Chapter II

Review of Related Literature and Studies

I. Foreign

Introduction

“The world produces enough food to feed every man, woman and child on earth. Hunger

and malnutrition therefore are not due to lack of food alone, but are also the

consequences of poverty, inequality and misplaced priorities.” – UNICEF Deputy

Executive Director, Kul C. Gautam (Executive speech, To the World Food Summit: Five

Years Later, 11/6/02)

Proper nutrition is a powerful good: people who are well nourished are more likely to be

healthy, productive and able to learn. Good nutrition benefits families, their communities

and the world as a whole.

Malnutrition is, by the same logic, devastating. It plays a part in more than a third of all

child deaths in developing countries. It blunts the intellect, saps the productivity of

everyone it touches and perpetuates poverty.

Although fewer children are undernourished than in the 1990s, 1 in 4, or 143 million

under-five children in the developing world are still underweight and only 38 per cent of

children less than six months are exclusively breastfed. While significant progress has

been made in relation to vitamin A supplementation and salt iodization, micronutrient

deficiencies remain significant public health problems in many countries. It is essential

to address under nutrition if there is any hope of achieving the Millennium Development

Goals (MDGs).

Malnutrition is called an “invisible” emergency because, much like an iceberg, its deadly

menace lies mostly hidden from view. Each year malnutrition is implicated in about 40%

of the 11 million deaths of children under five in developing countries, and lack of

immediate and exclusive breastfeeding in infancy causes an additional 1.5 million of

these deaths. However, contrary to popular belief, only a fraction of these children die

from starvation in catastrophic circumstances such as famine or war. In the majority of

cases, the lethal hand of malnutrition and poor breastfeeding practices is far more subtle:

they cripple children’s growth, render them susceptible to disease, dull their intellects,

diminish their motivation, and sap their productivity. ( http://www.unicef.org)

What is malnutrition?

Malnutrition is a disparity between the amount of food and other nutrients that the body

needs and the amount that it is receiving. This imbalance is most frequently associated

with undernutrition, the primary focus of this article, but it may also be due to

overnutrition.

Chronic overnutrition can lead to obesity and to metabolic syndrome, a set of risk factors

characterized by abdominal obesity, a decreased ability to process glucose (insulin

resistance), dyslipidemia, and hypertension. Those with metabolic syndrome have been

shown to be at a greater risk of developing type 2 diabetes and cardiovascular disease.

Another relatively uncommon form of overnutrition is vitamin or mineral toxicity. This is

usually due to excessive supplementation, for instance, high doses of fat-soluble vitamins

such as Vitamin A rather than the ingestion of food. Toxicity symptoms depend on the

substance(s) ingested, the severity of the overdose, and whether it is acute or chronic.

Undernutrition occurs when one or more vital nutrients are not present in the quantity that

is needed for the body to develop and function normally. This may be due to insufficient

intake, increased loss, increased demand, or a condition or disease that decreases the

body’s ability to digest and absorb nutrients from available food. While the need for

adequate nutrition is a constant, the demands of the body will vary, both on a daily and

yearly basis. (http://www.labtestsonline.org)

When a person is not getting enough food or not getting the right sort of food,

malnutrition is just around the corner. Disease is often a factor, either as a result or

contributing cause. Even if people get enough to eat, they will become malnourished if

the food they eat does not provide the proper amounts of micronutrients - vitamins and

minerals - to meet daily nutritional requirements.

Malnutrition is the largest single contributor to disease, according to the UN's Standing

Committee on Nutrition (SCN).

Impaired health caused by a dietary deficiency, excess, or imbalance. To support human

life, energy (from fat, carbohydrate, and protein), water, and more than 40 different food

substances must be obtained from the diet in appropriate amounts. Malnutrition can result
from the chronic intake of any of these substances at levels above, as well as below,

ranges that are adequate and safe, but commonly the term refers only to deficient intake.

The number of people throughout the world who suffer from nutritional deficiencies as a

result of inadequate dietary intake is uncertain, but even the most conservative estimates

place that figure at hundreds of millions; many experts consider the actual number to

approach 1 billion. Most malnourished people live in developing countries where income,

education, and housing are inadequate to buy, transport, store, and prepare food and

where nutritional deficiencies are almost always related to poverty. In industrialized

countries, chronic conditions of deficient dietary intake occur far less frequently but are

reported occasionally among people who are dieting to lose weight, fasting, or on an

unusually restrictive (“fad”) diet. Pregnant women, infants, and children are most at risk

for inadequate dietary intake because their nutritional requirements are relatively high.

