Eating on $1.75 a day

You may have heard of this new initiative “Live Below the Line” launched for the first time in Canada last Monday, April 29^th, by the Global Poverty Project and followed by hundreds of citizens across Canada to support four non governmental organizations: CUSO International, Results/Resultats Canada, Raising the Village and Spread the Net.

“Live Below the Line” is an innovative awareness and fundraising campaign that is challenging individuals and communities to see how well people can live on just $1.75 a day. The principle of this campaign is quite simple but really powerful: by living off just $1.75 per day for food and drink for five days, anyone can bring to life the direct experiences of the 1.4 billion people currently living in extreme poverty and can help to make real change.

I took the challenge for 5 days last week and raised money for Results/Resultats Canada. My mission accomplished, I went back eagerly to my real life. Moreover, I was still thinking about this valuable experience, how it has changed not only my perception of extreme poverty, but also my engagement as a nutrition security specialist, and more importantly, my implication as a citizen who wants to use her political will to enact change on global poverty issues. For me, the quintessence of “Live Below the Line” is still in motion!

To be honest, the first time I heard about “Live Below the Line” and started to picture myself doing this kind of challenge was an authentic moment of panic. How can I survive on $1.75 per day for food and drink? It was impossible for me to cope with the idea, since this budget was ridiculously low when compared to the Canadian standard of “eat well and be active.”

Living in Canada for many years now, I am used to a certain standard, and I expect to be able to attain healthy lifestyle without any major constraints. With $1.75 per day, mission impossible!

To give you an example, the city of Toronto defines each year the real cost of healthy eating, i.e., $49.87 per week for individuals my age range, which corresponds to $7.12 per day. In this context, $1.75 per day, which represents 24.6% of the cost of a nutritious food basket, is definitively below the line.

Forget as well the Canada Food Guide – 3 fruits and 4-5 vegetables, 5-6 grains, 2 dairy and/or alternatives, and 2 meat and/or alternatives – during these five days, this won’t be possible at all.

When you are health & food conscious, “Live Below the Line” demands a good understanding of nutrition science, a lot of planning and a strong mental spirit. And I really tried my best. Two weeks before the challenge, I tested different recipes, localized best bargains for food, found ways to maintain my protein intake at an optimal level, and made some drastic choices between having fruits or vegetables – not both, too expensive. My menu for this 5-day challenge was quite simple: oat pancakes with banana for breakfast, congee (Chinese soup with rice and lotus seeds) for lunch, rice with split peas and grapes for dinner, two snacks (a boiled egg and an apple) to stave off hunger and the same tea bag for the whole day as well as a lot of water. No fancy French cuisine!

My first day was difficult, a few hunger pains, a mild migraine and caffeine withdrawal. But the fact that I had 5 small meals per day, a good breakfast to start, and a good intake of protein, helped me to adjust quite well with my new diet. An analysis of my food showed me that my daily calorie intake was slightly too low to maintain my body weight (-23%); these calories were mostly carbohydrate (+26%, when compared to my daily requirement) and protein (-12%). In contrast, my fat intake dropped significantly (-64%). Impossible for me to meet my daily requirement for essential omega-3 fatty acids, I didn’t plan to eat fatty fish, enriched eggs, flaxseeds, chia or raw hemp seeds or walnuts, too expensive.

The “Live below the line” diet had also a significant impact on my micronutrient intake, mostly because I was not able to diversify my food during these five days. As I was able to maintain my iron and vitamin C adequately, my calcium (43% of my daily requirement), vitamin A (40%) and vitamin D (0%) were significantly low or nonexistent. Hypothetically, continuing the same foods and nutritional pattern may ultimately affect my overall health. I might develop cardiovascular disease – the leading cause of death for women in Canada, and suffer later in live from osteoporosis. This is a non negligible risk factor for me, mainly because I really think that access to diversified and nutritious foods is a pivotal aspect of a healthy and active lifestyle.

“Live below the line” requires a lot of discipline and self-control but this is not enough to ensure good health when nutritious food access is limited. There is no place for creativity around food. It is more like a routine. You fill your stomach, you just want to fill it and move on.

What I missed the most, was the possibility to diversify my food intake, to maximize my healthy food choices without financial constraint and more importantly, to cook, give and share food with my friends and relatives. Food defines our place in the society! Food is pleasure!

When doing this specific challenge, I was able to experience the dehumanization of the feeding process. Feeding ourselves, our family and friends is a social act. Generally, food is the most important thing a mother can give to a child. Universally, mother’s milk is definitely the best food for infants. Food is not just a symbol of love, it is also security, an opportunity for each child to grow adequately and develop his (her) full potential. Food is life!

As I am thinking one more time about my experience, I recall the definition of the Right to Food as a Human Right.  Each word resonates more deeply than before the challenge, and the whole statement becomes now a reality for me because I have modestly experienced the day-to-day life of people living in poverty. I was part of the “Live Below the Line” campaign.

Nutrition and food security are key in the context of human development, economic growth and poverty reduction; and a global effort has been growing around nutrition over the past decade. As a result, the G8 has now put global undernutrition high on its agenda. Moreover, 34 developing countries, “highly-impacted” by undernutrition, have committed to scaling up their nutrition programs.

On June 8^th, the UK Government will co-host an event with the Children’s Investment Fund Foundation (CIFF): “Nutrition for Growth: Beating Hunger through Business and Science”. It is going to be a day of international action, bringing together governments, business, science, and civil society to improve the quality and quantity of food available to the world’s poorest people.

On the eve of the G8 Summit in London (June 17-18), world leaders will have an opportunity to support the developing countries that have developed cost effective plans for scaling up their nutrition programs through the SUN Framework. It is important that we continue to bring international attention to the issue of undernutrition, invest in and scale up nutrition programs that not only reduce child mortality but also consolidate the future of children by reducing the incidence of stunting and its detrimental long-term impacts.

At the June “Nutrition for Growth” event in London, Canada will have the opportunity, because of its leadership in nutrition, to inspire other members to invest in developing country-led efforts to reduce undernutrition.  It is extremely important that we work together to commit additional finances and political capital to invest in nutrition and food security, to make sure that less and less women and children live below the line in a near future.

(Image from https://www.facebook.com/LBLca)

 

Published in the Ottawa Citizen – http://blogs.ottawacitizen.com/2013/05/12/francoise-briet-eating-on-1-75-a-day/

Invest in Nutrition

Eden, a young boy of 3 years old, was just diagnosed with speech delay. This is one more illness that is affecting him. He also suffers from immune deficiency and deafness. All are related to his first year of life when he has faced severe chronic malnutrition. He looks normal, but the consequences are detrimental; this lack of food (hunger), at a critical moment in his early life, will hamper his ability to learn and hinder opportunities later in life.

