intake was ,60% of the recommended level. The growth of preschool children began faltering as early as 34 mo of age, when energy intake was most limited. It was concluded that toddlers diets were otherwise quantitatively and qualitatively adequate for maintaining proper growth, but not for reversing the decit in nutrients noted earlier (28). However, no mention was made of micronutrient adequacy. The Central Bureau of Statistics (CBS) of the government of Kenya carries out extensive periodic surveys that generate much valuable information on the nutritional status and feeding patterns of both rural and urban children (2933). The

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surveys from 1977 to 1994 revealed that there was a progressive decline in breastfeeding throughout the country. This decline reduced the opportunity for the young child to benet from protein and other nutrients in breast milk, because their complementary foods were devoid of ASF. The surveys also conrmed that weaning was occurring early with the child introduced to cereal porridges. In some cases cows or goats milk was added to the porridge, but in most cases it was not. Hence, the child was fed a predominantly carbohydrate diet, low in protein. At 3 mo of age, 28.2% of the children were stunted. The situation became worse, so that by 24 mo, 41.6% were stunted. Wasting was less common, 5.8% at age 3 mo and 4.2% by age 24 mo. Cases of severe frank malnutrition such as marasmus or kwashiorkor were encountered in these surveys. Given the negligible consumption of ASF, there is no doubt that multiple micronutrient deciencies contributed to the poor nutritional status. Vitamin A deciency Vitamin A deciency (VAD) in Kenya was identied as early as 1928 by Phillip, who reported deciency among coastal people (1). In 1938 he found night blindness in varying degrees in 45% of school children in Nairobi, and 44% of the people surveyed in Githunguri, although he believed that the intake of vitamin A was high. Bohdal showed that the majority of families surveyed consumed ,60% of the recommended daily allowance of vitamin A (10). In 1974 Franken found xerophthalmia in patients with measles in East Africa (34). Sinabulya found cases of night or other blindness in the Machakos district in 1976, which he attributed to vitamin A deciency (35). Also in 1976, Sauter studied xerophthalmia and measles in Kenya and found that vitamin A deciency was widespread (36). This was doubted by various workers (3739), which led Jansen and Horelli (40) to review the evidence for vitamin A deciency in Kenya. They documented that VAD was common. Recognizing that micronutrient deciencies increase the risk of morbidity and mortality in young children, the government of Kenya, with assistance from UNICEF, embarked on surveys of micronutrient status. The objectives of the surveys included determination of the prevalence, extent, magnitude and severity of vitamin A deciency (VAD) in children aged 672 mo, its geographical distribution, risk groups and the identication of locally available resources that could be harnessed for its alleviation. The assessment of vitamin A status included serum retinol, night blindness, conjunctival xerosis, Bitots spots and corneal xerosis. The survey showed that without exception, there was patchy geographical distribution of severe, moderate, and mild VAD in all the sampled districts. This disproved the previous assumption that VAD was not a signicant public health problem in Kenya. Vitamin A deciency was considered to be caused by a low consumption of vitamin A rich foods, early cessation of breastfeeding, low dietary fat and a high prevalence of intestinal parasites that could impair its absorption (41). In 1994 in South Nyanza, Ngare and Kennedy reported a 13% prevalence of serum retinol ,0.35 mmol/L, and a 45% prevalence of values ,0.7 mmol/L. This makes vitamin A deciency a serious health problem in children in that part of the country (42). In a recent VAD survey, children aged 611 mo were the most affected by VAD, followed by those aged 1224 mo, with serum retinol ,0.35 mmol/L in 11.2% and 9.6% respectively. Serum retinol ,0.7 mmol/L was found in 40.7% of children

aged 611 mo, followed by 34.9% of those aged 1224 mo. The lowest prevalence occurred at age 6072 mo, with 6.8% and 31.3% serum retinol values ,0.35 and ,0.7 mmol/L, respectively. All degrees of VAD occurred in all the surveyed districts, thus conrming the ndings of the previous workers that VAD deciency was a serious public health problem in Kenya at that time. An important study showed that the consumption of foods rich in provitamin A, dark green leafy vegetables, were not followed by a rise in serum retinol concentration (43). The question arose as to whether absorption of vitamin A was impaired, perhaps by intestinal worms. A recent concern is that the conversion rate of b-carotene to retinol is not as efcient as was once believed. The severity of VAD was noted