Nutritional deficiencies also occur as a result of illness, injury, or alcohol or drug abuse

that interferes with appetite; the inability to eat; defective digestion, absorption, or

metabolism of food molecules; or disease states that increase nutrient losses. Secondary

malnutrition has been observed frequently among medical and surgical patients who are

treated in hospitals for prolonged periods of time. Regardless of cause, the effects of

malnutrition can range from minor symptoms to severe syndromes of starvation, protein-

calorie malnutrition, or single-nutrient deficiencies.

The chronic intake of energy below the level of expenditure induces rapid losses in body

weight and muscle mass accompanied by profound changes in physiology and behavior.

Together, these effects cause a starving person to become weak, apathetic, depressed, and
unable to work productively and to do whatever is necessary to reverse the malnutrition.

The consequences of nutritional deficiencies are seen first in tissues that are growing

rapidly. These changes are most evident in the gastrointestinal tract, skin, blood cells, and

nervous system as indigestion, malabsorption, skin lesions, anemia, or neurologic and

behavior changes. Of special concern is the loss of immune function that accompanies

severe malnutrition.

The combined effects of malnutrition and infection in young children are referred to as

protein-calorie malnutrition. It classified into two entities, marasmus and kwashiorkor, on

the basis of physical appearance and the relative proportions of protein and calories in the

diet. Children with the marasmus form appear generally wasted as a result of diets that

are chronically deficient in calories as well as protein and other nutrients. Children with

kwashiorkor are also very thin but have characteristically bloated bellies due to fluid

retention and accumulation of fat in the liver, symptoms attributed to diets relatively

deficient in protein.

Deficiency conditions due to lack of a single vitamin or mineral occur rarely and usually

reflect the lack of the most limiting nutrient in a generally deficient diet. In industrialized

countries, single-nutrient deficiencies are most evident in individuals who abuse alcohol

or drugs. Classic conditions of deficiency of niacin (pellagra), thiamine (beriberi),

vitamin C (scurvy), and vitamin D (rickets) have virtually disappeared as a result of food

fortification programs and the development of food distribution systems that provide

fresh fruits and vegetables throughout the year. Iron-deficiency anemia also has declined

in prevalence, although children in low-income families remain at risk. In developing

countries, however, such conditions are still observed among people whose diets depend

on one staple food as the major source of calories. A condition of substantial current

public health importance is vitamin A deficiency, which is the principal cause of

blindness and a major contributor to illness and death among children in developing

countries.

During infancy, adolescence, and pregnancy additional nutritional support is crucial for

normal growth and development. A severe shortage of food will lead to a condition in

children called marasmus that is characterized by a thin body and stunted growth. If

enough calories are given, but the food is lacking in protein, a child may develop

kwashiorkor – a condition characterized by edema (fluid retention), an enlarged liver,

apathy, and delayed development. Deficiencies of specific vitamins can affect bone and

tissue formation. A lack of Vitamin D, for instance, can affect bone formation – causing

rickets in children and osteomalacia in adults, while a deficiency in folic acid during

pregnancy can cause birth defects.

Chronic diseases may be associated with nutrient loss, nutrient demand, and with

malabsorption (the inability of the body to use one or more available nutrients).

Malabsorption may occur with chronic diseases such as celiac disease, cystic fibrosis,

pancreatic insufficiency, and pernicious anemia. An increased loss of nutrients may be

seen with chronic kidney disease, diarrhea, and hemorrhaging. Sometimes conditions and

their treatments can both cause malnutrition through decreased intake. Examples of this

are the decreased appetite, difficulty swallowing, and nausea associated both with cancer

(and chemotherapy), and with HIV/AIDS (and its drug therapies). Increased loss,
malabsorption, and decreased intake may also be seen in patients who chronically abuse

drugs and/or alcohol.