This disturbing story may be the intolerable reality of children living in India or Ethiopia; but in fact, this story happens next door to us in America. Eden is one among other protagonists of a provoking documentary launched last month – A Place at the Table.

This documentary is thought-provoking mainly because it shows us that obesity and hunger are neighbours, our neighbours. Access to affordable nutritious foods in a world of plenty seems an unacceptable challenge for too many. In fact, this is increasingly the reality for many children living in both the developing and developed world, mainly because hunger and obesity are globally interconnected. We cannot pretend that it is not visible; it is in fact in our backyard. The burden of malnutrition is one major challenge in the context of the post-MDGs if we really want to achieve sustainable human development for every child in the world.

It is true that we have made significant progress over the past 50 years in the sector of population health. Life expectancies for men and women have increased. A greater proportion of deaths are taking place among people older than 70 years. The burdens of HIV and malaria are falling. Far fewer children younger than five years are dying. But this encouraging picture is being challenged by old and new threats. Africa remains the most afflicted continent, where maternal, newborn, and child mortality, along with a broad array of vaccine-preventable and other communicable diseases, are still urgent concerns. Malnutrition and stunting continue to be a long-term damaging stigma for children in Africa and South East Asia, with an estimated 75% of the world’s 165 million stunted children living there.

The link to extreme poverty is incontestable – as children in the poorest communities are more than twice as likely to be stunted, particularly in rural areas where as many as one third of children are affected.

On the other hand, more young and middle-aged adults in low and middle-income countries are suffering from obesity and diet-related non-communicable diseases (diabetes, hypertension, stoke and cardiovascular disease…). These diseases are driven primarily by phenotypic predisposition and high consumption of ultra-processed foods. With increasing urbanization and shifts in diet and lifestyle, the result could be an escalating epidemic of such conditions in many low- and middle-income countries. This would create new economic and social challenges, especially among vulnerable groups.

Fighting stunting is the emerging battle in the context of optimal human development. It is the irreversible impact of not receiving enough nutrient dense foods within the first 1000 days of life, from pregnancy to a child’s second birthday. But stunting is more than a problem of stature; this lack of nutritious food also impacts the overall physical (organ as well as immune cell function) and cognitive development, and determines the susceptibility to obesity and food-related non communicable diseases later in life.

During the first 1000 days, nutritional requirements to support rapid growth and development are very high, and the baby is totally dependent on others for nutrition, care and social interactions. For example, the first year of life is a time of astonishing change during which babies in normal conditions, on average, grow 55% in length, triple their birth weights and increase head circumference by 40%. Between 1 and 2 years age, an average child grows about 12 cm in length and gains about 3.5 kg in weight. During these crucial days as well as during fetal life, the body is putting together the fundamental human machinery (similar to hardware and software for computer). This process is done over a very short period of time and requires specific nutrients like vitamin A, iron, folic acid, zinc but also protein, long-chain polyunsaturated fatty acids and choline. The immune-system and brain-synapse development are particularly vulnerable. As a result, any disturbance of this frantic activity leaves a terrible mark. Smaller than their non-stunted peers, stunted children are more susceptible to sickness. In school, they often fall behind in class. They enter adulthood more likely to become overweight and more prone to non-communicable diseases. When they start work, they often earn less than their non-stunted co-workers. The drama of this situation is the fact that an undernourished mother is more likely to give birth to a stunted child, perpetuating a vicious cycle of high prevalence of premature death (an estimated 60-80% of neonatal deaths occur among low birth weight babies), undernutrition and poverty.

It is imperative to focus on the first 1000 days of a child’s life as the crucial window of opportunity for change. It is during this time that proper nutrition has the greatest impact on a child’s health and potential future wellbeing and opportunities. A recent publication in Lancet has reinforced this idea, and has showed that attaining optimal growth before 24 months of age is desirable; becoming stunted but then gaining weight disproportionately after 24 months is likely to increase the risk of becoming overweight and developing other health problems. UNICEF’s latest publication “Improving Child Nutrition: The achievable imperative for global progress” is closing the loop. It shows that there are proven low cost solutions for reducing stunting and other forms of undernutrition. These simple and proven nutrition activities need to be integrated together. They include improving women’s nutrition, early and exclusive breastfeeding, providing additional vitamins and minerals as well as giving appropriate nutrient dense foods, especially in pregnancy and the first two years of a child’s life.

Investing in children’s and women’s nutrition is not only the right thing to do from a human right point of view; it is also a cost-effective investment. It can increase a country’s gross domestic product (GDP) by at least 2-3% annually. Every US$1 spent on nutrition activities to reduce stunting will have a return on investment of US$30. This integrated nutritional strategy as proposed by UNICEF and other international stakeholders is the locomotive that can accelerate economic growth and pull millions of people out of poverty.

Let’s work all together to be sure that every children around the world has a place at the table. This is our responsibility!

This article was publish in the Ottawa Citizen last week. This is the link:

http://blogs.ottawacitizen.com/2013/04/26/francoise-briet-invest-in-nutrition/

Don’t bring me the food that western people love!

Over the past few months, I was busy writing articles for different magazines and newspapers.

This is one of them: Don’t bring me the food that western people love!

This is part of a series of articles on food in the context of global development.

All the articles are really interesting. It will give you a different perspective on some key issues. But not only this, there is more. 

This is the link:

http://content.yudu.com/A24lyd/iAMVol4/resources/index.htm?referrerUrl=http%3A%2F%2Focic.on.ca%2Fiam

Hope you will enjoy the voyage…  

Focusing on linear growth and relative weight gain during early life – a winner ticket for human capital development and future adult health

We have seen in the previous blog that the children who are suffering from stunting (short stature) may look normal but the consequences of becoming and remaining stunted can be detrimental. In fact, we can observe an increased risk of morbidity and mortality, but also delays in cognitive (ability to think and understand) and physical development, which result in a decreased ability to learn and capacity to work.

In fact, stunted height (and not underweight) is a dreadful marker of multiple deprivations regarding food intake, care and play, clean water, good sanitation and health care. It is an important indicator of child well-being – not only physical growth but also cognitive and socio-emotional development.

These days, not only in the context of post Millennium Development Goals (MDGs) but also because of the importance to focus on sustainable human development, the key questions for nutritionists, pediatricians and policy makers are:

• What is the optimum age for promotion of growth for enhanced survival and human capital?
• Will this promotion necessarily lead to an increase in cardio-metabolic disease later in life?  