to be worst in the Lake Basin and the Western highlands, both malaria-endemic areas. In a subsample of 926 children, those aged ,6 mo had the highest proportion (34.3%) of severe retinol deciency (3.5 mmol/L). Malaria parasitaemia was associated with low serum retinol values (p , 0.01) (43). Supplementation with high dose vitamin A capsules was implemented as a short-term solution, while evaluating the feasibility of fortifying a suitable food carrier. The best overall strategy was considered to be dietary diversication and improvement of dietary quality. Anemia, iron and zinc deciencies The government of Kenya, with the assistance of UNICEF, determined the prevalence of anemia and iron, vitamin A and zinc deciency countrywide (44). The mean hemoglobin concentration in children was below the cutoff of 108 g/L for anemia, adjusted for altitude. For infants ,6 mo, the overall average hemoglobin for all children surveyed was 96.3 g/L, and at age 672 mo it averaged 101 g/L. Hemoglobin levels were lower in lake basin and coastal areas (the malaria endemic regions), than in the nonmalarial highland areas. Among children 672 mo of age, prevalence was 17.1%, 41.5% and 11.0% for mild, moderate and severe anemia, respectively. The prevalence was higher in infants aged ,6 mo, in whom the corresponding prevalences were 37.4%, 45.7% and 13.4%, respectively. As for iron status, 19.5% of children had a serum ferritin concentration ,2.2 mmol/L. Overall, a very high prevalence of low serum ferritin was recorded in some semiarid areas. The prevalence of marginal, moderate and severe iron deciency was relatively uniform across all age groups. The prevalence and intensity of malaria, hookworm and schistosomiasis varied greatly in the surveyed areas and increased the risk of anemia. Plasma zinc was determined in a subsample of 541 children, and ranged between 8.7 and 13.5 mmol/L with an overall sample mean of 10.2 mmol/L. The proportion of children with low serum zinc (#10.2 mmol) was 50.8%. In semiarid areas such as Garissa, a pastoralist region, the higher intake of meat was associated with markedly higher average concentrations of serum zinc (13.0 mmol/L) than in other clusters. Clusters in malarial regions had a higher prevalence of low serum zinc (60 90%). The risk of zinc deciency was signicantly associated with malaria-parasitaemia and diarrhea (44). As zinc promotes linear growth, the low intake may contribute to the high prevalence of childhood stunting. Resurgence of rickets Rickets is reemerging in Kenya. Phillip reported 45 cases of rickets through the analysis of records in one hospital in Central Province in 19261930 (1). The Nutrition CRSP in Kenya

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project did not nd clinical evidence of rickets in the Embu children that were studied in the early 1980s. It was surprising that several cases of rickets were encountered in the recent Child Survival Project (CSP), carried out in the same area in Embu. The toddlers were enrolled in a feeding intervention study from 20002003. Twenty-four such cases were diagnosed clinically out of 324 children registered for the CSP project. The children with rickets shared the following risk factors: short breastfeeding duration, vegetable and cereal-based complementary foods with negligible cows or goats milk, and connement indoors when the mothers were cultivating the elds. The children, aged 1836 mo, included three sets of twins. Multiple factors are at play here, including a low intake of milk and hence of calcium and phosphorus, no intake of ocean sh hence a low vitamin D intake, and perhaps reduced exposure to sunshine and ultraviolet light. All these factors operate jointly, but the lack of milk in the diet was a major factor. The affected children were provided with milk supplements and vitamin D-3 for 1 mo, which caused a noticeable regression of their rickets. The Kenya school milk program To address the problem of low milk intake in schoolers and kindergarten children, the daily provision of milk to children during midmorning sessions at school was a promising strategy. The program was started in 1982 by the president of the Republic of Kenya, to alleviate hunger among children, many of whom went to school on an empty stomach and appeared to have difculty concentrating in class in the late morning. This program continued for several years in the 1980s but was then abandoned for lack of funds to sustain it. Unfortunately, this program was not evaluated. The program was short-lived due to the rapidly expanding population of school children. At present, only sporadic and short-term school milk programs are in existence, usually sponsored at times of drought by the World Food Program. Lessons from the nutrition Collaborative Research Support Program (CRSP) The Nutrition CRSP longitudinal observational study in Embu entitled, Energy Intake and Human Function, (1982 1984), focused on mild-to-moderate energy malnutrition (45). Quantitative data were collected on food prepared and consumed by household members, including direct weighing and volume measurements of ingredients and cooked dishes, and recall of consumed foods and prepared dishes when direct measurement was not possible. Toddlers, and to a limited extent schoolers, were followed whenever possible to observe and record self-obtained snacks (46). The diet in the Embu CRSP households was generally low in energy and fat (animal and vegetable), and extremely low in ASF. Cows milk and goats milk were the main sources of animal protein, consumed mainly in sweet tea, and in small quantities. Maize was the main staple, complemented by beans. Millet and sorghum, used elsewhere in Kenya, were much less frequently consumed than maize. The phytate and ber content of the diet was extremely high. Potatoes and various vegetables were eaten as available. Fruits such as mango, papaya, avocado and banana were consumed in season. Energy intake was particularly low in most of the households. Boys and girls aged 89 y had energy intakes of 1509 6 239 kcal/d (6,338 6 604 kj) and 1344 6 209 kcal/d (4645 6 878 kj), respectively. This was 78% of their Re-

commended Daily Allowance, with only 6% of the energy coming from ASF. The situation was worse among the toddlers aged 1830 mo, whose energy intake met 73% and 70% of their RDA, for boys and girls, respectively. ASF, meat, sh and fowl were rarely if ever consumed. Hence there was an inadequate intake of micronutrients: iron, zinc, vitamin A, vitamin B-12, riboavin and calcium. The dietary iron and zinc was made relatively unavailable by the high phytate and ber in the diet. Anemia was common, due to iron deciency, but compounded by malaria and hookworm infestation. Mean hemoglobin levels were 121, 107 and 109 g/L for the same childhood age groups, respectively, with a prevalence of anemia over 50% in all groups. Toddlers aged 1230 mo demonstrated very little severe malnutrition, but 27% and 30% were stunted and moderately underweight, respectively. Stunting started early during infancy. Zinc deciency, which was not known to exist in Kenya before this study, may have played a role in the stunting among these children. There was no clinical evidence of vitamin A deciency or rickets. However, malnutrition was encountered depending on the season with 2748% of all school-age children moderately malnourished and 1.5% severely so. Functional outcomes of diet quantity and quality were studied. Based on monthly quantitative food intake data, the children who consumed the smallest amount of ASF, mainly meat, performed the least well on cognitive tests, verbal comprehension and abstract and perceptual abilities, as tested by the Ravens matrices (47). In addition, school children who consumed the fewest animal products were the least attentive in the classroom, less active physically, less happy and showed the least leadership behavior in the playground (48). Such children also exhibited the greatest decit in linear growth (49). Conversely the children who consumed ASF, particularly meat, performed better on cognitive tests, had better growth and less morbidity, were more attentive in the classroom and more active in the playground than those who consumed no ASF. This association remained positive even after statistical control for a large number of covariables and confounding factors such as socioeconomic status, morbidity and parental literacy. Stunting was prevalent, occurring in 30% of the children (49). These ndings suggest the benet of ASF in the diet of the Kenyan children. Nonetheless, the above ndings were based on observational studies. A randomized controlled feeding intervention study was needed to establish a causal relationship between ASF, both meat and milk, and functional outcomes. This led to the randomized controlled intervention feeding study to test whether there is a causal relationship between intake of ASF, such as milk or meat, and cognitive function, activity, growth, development and morbidity. The design, methods, conduct and early results are described by authors in this supplement. The need to address the low intake of ASF by children in Kenya is obvious. The literature review shows the persistent lack of ASF in the diets of young and older children, and the predominance of carbohydrate in the cereal-based diets. Breastmilk is often interrupted early by the introduction of porridge or gruel from cereals, with little or no addition of cows or goats milk. As the child grows, the main foods remain cereal-based, initially as overdiluted porridge/gruel and later, as bulky solids. The diluted foods have a low energy content, whereas the bulky solid foods cannot be eaten in large enough amounts to provide the required energy. Feeding frequency may not be frequent enough to provide adequate quantities of nutrients. The solid foods are not eaten with milk. Almost no meat, sh or fowl is consumed by children even if available.