Elderly patients require fewer calories but continue to require adequate nutritional

support. They are often less able to absorb nutrients due in part to decreased stomach acid

production and are more likely to have one or more chronic ailments that may affect their

nutritional status. At the same time, they may have more difficulty preparing meals and

may have less access to a variety of nutritious foods. Older patients also frequently eat

less due to a decreased appetite, decreased sense of smell, and/or mechanical difficulties

with chewing or swallowing. (http://www.answers.com)

Causes of Malnutrition

In the late eighteenth and early nineteenth century, the English economist Thomas

Malthus noted how increases in food production were likely to occur along a slow

arithmetic progression due to the law of diminishing returns while population growth

follows much faster, geometric progressions. His theory argued that this lag in

productivity caused food shortages, that it would lead to famines worldwide as humans

surpassed the carrying capacity of the land, and that it would create checks on socio-

cultural systems in the forms of poverty and misery as humans would earn and live off of

just enough to subsist and survive. This Malthusian argument has long since been refuted

on several grounds but has none the less served as a backdrop for understanding of the

causes of malnutrition.
The actual causes of malnutrition can be varied and complex and are difficult to

encapsulate in a single theory. Certainly, as Malthus suggests, lack of agricultural

productivity combined with increases in population can cause and are often correlated to

malnutrition. Over-cultivation, overgrazing, and deforestation lead to desertification or

otherwise impoverished soils that can not support crops or cattle for subsistence

agriculture but this scenario only accounts for malnutrition in certain, specific instances

and does not consider larger social issues such as the influence of political inequality.

Further, malnutrition can stem from impacts of natural disasters, from the results of

conflict and war, as an impact of the HIV/AIDS pandemic as a consequence of other

health issues such as diarrheal disease or chronic illness from lack of education regarding

proper nutrition, or from countless other potential factors.

Various scales of analysis also have to be considered in order to determine the

sociopolitical causes of malnutrition. For example, the population of a community may

be at risk if it lacks health-related services, but on a smaller scale certain households or

individuals may be at even higher risk due to differences in income levels, access to land,

or levels of education . Also within the household, there may be differences in levels of

malnutrition between men and women, and these differences have been shown to vary

significantly from one region to another with problem areas showing relative deprivation

of women . Children and the elderly tend to be especially susceptible. Approximately 27

percent of children under 5 in developing world are malnourished, and in these

developing countries, malnutrition claims about half of the 10 million deaths each year of

children under 5.
Often the consequences of malnutrition exacerbate its causes and form a vicious

downward spiral. For example, in cases of malnourishment, lack of sufficient nutrients

can weaken the immune system and invite infectious disease , and by compromising

digestive function, many of these diseases can intensify malnutrition. In communities or

areas that lack access to safe drinking water, these additional health risks present a critical

problem. Lower energy and impaired function of the brain also represent the downward

spiral of malnutrition as victims are less able to perform the tasks they need to in order to

acquire food, earn an income, or gain an education.

Since the time of Malthus, various new theories and approaches have developed for

understanding the truly complex mechanisms and underlying causes of malnutrition.

Most famous among recent theorists is the Indian economist and philosopher Amartya

Senwhose breakthrough 1981 book Poverty and Famines: An Essay on Entitlement and

Deprivation went beyond the Malthusian argument that lack of food production led to

hunger and demonstrated that malnutrition and famine were more related to problems of

food distribution A person’s entitlements, according to Sen, are “commodity bundles that

a person in society can command using the totality of rights and opportunities that he or

she faces,” (p.8) and famine can then be described as a collapse of entitlements for a

certain segment of society and the failure of the state to protect those entitlements.

According to the Global Hunger Index, South Asia has the highest child malnutrition rate

of world's regions. India contributes to about 5.6 million child deaths every year, more

than half the world's total. The 2006 report mentioned that "the low status of women in

South Asian countries and their lack of nutritional knowledge are important determinants
of high prevalence of underweight children in the region" and was concerned that South

Asia has "inadequate feeding and caring practices for young children".

For example, many older people in all countries have serious protein and micronutrient

deficiencies. As people age, their traditional foods may be difficult to chew, swallow or

digest, or it may seem bland, and eating then loses its appeal. They may also simply

forget to eat. And many aboriginal groups worldwide now suffer from a host of diseases

previously unknown to them such as diabetes and certain cancers. This is largely due to a

shift from more traditional diets, which included fresh meat, vegetables, fruits, legumes

and nuts, to some of the highly processed foods of the "modern" society, which are often

very nutrient-deficient. Another example would be most people from the former Eastern

Bloc and Soviet Union countries, who consume sufficient or too many calories, but who

have protein, vitamin and mineral deficiencies. The worldwide size of this group is

estimated at 2 billion people.