These aspects have their importance knowing that a lot of feeding programs in developing countries are aimed at older children, at a time where optimal linear growth is already compromise. For example, traditional school feeding programs that increase BMI with little effect on height might be doing more harm than good in terms of future health.

Why?

According to a study published in Lancet last month (see reference below), patterns already observed in the Western world are starting to be seen in low- and middle-income countries: i.e. putting on too much weight in relation to height in middle and late childhood (after 2 years old) can increase the risk for chronic diseases, such as diabetes, in later life.

This scientific analysis that involved five prospective birth cohort studies from Brazil, Guatemala, India, the Philippines, and South Africa showed that it is important to focus on improved nutrition in the first few years of life, i.e. the 1,000 days from the start of a woman’s pregnancy until her child’s 2nd birthday.

Their analysis showed that:

• Higher birth weight is associated with an adult BMI of greater than 25 kg/m² (mostly lean body mass – muscle, which is good), and a reduced likelihood of short stature and of not completing secondary school,
• Fast linear growth during the first 2 years of life is associated with increased adult height and amount of schooling,
• Weight gain earlier in infancy is not associated later with any increased risk of chronic disease. In fact, it is good for the child, good for survival, giving some protection from adult chronic disease and better educational attainment,
• Faster relative weight gain after the age of 2 years has little benefit for human capital, and weight gain after mid-childhood could lead to large adverse effects on later cardiovascular risk factors like elevated blood pressure. Notably, this is particularly true for weight gain that is not accompanied by height gain,
• In fact, rapid weight gain should not be promoted after the age of 2–3 years in children who are underweight (weight for age) but not wasted (weight for height)

This study shows the importance to promote nutrition and linear growth during the first 1,000 days of life (from conception to age 2 years), and also reinforces the importance of prevention of rapid relative weight gain after age 2 years.

These findings have implications for present practices in low-income and middle-income countries, particularly emphasizing the need to monitor linear growth as well as weight, and to avoid promotion of excess weight gain in children older than 2 years. Optimum growth patterns in early life are likely to lead to less undernutrition, increased human capital, and reduced risks of obesity and non-communicable diseases, thus addressing both components of the double burden of nutrition.

According to one of the authors, Dr Fall: “One of the challenges we are facing is the fact that we need to find ways to get very small children to be taller, and we don’t really know how to do it“. More work is needed on imaginative interventions to specifically promote height growth, instead of weight gain. These could include exclusive breast-feeding, long-chain polyunsaturated fatty acids like DHA, high-quality protein, and micronutrients.

Mortality and undernutrition are falling substantially in most parts of the world, except for Sub-Saharan Africa, and new targets are being formulated to replace the present set of 2015 MDGs. A new goal for optimum linear growth that is expressed as a reduction in stunting can replace the present target of a reduction in underweight alone, which is one of the indicators for the first MDGs towards the eradication of extreme poverty. This new target can be associated with the assessment of developmental functioning using a set of indicators based on the Psychomotor Development Index (PDI) and Mental Development Index (MDI) of the Bayley Scales of Infant Development. This integrated approach will help to evaluate appropriately physical as well as cognitive and socio-emotional development, which is so important when building human capital.

 

References:

http://www.medscape.com/viewarticle/781535

Associations of linear growth and relative weight gain during early life with adult health and human capital in countries of low and middle income: findings from five birth cohort studies. Adair LS et al, Lancet 28^th March 2013 (http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673613601038.pdf?id=a02f57d1811fcb77:524f7ce2:13db1412973:-60f11364479623359)

 

To prevent stunting that blights the developing world … a better understanding of what nutrition means in the context of human development, an integrated approach and a strong leadership are needed (Part 3)

Addressing the issue of stunting or chronic undernutrition, resulting in growth retardation, is currently a big issue because it affects dramatically children’s development and compromised irremediably their future professional life.

As announced last week by the EU Commissioner for development, Andris Piebalgs: “Undernutrition is the biggest threat to people’s health in the developing world, causing at least one third of all child deaths, and a fifth of mothers. This shocking and shameful reality calls for an improved, global and decisive response. The EU is firmly committed to reduce by 7 million the number of stunted children by 2025. Increased international mobilization is vital. That’s why, today, I am also calling on other major donors and development actors to join us in this global movement and make their own commitments.”  

 When I decided to embark in this journey, I didn’t know that I would spend days reading articles, analyzing, pondering the pro and con… My personal objective was to be able to put together different pieces of the puzzle to really understand how we can impact poverty through preventing stunting and as a result, ensuring a dignified future for everyone.  One of my lesson learnt is the fact that we need to change our mindset … Access to food is not only based on quantity (calories) but it is more importantly based on quality (micronutrients for sure, but also macronutrients) when nutrition becomes the corner stone of global health and food security. This change in mindset is the future of sustainable human development not only in the developing world but also in the developed countries.

This article will review different aspects to help us to better understand the issue of stunting (and its adverse outcomes) not only in children but also in women. A short stature can predict more than one dimension of the potential impact that malnutrition can have on human being — it is why it is so critical to address this issue appropriately.

 

The current situation – a decrease of the incidence of stunting, yes but not for everyone:

The children who are suffering from stunting (short stature) may look normal but their brain development and immune systems most certainly are not. Stunting is much more common than underweight (low weight-for-age) or wasting (low weight-for-height), affecting globally in 2010 about 171 million or 27% of children aged 0–5 years.

 The good news … Worldwide, the prevalence of childhood stunting has decreased and will continue to decrease as shown in the figure below:

 

 (Adapted from Maternal and Child Nutrition (2011), 7 (Suppl. 3), pp. 5–18)

Trends in stunting follow different patterns in developing and developed countries. While the prevalence of stunting in developed countries has been stable at 6% since 1990 and is expected to remain at this level, developing countries have experienced a decrease from 44.4% in 1990 to 29.2% in 2010. The prediction is that this decreasing tendency will continue and will reach a prevalence of 23.7% in 2020.

 Africa vs Asia – not the same story:

  (Adapted from Maternal and Child Nutrition (2011), 7 (Suppl. 3), pp. 5–18)

 

In Africa, given population growth, the result presented above has translated into increasing numbers of stunted children (from 45 million in 1990 to 60 million in 2010). In contrast, Asia has showed a dramatic decrease and this declining trend will continue, reaching a total number of stunted children in Asia (68 million) similar to the number in Africa (64 million) in 2020. In Latin America both the prevalence and number of affected children were much lower than in Africa and Asia (14 % or 7 million in 2010) and they are expected to continue decreasing in the coming decade). Data in Oceania remain scarce and thus trend modeling is not possible. However, individual countries like Papua New Guinea show high rates of stunting (44 % in 2005).