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21. Ochere, S. R. (1982) The Pattern of Food Production, Availability and Intake of People of Eastern Kenya. The Case of North-Western Machakos. Doctoral thesis. University of Reading, Reading, UK. 22. Van Steenbergen, W. M., Kusin, J. A. & Onchere, S. R. (1987) Household activities and dietary patterns In: Maternal and Child Health in Rural Kenya. An Epidemiological Study. (Van Ginneken, J. K. & Muller, A. S., eds.) Croom Helm, London, UK and Sydney, AU. 23. Van Steenbergen, W. M., Kusin, J. A. & Onchere, S. R. (1978) Machakos Project Studies VIII. Food resources and eating habits of Akamba households. Trop. Geogr. Med. 30: 393401. 24. Van Steenbergen, W. H., Kusin, J. A., Norbeck, H. J. & Jansen, A. A. J. (1984) Food consumption of different household members in Machakos Kenya. Ecol. Food Nutr. 14: 119. 25. Van Steenbergen, W. M., Kusin, J. A., Van Rens, M., de With, K. & Jansen, A. A. J. (1980) Measured food intake of pre-school children in Machakos District. East Afr. Med. J. 62: 734743. 26. Van Steenbergen, W. M., Kusin, J. A., Voohere, A. M. & Jansen, A. A. J. (1978) Machakos Project Studies IX. Food intake, feeding habits and nutritional state of the Akamba. Infants and toddlers. Trop. Geogr. Med. 30: 505516. 27. Van Steenberger, W. H., Kusin, J. A. & Jansen, A. A. J. (1984) Food consumption of preschool children. In: Maternal and Child Health in Rural Kenya: An Epidemiological Study. (Van Ginneken, J. K. & Muller, A. S., eds.) Croom Helm, London, UK and Sydney, AU. 28. Van Steenbergen, W. M., Kusin, J. A. & Jansen, A. A. J. (1980) Measured food intake of pre-school children in Machakos District. East Afr. Med. J. 57: 734742. 29. Central Bureau of Statistics. (1977) The Rural Kenyan Nutrition Survey. Social Perspectives 2: No. 4. Nairobi, Kenya. 30. Central Bureau of Statistics. (1977) First Rural Child Nutrition Survey. Ministry of Economic Planning and Community Affairs, Republic of Kenya. UNICEF, Nairobi, Kenya. 31. Central Bureau of Statistics. (1980) Report of the Child Nutrition Survey 1978/1979. Ministry of Economic Planning and Development. Nairobi, Kenya. 32. Central Bureau of Statistics. (1983) Third Rural Kenyan Nutrition Survey, 1982. Ministry of Finance and Planning. Nairobi, Kenya. 33. Central Bureau of Statistics. (1994) Fifth Nutrition Survey, Ministry of Planning and National Development, Republic of Kenya. UNICEF, Nairobi, Kenya. 34. Franken, S. (1974) Measles and xerophthalmia in East Africa. Trop. Geogr. Med. 26: 3946. 35. Sinabulya, P. M. (1976) An assessment of the extent of blindness in Machakos District. East Afr. Med. J. 53: 6469. 36. Sauter, J. M. (1976) Xerophthalmia and Measles in Kenya. Doctoral thesis. Van Denderen, Gronigen, The Netherlands. 37. Whiteeld, R. & Dekkers, N. W. H. M. (1978) A critique of Dr. Santers thesis, Xerophthalmia Club Bull. 10. 38. Jansen, A. A. J. & Alnwick, D. (1979) In: The Katilu Irrigation Scheme in Turkana District, Kenya. (McCarthy, ed.). FAO/ Ministry of Economic Planning, Nairobi, Kenya. 