Over-consumption, taking in many more calories than required, is often accompanied by

a deficiency in vitamins and minerals. Many food companies sometimes exploit the

human inclination towards fatty and sugary foods by offering consumers cheap and often

nutritionally empty products. Compounded with their reduced physical activity and

greater meat consumption, these people, the overweight and obese, are a fast-growing

segment of the world's population. Ironically they often live, as the middle and upper

class, in those countries where hunger is prevalent, such as in India and China. The health

care costs, missed productivity and environmental costs associated with this group are

huge. The W.H.O. estimates this group to be 1.2 billion people worldwide.
The common thread that affects all of these groups, 4.4 billion people, is malnutrition.

(http://www.malnutrition.org)

Effects of Malnutrition

According to Jean Ziegler (the United Nations Special Rapporteur on the Right to Food

for 2000 to March 2008), mortality due to malnutrition accounted for 58% of the total

mortality in 2006: "In the world, approximately 62 millions people, all causes of death

combined, die each year. One in twelve people worldwide are malnourished. In 2006,

more than 36 millions died of hunger or diseases due to deficiencies in micronutrients".

The World Health Organization estimates that one-third of the world is well-fed, one-

third is under-fed and one-third is starving. Every 3.6 seconds someone dies of hunger.

Hunger and malnutrition have an even bigger impact on children’s health than was

previously thought. According to the World Health Organization, malnutrition is by far

the biggest contributor to child mortality, present in half of all cases. Underweight births

and inter-uterine growth restrictions cause 2.2 million child deaths a year. Poor or non-

existent breastfeeding causes another 1.4 million. Other deficiencies, such as lack of

vitamin A or zinc, for example, account for 1 million.

According to The Lancet medical journal, malnutrition in the first two years is

irreversible. Malnourished children grow up with worse health and lower educational

achievements. Their own children also tend to be smaller. Hunger was previously seen as

something that exacerbates the problems of diseases such as measles, pneumonia and
diarrhea. But malnutrition actually causes diseases as well, and can be fatal in its own

right. This is the impact The Lancet seeks to identify.

Children are not only affected by the consequences of malnourishment, but the societies

they live in suffer as well. Both severe and moderate cases of malnutrition have a

significant impact on the outcomes children face for the remainder of their lives and are

also a cause of severe illnesses leading to growth retardation both physical and mental,

and possibly death. The risk of death is not limited to only those who suffer from severe

forms of malnutrition, though the risk of death is higher among severely malnourished

children. Considering the elevated risks of mortality among children that are associated

with moderate forms of malnutrition, combined with a high prevalence worldwide, it

would seem more appropriate to distinguish that the deaths of children as a result of

malnourishment is attributable to moderate, rather than severe conditions of malnutrition.

Another factor that largely keeps malnutrition from being properly treated is a lack of

education in many developing countries. This lack of education allows cultures of

superstitions to persist. For example, in some cases in China, breast-feeding started at a

very late stage. As such, there is an increasing wide effort to implement an access for

education about proper feeding methods.

Responses to Malnutrition

In the late 1700’s, Thomas Malthus originally argued that nothing could be done as only

natural disasters could check population growth, but he later included the possibility of
voluntary limits through “moral restraint.” 1 More recently, Robert Chapman suggests

that an intervention through government policies is a necessary ingredient of curtailing

global population growth. Garret Hardin takes an anti-immigration, isolationist approach

arguing that “…all sovereign states must accept the responsibility of solving their

population problems in their own territories.” Hardin also asserts that immigration acts as

a sort of pressure release valve which allows countries to continue to ignore solving their

population problems.

Others, Amartya Sen among them, argue that other social and economic factors, such as

declining wages, unemployment, rising food prices, and poor food-distribution systems,

rather than population numbers per se, lead to malnutrition and in severe cases famine.

For Sen, “no matter how a famine is caused, methods of breaking it call for a large supply

of food in the public distribution system. This applies not only to organizing rationing

and control, but also to undertaking work programmes and other methods of increasing

purchasing power for those hit by shifts in exchange entitlements in a general inflationary

situation.”