 

 

There is a great variation in rates of childhood stunting among countries. The figure above maps countries according to their latest national stunting prevalence estimation. Extremely high rates appear in countries like Afghanistan, Yemen, Guatemala, Burundi, Madagascar, Malawi and Ethiopia, with levels closed to or above 50 % in most recent surveys. Other countries of sub-Saharan Africa, South-central and South-eastern Asia also present high to medium stunting rates.

 

The causes – inadequate dietary intake but also disease like infection and diarrhea:

The causes and etiology of stunting are the result of multiple circumstances and determinants. To schematize, the immediate determinants refer to inadequate dietary intake and disease. The underlying determinants include food insecurity, inappropriate care practices and an unsafe environment including access to water and hygiene, inadequate health services and air pollution. A new determinant that has received a lot of attention over the past few years is mother-infant interaction (maternal nutrition and stores at birth, and behavioral interactions). All these circumstances result in increased vulnerability to shocks and long term stresses.

 

 

 (Sphere project – http://www.sphereproject.org/)

 

In actual fact, the determinants of undernutrition are rooted in poverty and involve interactions between social, political, demographic, and societal conditions. Over the past decade, It became important to go beyond the traditional concept of food security (access, availability, stability and utilization of food) and recognizes that the nutritional status is dependent on a wide and multi-sectoral array of factors. It is why the international community has starting to introduce the concept of nutrition security because …

 A household can achieve nutrition security only when it has secure access to food coupled with a sanitary environment, adequate health services, and knowledgeable care to ensure a healthy life for all household members.

But it is important to remind that stunting is a complex issue. The causes and etiology of stunting are much less understood than are its timing and consequences. In particular, there is little understanding of why and how stunting occurs extensively in environments that are poor, but not desperately so, and in environments that seem to be improving (India is the good example). In a population, an individual child can become stunted or not. In addition, some populations are much more stunted than others. This means that an understanding of why and how children become stunted is needed at both the individual and ecological levels.

 

The consequences – a dramatic long term impact that affects human capital:

The consequences of becoming and remaining stunted are increased risk of morbidity, mortality, delays in cognitive (ability to think and understand) and physical development, and decreased work capacity. Actually, it is well documented that impaired mental and physical development has long-term negative consequences on both micro and macro levels, reducing human and overall economic development. The economic cost of undernutrition has been estimated at 2 to 8 % of Gross Domestic Product (GDP).  

Moreover, children who have suffered of malnutrition (stunting) during their childhood are also at higher risk of suffering from chronic diseases (such as diabetes and cardiovascular disease) in adulthood. As highlighted in one of the latest Lancet Series “The global burden of diseases study 2010“: fewer children are dying every year (big progress), but more young and middle-aged adults are dying and suffering from disease and injury, as non-communicable diseases (cancer and heart disease) that become the dominant causes of death and disability worldwide: 54% of disability-adjusted life years worldwide were caused by non communicable disease in 2010, compared with only 43% in 1990.

 

The vicious inter-generational cycle of malnutrition = the inter-generational transmission of  poverty:

Although a child may not be classified as ‘stunted’ until 2–3 years of age, the process of becoming stunted typically begins in utero. The result – a very short height – usually reflects the persistent, cumulative effects of poor nutrition and other deficits that often span across several generations (see figure below).

 

 

Poor nutrition often starts in utero and extends, particularly for girls and women, well into adolescent and adult life, and extends over to the next generations. The infants with low body weight, who suffered intrauterine growth retardation, and born undernourished, are at higher risk of dying in the neonatal period or later infancy. If they survive, they are unlikely to significantly catch up on this lost growth later and are more likely to experience a variety of developmental deficits. In fact, an infant with low body weight at birth (which is strongly correlated with birth length) is thus more likely to be underweight or stunted in early life.

Actually, stunting can be found at many levels in society. In Bangladesh, for example, stunting in children less than 5 years of age was found in one-fourth of the richest households [National Institute of Population Research and Training (NIPORT), 2009]. In developing countries, stunting is more prevalent than underweight (low weight for age, 20%) or wasting (low weight for height, 10%), possibly because height gain is even more sensitive to dietary quality than is weight gain.

Stunted height is a dreadful marker of multiple deprivations regarding food intake, care and play, clean water, good sanitation and health care. As a result, stunting is an important indicator of child well-being and is considered as a marker of endemic poverty.

To summarize, it is important to remember that small size at birth and childhood stunting are linked with:

• short adult stature,
• reduced lean body mass,
• less schooling,
• diminished intellectual functioning,
• reduced earnings, and
• lower birth weight of infants born to women who themselves had been stunted as children

 These outcomes have long-term impact if not addressed appropriately.

The figure below presents the % of low infant birthweight. The highest % is observed in 3 of the countries where we also observe a high incidence of short maternal stature, i.e. Afganistan, Yemen and Ethiopia. Sub-Sahara Africa (and specifically the Sahel region) and South East Asia are the regions where we observe the higher prevalence of low infant birth weight and stunting (see world map on prevalence of stunting above). 

 

 

The importance of maternal malnutrition (short stature and/or low body weight) – a key issue in the context of sustainable human development:

We now all agree that adult height in women reflects a cumulative outcome measure of environmental exposures from fetal to adult life encompassing nutritional, infectious, socio-cultural, and economic influences that can be transmit to the next generation through the inter-generational cycle of malnutrition. In this context, investing in women can have an astonishing impact!

Maternal undernutrition, embodied by short stature and a low body mass index (BMI), is highly prevalent in many developing countries. Short stature (<145 cm) affects more than 10% of women of reproductive age across South Central Asia and Latin America, but only 1% to 2% in sub-Saharan Africa, whereas a low BMI (<18.5) is found among 20% or more women in sub-Saharan Africa and South Central Asia but not in Latin America.

It was really interesting to go through the scientific publications & international agency reports to better understand this issue. More I was reading about this issue, more I was conscious of what are the overwhelming consequences of maternal chronic undernutrition in the context of child and maternal health, and how it is crucial to invest in women nutrition, health, education and empowerment. Let me to put together some numbers, facts and of course, maps/graphs to help us to better understand the problem. 