39. Kusin, J. A., Van Rens, M., Lakhani, S. & Jansen, A. A. J. (1980) Vitamin A status of pregnant and lactating women as assessed by dietary and serum levels in Machakos Kenya. East Afr. Med. J. 65: 3441. 40. Jansen, A. A. J. & Horelli, H. T. (1982) Vitamin A deciency in Kenya past and present. East Afr. Med. J. 59: 107111. 41. UNICEF. (1994) Vitamin A deciency in Kenya. A Report of National Micronutrients Survey. Government of Kenya and Kenya Country Ofce, Nairobi, Kenya. 42. Ngare, D. & Kennedy, E. (1994) Vitamin A Nutritional Status of School Children in South Nyanza, Western Kenya. IFPRI Research Reports, Washington, DC. 43. De Pee, S., West, C. E., Muhilal, D. K. & Hautvast, J. (1995) Lack of improvement in vitamin A status with increased consumption of dark green leafy vegetables. Lancet 346: 7581. 44. Government of Kenya. (1999) Anaemia and status of iron, vitamin A and zinc in Kenya. The 1999 National Survey Report. UNICEF, Nairobi, Kenya. 45. Neumann, C. G., Bwibo, N. O. & Sigman M. (19891992) Final Report Phase II: Functional Implications of Malnutrition. Kenya Project Human Nutrition Collaborative Research Support Program, USAID Ofce of Nutrition, Washington, DC. 46. Murphy, S. P., Weinberg, S. W. & Neumann, C. G. (1999) Randomized clinical trial comparing different nutrient data bases. An example using foods consumed in rural Kenya. J. Food Comp. Anal. 3: 115. 47. Sigman, M., Neumann, C. G., Jansen, A. A. J. & Bwibo, N. O. (1989) Cognitive abilities of Kenyan children in relation to nutrition, family characteristics and education. Child Dev. 60: 14631474. 48. Espinosa, M. P., Sigman, M., Neumann, C. G., Bwibo, N. O. & McDonald, M. A. (1992) Playground behavior of school-aged children in relationship to nutrition, schooling, and family characteristics. Dev. Psychol. 28: 11881195. 49. Neumann, C. G. & Harrison, G. G. (1994) Onset and evolution of stunting in infants and children. 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There is a great need for more ASF, both meat and milk, to provide high quality protein and micronutrients for growth and development, including iron, calcium, zinc, vitamin B-12, riboavin, vitamin A and vitamin D. Because infections such as malaria and intestinal parasites have deleterious effects on micronutrient intake and absorption, their roles should also be addressed. Factors such as cultural barriers and food taboos that may hinder the intake of ASF foods, and knowledge about the importance of ASF, especially meat and milk, should be addressed through appropriate nutrition education. There is a great need for the health, nutrition, and livestock sectors to work collaboratively. ACKNOWLEDGMENTS
We wish to acknowledge the assistance of all the data entry staff of Child Nutrition Project, and in particular Bernice Gitiri Laban, Martin Ayub Ehenzo and David Maina Gichobi who typed the nal manuscript. I also acknowledge the assistance of Benta Shako of the UNICEF Kenya Country Ofce for providing a copy of the report by Gok et al. (44).

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LITERATURE CITED
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