Neoliberals advocate for an increasing role of the free market. The World Bank itself

claims to be part of the solution to malnutrition, asserting that the best way for countries

to succeed in breaking the cycle of poverty and malnutrition is to build export-led

economies that will give them the financial means to buy foodstuffs on the world market.

Poor nutrition is part of an intergenerational cycle of poverty, poor growth and unrealized

potential. UNICEF uses a holistic approach to improve the nutritional status of both
mother and child, with special emphasis on pregnancy, breastfeeding and the first three

vulnerable years of life.

Poor physical growth is linked closely to overall health and development, and affects a

third of the world’s children. UNICEF works with governments and non-governmental

organizations on a range of issues from growth monitoring to prevention and

management of childhood illnesses. At this time, UNICEF supports growth monitoring in

health facilities and communities in more than 40 countries, generating information that

is used by the immediate care takers and local health workers to assess child growth,

analyze the causes of any problems that exist, and determine necessary action.

Supporting community-based programmes

Families and communities are the key players in the battle against childhood malnutrition

and must work together to assess, analyze and take action to solve any problems.

UNICEF’s strategy is to empower community members to become their own agents of

change. UNICEF's role is to work with governments to support participatory, community-

based programmes focusing on children’s survival, growth and development.

The Tamil Nadu Integrated Nutrition programme in South India and the Iringa

Programme in Tanzania are among the largest and most well known community-based

child survival, growth and development programmes. Thailand, Cambodia, Indonesia, Sri

Lanka, Bangladesh, Uganda, Kenya, Madagascar, Ghana, Niger, Oman, Brazil and others

are working on similar programmes.

UNICEF's programmes in the area of child and maternal health, basic education, water

and sanitation, and improved child protection contribute to the reduction of child

malnutrition. (http://www.unicef.org)

II. Local

Malnutrition in the Country

Protein-energy malnutrition (PEM) and micronutrient deficiencies remain the leading

nutritional problems in the Philippines. The general declining trend in the prevalence of

underweight, wasting and stunting among Filipino children noted in the past 10 years was

countered with the increase in the prevalence rate in 1998. About 4 million (31.8%) of the

preschool population were found to be underweight-for-age, 3 million (19.8%)

adolescents and 5 million (13.2%) adults, including older persons were found to be

underweight and chronically energy deficient, respectively.

The status of micronutrient malnutrition is likewise an important concern in the country.

The vitamin A status of the country is considered severe subclinical deficiency affecting

children 6 months - 5 years (8.2%) and pregnant women (7.1%). Iron deficiency anemia

is the most alarming of the micronutrient deficiencies affecting a considerable proportion

of infants (56.6%), pregnant women (50.7%), lactating women (45.7%) and male older

persons (49.1%). Prevalence of IDD was mild (71mg/L). However, 35.8% children 6 –

12 years old still suffer from moderate and severe IDD.

Overweight and obesity are also prevalent in the country affecting a significant

proportion of children, adolescents and adults, which predispose them to certain nutrition
and health risks. This is evident in the rising trend in the prevalence of diseases of the

heart and the vascular system.

Malnutrition in the Philippines is caused by a host of interrelated factors – health,

physical, social, economic and others. Food supply and how it is distributed and

consumed by the populace have consequent impact on nutritional status. While reports

indicate that there are enough food to feed the country, many Filipinos continue to go

hungry and become malnourished due to inadequate intake of food and nutrients. In fact,

except for protein, the typical Filipino diet was found to be grossly inadequate for energy

and other nutrients. In order to compensate for the inadequate energy intake, the body

utilizes protein as energy source. Thus, the continuing PEM problem in the country.

The present economic situation of the country further aggravates the malnutrition

problem with about 28 million Filipinos unable to buy food to meet their nutritional

requirements and other basic needs. While it was reported that the health status of

Filipinos improved in terms of the decrease in the mortality rates of mothers and infants,

the rising incidence of infectious diseases such as diarrhea and respiratory diseases

contributed to the poor nutritional status of many Filipinos. The effect of the 1997 Asian

financial crisis as well as the El Niño phenomenon was also manifested in the increase in

the prevalence of malnutrition in the national nutrition survey of 1998.