Because the consequences of maternal malnutrition (mortality and morbidity) in the context of pregnancy are dramatic…

Both indicators (short stature and low BMI) can predict adverse pregnancy outcomes. However, only

• Maternal height is a strong predictor of birth size, and
• It is inversely associated with risks of child mortality, underweight, stunting, and wasting

From a clinical point of view, short maternal stature can restrict uterine blood flow and growth of the uterus, placenta and fetus. Intrauterine growth restriction (IUGR) is associated with many adverse fetal and neonatal outcomes like chronic fetal distress or fetal death. Moreover, short maternal stature is consistently associated with an elevated risk of perinatal mortality (stillbirths and deaths during the first 7 days after birth), mostly related to obstructed labor resulting from a narrower pelvis in short women. In a hospital based study in Nigeria, obstructed labor accounted for 53% of perinatal mortality that is largely the result of birth asphyxia.

The world map below shows the cause of under 5 mortality for the World Health Organization region. Neonatal causes of death (the yellow part of the disk) represent more than 40% of all causes of death in all the regions, except Africa (brown color).

 

Globally, birth asphyxia accounts for 23% of the four million neonatal deaths each year. An estimated one million children who survive birth asphyxia live with chronic neuro-developmental disorders, including cerebral palsy, mental retardation and learning disabilities (World Health Organization 2005).

 Interestingly, the effect of short maternal stature on child mortality is comparable to the effect of having no education or being in the poorest 20% of households.

Moreover, short maternal stature because of the risk of disparity in size between the baby’s head and the mother’s pelvis increases also the risk of maternal mortality and short and long-term disability. The consequences of obstructed labor include injury to the birth passage, postpartum hemorrhage, rupture of the uterus, genital sepsis or fistula, leading to urinary dribbling or incontinence (see the documentary: A walk to beautiful – http://ww3.tvo.org/video/162183/walk-beautiful). In the worst case scenario, obstructed labor can lead to maternal death, mostly because of ruptured uterus or puerperal sepsis.

 

 

 Causes of maternal death (World Health Organization – 2008)

The percentages of maternal mortality attributable to obstructed labor (grey color) are 4% in Africa, 9% in Asia and 13% in Latin America and the Caribbean. Mothers who survive but have long-term disability due to complications such as fistula experience social, economic, emotional and psychological consequences that have an enormous impact on maternal health and well-being.

Finally, lower birthweight (which is strongly correlated with birth length) and undernutrition in childhood are risk factors for high glucose concentrations, blood pressure and harmful lipid profiles in adulthood. The “developmental origins of health and disease”  (or Barker) hypothesis hypothesizes that the intrauterine and early post-natal environment can modify expression of the fetal genome and lead to lifelong alterations in metabolic, endocrine and cardiovascular function. In this case, it is likely that the process of stunting is harmful and not necessarily short stature itself.

 

  

Let me to put some perspective because the numbers talk by themselves….

Compared with the highest maternal height category of more than 160 cm, women with short stature (<145 cm) have an approximately 40% higher risk of any of their offspring dying, after adjusting for confounders.

A similar analysis revealed risks of stunting and underweight in offspring to be 2-fold greater among short mothers, whereas that of wasting was only 17% higher.

However, with every 1-cm increase in height, the relative and absolute risk of each of the adverse outcomes listed above (i.e. child mortality, underweight, stunting, and wasting) can be significantly decreased.

 

The “window of opportunity” for improvement – yes, it is possible to change things:

During fetal life and the first 2 years after birth (the famous 1000 days), nutritional requirements to support rapid growth and development are very high.

Envision! … The first year of life is a time of astonishing change during which babies in normal conditions, on average, grow 55% in length, triple their birth weights and increase head circumference by 40%. Between 1 and 2 years age, an average child grows about 12 cm in length and gains about 3.5 kg in weight. A costly process! 

During these crucial days as well as during fetal life, the body is putting together the fundamental human machinery (similar to hardware and software for computer). This process is done over a very short period of time, with demanding nutrient requirements. Immune-system and brain-synapse development are particularly vulnerable. As a result, any disturbance of this frantic activity leaves a terrible mark.

In this context chronic malnutrition can have a dramatic impact. Then, let me discuss the importance of nutrition for both immune-system and brain-synapse development. We will take the opportunity to highlight the importance of diversified nutrition (macro as well as micronutrients intake) in the context of “in 1000 days you can change the future” (http://www.thousanddays.org/).

 

In the case of brain-synapse development, which nutrients are important?

Growth factors, but also nutrients regulate brain development during fetal and early postnatal life. The developing brain between 24 and 42 wk of gestation is particularly vulnerable to nutritional insults because of rapid neurologic processes, including synapse formation and myelination. All nutrients are important for neuronal and glial cell growth and development, but some appear to have greater effects during the late fetal and neonatal life. These include protein, iron, zinc, selenium, iodine, folate, vitamin A, choline, and long-chain polyunsaturated fatty acids. The effect of nutrient deficiency or supplementation on the developing brain is a function of the brain’s requirement at a specific time for a nutrient in specific metabolic pathways and structural components. For example, during late fetal and early neonatal life, regions such as the hippocampus, and the visual and auditory cortices are undergoing rapid development characterized by the morphogenesis and synaptogenesis that make them functional. In this case, protein-energy and long-chain polyunsaturated fatty acids are important.

For any given region, early nutritional insults have a greater effect on cell proliferation, thereby affecting cell number. Later nutritional insults affect differentiation, including size, complexity, and in the case of neurons, synaptogenesis and dendritic arborization (the neuronal circuit that permits to send information).

All nutrients are important for brain development, but some appear to have a particularly large effect on developing brain circuits during the last trimester and early neonatal period as shown in the table below:

Important nutrients during late fetal and neonatal brain development

(Adapted from Am J Clin Nutr February 2007 vol. 85 no. 2 614S-620S)

 

Nutrient	Brain requirement for the nutrient	Predominant brain area or activity affected by deficiency
Protein-energy	Cell proliferation, cell differentiation Synaptogenesis …	Global Cortex …
Iron	Myelin Neuronal and glial energy metabolism …	White matter Hippocampal-frontal …
Zinc	DNA synthesis …	Autonomic nervous system …
Copper	Neurotransmitter synthesis, neuronal and glial energy metabolism, antioxidant activity	Cerebellum
Long-chain polyunsaturated fatty acids	Synaptogenesis Myelin	Eye Cortex
Choline	Neurotransmitter synthesis Myelin synthesis …	Global White matter …

 

Breast feeding is the best food in this context…

The potential mechanisms through which breastfeeding may improve cognitive development relate both to the composition of breast milk and to the experience of breastfeeding. Breast milk contains a suite of nutrients, growth factors, and hormones that are important for brain development, including critical building blocks such as docosahexaenoic acid (DHA – fish oil) and choline. In addition, the physical act of breastfeeding may promote the quality of the mother-infant relationship and enhance mother-infant interaction, which are important for cognitive and socioemotional development. For instance, cognitive effects of nutritional deficiencies (as measured by the mental development index of Bayley Scales) are more severe for children living in homes where there is less stimulation compared to homes with higher levels of stimulation.

When compared to formula, human milk provides all the essential n-6 and n-3 PUFA like linoleic acid and alpha-linolenic acid, as well as their longer-chain more-unsaturated metabolites, including arachidonic acid and DHA that support the growth and development of the breast-fed infant. In fact, the role of DHA in infant nutrition is of particular importance because DHA is accumulated specifically in the membrane lipids of the brain and retina, where it is important to visual and neural function. In this context, it is crucial to ensure an adequate maternal dietary lipids and DHA intake if this is the only source of essential fatty acids for infant development both before and after birth to minimize the risk of low infant neural system maturation.

In this case, investing in programs that focus on exclusive breast feeding during the first 6 months, that will continued along with appropriate complementary foods up to two years of age as well as increased access to nutritious food for breastfeeding mothers makes sense because these strategies will pay back…

In the case of immune-system development, which nutrients are important?

Immune cells and organs rapidly proliferate in the first trimester of pregnancy. Early cells undergo progressive waves of maturation, some unique to the fetal period, as they build the capacity to recognize and adapt defenses to specific pathogens. Although the immune system is qualitatively complete at birth (but still immature), exposures to colonizing commensal bacteria, environmental antigens, bioactive dietary substances, and potential pathogens during infancy and early childhood are essential for expansion and priming of adaptive cell populations. These critical periods of development are highly vulnerable to insult, which may permanently alter immune defenses.

Moreover, the ability of the immune system to prevent infection and disease is strongly influenced by nutritional status of the host. In fact, malnutrition is the most common cause of immunodeficiency in the world. Nutrient deficiencies can cause immunosuppression and dysregulation of immune responses. Because nutritional status can modulate the actions of the immune system, the sciences of nutrition and immunology are tightly linked.

 Impact of maternal malnutrition in infant immune system development:

The impact of maternal protein-calorie malnutrition (PCM) on neonatal vulnerability to infectious disease is well known. Much of the damage to neonatal host defense occurs through impact on the developing immune system, especially the thymus, often called the barometer of nutrition. In this context, malnourished children have lower levels of thymulin* and deficient T-cell development.

Micronutrient imbalance or deficiency in the mother in the absence of PCM can alter the program of immune development in the infant. The strongest evidence for micronutrient programming effects comes from studies of vitamin A deficiency. In fact, vitamin A is required for the homing of T cells into the gastrointestinal tract and promotion of antigen-specific regulatory T cells development.

Impact of malnutrition in infant:

PCM primarily affects cell-mediated immunity (increased phagocyte activity, cytotoxic T cells activation and cytokine release) rather than humoral immunity (antibody response). In particular, PCM leads to atrophy of the thymus, the organ that produces T cells, which reduces the number of circulating T cells and decreases the effectiveness of the memory response to antigens. Additionally, PEM compromises the integrity of mucosal barriers, thereby increasing susceptibility to infections of the respiratory, gastrointestinal, and urinary tracts. PCM often occurs in combination with deficiencies in essential micronutrients, especially vitamin A, zinc, copper, selenium, and magnesium.

The good news is that the effects of PCM are reversible by refeeding. Renutrition studies in children showed that innate immune functions and adaptive lymphocyte proliferative response improve in parallel with growth. Treatment of severely malnourished infants has shown that after refeeding, previously deficient phagocytosis, microbicidal activity, chemotaxis, and cell proliferation indices normalized along with anthropometric gains.

Micronutrient deficiencies are a major complication of PCM and promote infectious processes. Oxidative stress is worsened in infection if micronutrients are deficient. Vitamin A, β-carotene, folic acid, vitamin B12, vitamin C, riboflavin, iron, zinc, and selenium have immunomodulating functions and influence both the susceptibility of the host to infectious diseases and the course and outcome of these diseases. For example, vitamin A deficiency impairs mucosal barriers and diminishes the function of neutrophils, macrophages, and NK cells.

And again …Breast feeding is the best food in this context…

Human milk provides virtually all the protein, sugar, and fat baby needs to be healthy. It also enhances the immature immunologic system of the neonate and strengthens host defense mechanisms against infective and other foreign agents. Some mechanisms that explain active stimulation of the infant’s immune system by breastfeeding are the bioactive factors in human milk such as hormones, growth factors and colony stimulating factors, as well as specific nutrients like lactoferrin, one of the most abundant proteins in human milk, nucleotides, complex sugars and long-chain polyunsaturated fatty acids.

 

To conclude…

Simply providing an adequate food supply likely would not be enough to keep kids growing well. Researchers said that common childhood incidents in the developing world, such as a high burden of early childhood infections (acute diarrhea and infection with a parasite), compound the problem. Both diarrhea and parasites can lead to malnutrition—and vice versa—so the path to well-nourished, healthy children is not quite as simple as making sure that their families have enough food.

To have an impact on stunting levels, nutrition-sensitive interventions (bringing quality and not only quantity) and promotion of adequate nutrition practices need to be targeted to women during pregnancy and to children from birth to 24 months of age. In addition, communities require increased income among the poor, improved food security, sanitation and water supplies as well as better public health education and health care availability. Investment in these changes in the near term should pay off later in improved earning power and an easier ascent out of poverty, which in turn should also lead to better health for the generations to come.

Moreover, tackling undernutrition will require solutions to be developed with the integration of the food security, livelihoods, health, care practices and nutrition sectors. Yet, the linkages between the different sectors are complex and are increasingly under scrutiny as experience has shown that each sector tended to operate in separate spheres.

Malnutrition is often said to be no one’s responsibility but everyone’s business. We must make it everybody’s responsibility. Leaders are needed if we want to make the legacy of the first 1,000 days last forever.