(http://www.fao.org)

CENTURY PARK HOTEL, Manila, 6 April 2006 – In the first National Conference of

Nutrition Stakeholders in the Philippines, United Nations Children’s Fund (UNICEF)

Country Representative Dr. Nicholas K. Alipui disclosed that major, irreversible damages
caused by malnutrition occur in the womb and during the first two years of the child’s

life. “Molecular biology confirms this finding. We must therefore focus on how to

prevent and treat malnutrition among pregnant and lactating women, and children aged

zero to two years old,” Dr. Alipui said.

“Damages to children include lower intelligence, reduced physical capacity, and passing

on malnutrition to the next generation. These result to reduction in productivity and

sluggish economic growth, which perpetuate the cycle of poverty. Most importantly,

every child has a right to be free of malnutrition,” he added.

Dr. Rodolfo Florentino, Chairman and President of the Nutrition Foundation of the

Philippines, discussed the state of pediatric nutrition in the country in the State-of-the-Art

(SOA) lectures for the year 2006. Clearly, he noted that undernutrition predominates over

overnutrition in children but the later is increasing as shown by recent statistics.

Nutritional status of children (with the exception of anemia in infants) is slowly

improving. However, at its current rate, achieving the Millennium Development Goal

(MDG) may not be reached by the year 2015. The lecture of Dr. Emilie Flores,

underscored the fact that breast feeding is still unequalled in providing optimum growth

and development of infants. She mentioned that although this form of feeding is the

feeding of choice in 90% of cases, exclusive breastfeeding is not widely practiced locally.

Dr. Enrique Ostrea from Wayne State University, delivered a very interesting talk on the

“Fetal Basis of Adult Diseases”. Based on the Barker Hypothesis, mechanisms related to

intrauterine malnutrition were associated with increased risks of acquiring hypertension,

coronary artery disease, Metabolic Syndrome and Diabetes Mellitus, among others. Dr.
Vasundhara Tolia, also from Wayne State University, discussed “Hepatic Steatosis in

Under- and Overnutrition”. Other discussions worthy of note were delivered by Drs.

Susan Padilla-Campos, Elizabeth Gabriel-Martinez and Jossie Rogacion.

Actions Against Malnutrition

The Food Fortification program is the government's response to the growing

micronutrient malnutrition, which have been prevalent in the Philippines for the past

several years.

Food Fortification is the addition of Sangkap Pinoy or micronutrients such as Vitamin A,

Iron and/or Iodine to food, whether or not they are normally contained in the food, for the

purpose of preventing or correcting a demonstrated deficiency with one or more nutrients

in the population or specific population groups.

Sangkap Pinoy or micronutrients are vitamins and minerals required by the body in very

small quantities. These are essential in maintaining a strong, healthy and active body;

sharp mind; and for women to bear healthy children.

Past studies have shown that worldwide, the problem of malnutrition has been the cause

of death of 60% of children less than 5 years old. (http://doh.gov.ph)

Throughout the country, nutrition workers such as the Barangay Nutrition Scholars work

hard and dedicated to address the problems of malnutrition and hunger. Aside from

educating especially mothers on proper diet and nutrition, barangay nutrition scholars

promote vegetable gardens and livelihood skills. Despite limited educational attainment

and limited available resources, these barangay workers try their best to make a

difference in the community. (http://www.manilatimes.net)

The National Nutrition Council (NNC) said an all-out drive to cut hunger incidence by

half under the Accelerated Hunger Mitigation Program (AHMP) will be pursued

specifically in Bicol considered as among the food-poor areas in the country.

Arlene Reario, NNC Bicol program coordinator, quoting a 2008 Social Weather Station

(SWS) survey on hunger incidence in the country indicated that many Filipinos

experience hunger.

The study revealed that 4.3 million families or 23.7 percent of the total number of

families in the Philippines experience hunger, of which 940,000 or 5.2 per cent are in

sever hunger; while 3.3 million families or 18.5 per cent are in moderate hunger.

Around one million poor and underprivileged Filipino families struggling to feed and

educate their children benefited from a massive school feeding program undertaken by

the Arroyo administration during the height of the global oil and rice crises last year,

according to the National Anti-Poverty Commission (NAPC).

NAPC Secretary Domingo Panganiban on Monday said that some 1.04 million Filipino

families received rations of rice under the Food-for-School Program (FSP) in 2008

following the directive of President Gloria Macapagal-Arroyo for all government

agencies to step up efforts to mitigate the adverse effects of the global oil and food crises

on the welfare of the poor.