Let move in this direction all together…

 

* A zinc-dependent thymic hormone that regulates the differentiation of the immature thymocyte subpopulation and the function of mature T and natural killer cells and also functions as a transmitter between the neuroendocrine and immune systems

 

References:

http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

http://onlinelibrary.wiley.com/doi/10.1111/j.1740-8709.2011.00349.x/pdf

http://www.who.int/nutgrowthdb/publications/Stunting1990_2011.pdf

http://www.prb.org/Publications/PolicyBriefs/HealthyMothersandHealthyNewbornsTheVitalLink.aspx?p=1

http://journals.cambridge.org/download.php?file=%2FPHN%2FPHN15_01%2FS1368980011001315a.pdf&code=9388ad17651c06a950aadfcbedad50cd

http://www.guardian.co.uk/commentisfree/2013/mar/13/undernutrition-invisible-killer-children

http://ajcn.nutrition.org/content/85/2/614S.full

http://satvenandmer.hirezz.com/pdf/dha/Nutrition%20and%20Cognitive%20Development%20.pdf

http://journals.cambridge.org/download.php?file=%2FPNS%2FPNS66_03%2FS0029665107005666a.pdf&code=3d8f0f9371eabfc67ed3eff3d6c22b2f

http://advances.nutrition.org/content/2/5/377.full

http://images.abbottnutrition.com/ANHI2010/MEDIA/Cunningham_Rundles_112th%20ANRC.pdf

http://www.jacionline.org/article/S0091-6749(05)01274-1/fulltext

http://listas.exa.unne.edu.ar/bioquimica/inmunoclinica/documentos/protection_neonate.pdf

http://thousanddays.org/wp-content/uploads/2013/03/Technical-Brief-4-Nutrition-and-brain-development-in-early-life-2.pdf

http://www.unicef.org/nutrition/training/2.3/2.html

http://jn.nutrition.org/content/129/2/529.full.pdf

http://blogs.scientificamerican.com/observations/2011/12/08/stunted-growth-from-common-causes-threatens-childrens-later-achievement/

http://www.childinfo.org/files/low_birthweight_from_EY.pdf

http://gamapserver.who.int/gho/interactive_charts/mdg1/atlas.html

http://www.who.int/gho/mdg/poverty_hunger/underweight_text/en/index.html

Quinoa Year aims to ease food insecurity and transform the global diet

2013 is the International Quinoa Year: http://www.rlc.fao.org/en/about-fao/iyq-2012/

This is an interesting article published by the UN news Centre…. and I would like to share with you some of the key points and highlight why quinoa is an interesting staple in the global context of food security. However, quinoa’s success starts to initiate problems and challenges that need to be addressed if we want to make this food revolution sustainable locally as well as globally. 

Quinoa farmed on the Bolivian antiplano ranges in colour from white to pink to orange. Photo: Claudio Guzmán/FAO

Quinoa, a highly nutritious grain-like crop that has made its entry into the food basket of culinary connoisseurs has been a staple for centuries in South America, among pre-Columbian Andean farming communities from Colombia to Ecuador. In fact, most of the world’s quinoa is grown on the altiplano, a vast, cold, windswept, and barren 14,000-foot Andean plateau spanning parts of Peru and Bolivia.

By declaring 2013 the ‘International Year of Quinoa’, the United Nations is hoping to popularize a life-sustaining seed that could help promote food security and poverty eradication, cut malnutrition and boost biodiversity in support of the achievement of the Millennium Development Goals. It is also a way to recognize the indigenous peoples who preserved quinoa through traditional knowledge and practices passed down through the ages.

Quinoa famers in Bolivia show off their latest crop which could help promote food security and eradicate poverty. Photo: Claudio Guzmán/FAO

In Resolution 66/221, the General Assembly declared the International Year of Quinoa in recognition of the Andean indigenous people “who have managed to preserve quinoa in its natural state as food for present and future generations, through ancestral practices of living in harmony with nature.” Hence the theme for this year: “A future sown thousands of years ago.”

Pronounced ‘keen-wah’, quinoa is not really a grain, not really a vegetable. It is a pseudo-cereal, part of the chenopodium family related to beets and spinach. Quinoa seeds are gluten-free and have all the essential amino acids, trace elements and vitamins needed to survive. Due to its high nutritional value, indigenous peoples and researchers call it “the golden grain of the Andes.”

One cup of quinoa (a single serving size) brings:

• 220 calories (70 % carbs, 15 % fat, 15 % protein)
• 40 grams of carbohydrates (13 % daily value)
• 8 grams of protein (16 % of daily value)
• 3.5 grams of fat (5 % daily value with no saturated fat)
• A glycemic load (blood sugar spike) of only 18 out of 250
• 5 grams of fiber (20 % of daily value)
• 20 % of daily value of folate (various forms of Vitamin B)
• 30 % of magnesium daily value; 28 % daily value of phosphorous; iron (15 %); copper (18 %); and manganese (almost 60 %)

Quinoa’s link to food security

Cautioning that the crop is “still in the experimental phase” in some areas, Mr. Bojanic, who is the Deputy Regional Representative at the FAO Regional Latin America and the Caribbean Office and also serves as the Secretary for the International Year of Quinoa’s Secretariat, said that quinoa “is beginning to be taken up by countries that would not have thought of having it a few years ago.” Those include Canada, China, Denmark, Italy, India, Kenya, Morocco and the Netherlands, which are already producing or undertaking agronomic trials towards commercial production of quinoa.

Bolivia and Peru account for more than half of the annual 70,000 tons produced of quinoa, with the United States responsible for about 7,000 tons and France close behind, FAO reports. Quinoa is hardy. It thrives in temperatures from -8 degrees Celsius to 38 degrees Celsius, at sea level or 4,000 metres above, and is not impacted by droughts or poor soils.

“This crop can be grown under very difficult conditions like semi-arid, at high altitudes, sea level, with no fertilizer. It’s an amazing crop in terms of the adaptability that it has to stressful environments,” Mr. Bojanic said.

Researcher from the University de Valparaiso with quinoa farmers in Chile. Photo: Didier Bazile/CIRAD

This adaptability makes quinoa potentially viable for areas with regular droughts, such as the Sahel Region – which includes Senegal, Chad, Niger and Mauritania – where million of people are in need of emergency food aid and malnutrition is rampant.

The latest figures in FAO’s State of Food Insecurity in the World 2012 Report show that despite significant progress, almost 870 million people – or one in eight – are still suffering from chronic malnutrition.

UN officials say there is still time to reach the Millennium Development Goal for reducing the proportion of hungry people around the world by half by 2015, but countries need to step up their efforts and quinoa offers hope.

The quinoa quandary

Agronomical and nutritional attributes aside, quinoa’s global success relies on making it affordable. Consumers will not buy what they cannot afford, and farmers will not grow large quantities of a crop that is not financially viable.

Such is the so-called quinoa quandary that as the demand for quinoa has grown in recent years, so has its price. Less than $70 per ton a decade ago, quinoa now sells for more than $2,000, according to FAO figures.

In Bolivia, quinoa farmers near Lake Titicaca, the world’s highest body of water, carry waist-high stalks covered with purple, yellow, green and orange flowers to harvest. This is considered the cradle of great civilizations for the Tiahuanaco and the Incas, and is the origin of quinoa.

“Now people everywhere are buying quinoa. In La Paz, they sell it in the markets. It’s everywhere. For that reason we are also able to sell small quantities. With that money we sustain our families,” Elias Vargas, a farmer, told the United Nations.

Mr. Vargas and his neighbours sell their crops to a Bolivian coffee chain, Alexander Coffee, which uses quinoa in its salads, sandwiches and desserts. The company bakery turns out more than 1,000 quinoa chocolate chip cookies per day.

“In the beginning it was hard to change the mentality,” recalled Pamy Quezada Velez, CEO of Alexander Coffee. Quinoa used to be known as ‘poor man’s food’ with Bolivians preferring to eat wheat and rice. “More people are opening up to the idea, and we’re doing well with quinoa.”

The partnership between small farmers and small businesses is part of a project supported by the UN’s International Fund for Agricultural Development (IFAD). While farmers like Mr. Vargas do not grow enough to sell to foreign markets, increased domestic consumption provides them with new opportunities.

Almost all of the estimated 250,000 acres of quinoa farmland is in the hands of small farmers and associations around the world. FAO estimates that at least 130,000 small quinoa growers from South America alone will benefit this year from increased sales, higher prices for their crops and a return to indigenous practices in a sustainable manner.

“In the traditional markets, it is still rather accessible to poor people but when you find it in the supermarket it tends to be rather expensive,” Mr. Bojanic said.

The rapid expansion of quinoa farming in the last years has been a double-edged sword. As prices rise, farmers are more likely to sell the quinoa crops they would have consumed, sparking concerns of malnutrition. About one-third of children under the age of five in the Andean countries are already chronically malnourished, according to figures from the World Health Organization (WHO).

Quinoa fields on the Bolivian altiplano. Photo: Claudio Guzmán/FAO

The change in food choices as a result of higher income is also causing some farmers to turn from traditional staples to more caloric, processed foods. The change is particular among youth who would prefer a sugary soda to a home-made drink of boiled water, sugar and quinoa flour.

In addition, the increased incentives to produce more quinoa are also contributing to land disputes. “Land that had barely any use in the past and small farmers who were not in conflict are starting to – now that the land has more value – struggle among themselves so they can claim such lands to produce quinoa,” Mr. Bojanic said.

Property disputes are further aggravated by reverse migration, as the high prices for quinoa are motivating residents who moved to cities to return to plots, and by not giving the soil enough time to rest between harvests.

The push for increased production is seemingly at odds with the traditional life of the quinoa farmers, a main reason quinoa was selected for the honour. But UN officials stress that boosting the importance of developing sustainable production systems for quinoa consumption and food security are among the main objectives for the year.

Boosting sustainable agricultural practices and partnerships

The International Year of Quinoa, is overseen by the IYQ- International Coordination Committee composed of the ministries of agriculture of Andean countries and France. Bolivia has the presidency of the Committee, with Ecuador, Peru and Chile sharing the vice-presidency.

“The reaction is very enthusiastic,” said Mr. Bojanic. “Governments are looking at a coordinated approach to increase production nationally and regionally.”

Experimental quinoa plants at the Instituto Nacional Autónomo de Investigaciones Agropecuarias in Ecuador. Photo: INIAP

In the public sector, the UN is looking to engage with international agricultural research centres and national research centres on a global research network and gene bank database to maintain the crop’s 120 variations. The idea is that experts will test the crops and show farmers how they can best be grown under different conditions.

Professor Luz Gomez Pando is one of the local experts and scholars working with the UN in Lima, Peru. Based at La Molina University, she uses nuclear radiation to develop new varieties of quinoa that have a higher yield. The gamma rays speed up the evolution process that would take millions of years in nature. She then gives her seeds to the women farmers and at harvest time, cooks quinoa with them.

“I am from the highland above 3,000 metres and I was the daughter of two farmers,” Ms. Gomez told UN Radio and the International Atomic Energy Agency (IAEA). “What we need right now is to have these crops very fast in big fields.”

The majority of quinoa is produced using traditional technologies that result in low yields. A hectare normally results in 600 kg of quinoa. FAO wants to raise the production to a ton of quinoa per hectare. That would help raise the overall production from 70,000 tons per year to 200,000 tones annually by 2018 through improved technologies and engagement with businesses already processing quinoa, including large importers and exporters.

References:

http://www.un.org/apps/news/story.asp?NewsID=44180#.US1C3jCR98E

http://nutritiondata.self.com/facts/cereal-grains-and-pasta/10352/2

Understanding the different dimensions of malnutrition (undernutrition) to maximize human capital development (Part 2: the facts)

This is it!

We are moving to the next blog and we will start by defining briefly the different dimensions of malnutrition (undernutrition) using an interactive approach (maps, figures and facts). It will be a long journey, but I think an interesting learning path not only for you, the people who are reading this blog but also for me and CKi. Let’s start …

(http://timpanogos.wordpress.com/2006/12/22/ranan-lurie-cartoon-competition/)

What is malnutrition?

I won’t give you an academic definition of what is malnutrition. A simple way to understand the concept is the fact that:

Hunger = Undernutrition = Malnutrition

 

Malnutrition = undernutrition or overnutrition

Malnutrition = not enough diversified foods in quantity and/or quality

 

To be healthy (not malnourished): you need to eat well….Your body needs to digest the food and absorb the nutrients released during the digestion process appropriately… Finally, the cells in your body need to use effectively the absorbed nutrients to build tissue, provide energy and/or regulate various organ and cell functions

 

Environmental issues like disease, stress… can affect the overall mechanism and exacerbate the degree of malnutrition

 

Complicate…. No!

 

Tackling the problem of malnutrition demands an integrated approach

 

 Undernitrition – where are we in 2013?

Undernutrition affects millions of people each year all over the world, although the main concentration of cases is found in Sub-Saharan Africa and Asia (see figure below).

870 million people are undernourished in the world today. That means one in eight people do not get enough food to be healthy and lead an active life.

Hunger and malnutrition are in fact the number one risk to the health worldwide — greater than AIDS, malaria and tuberculosis combined. It is recognized as the underlying cause of nearly a third of deaths from all diseases in children in pre-school years. In fact, maternal and child undernutrition account for 11 % of the global burden of disease.

The different types of undernutrition:

(UNICEF information)

There are two main types of undernutrition as shown in the figure above: growth failure and micronutrient deficiency(see figure below). Each form of undernutrition depends on what nutrients are missing in the diet, for how long and at what age. They include:

1)      Growth failure:

• Severe and moderate forms of acute malnutrition (leading to wasting) are indicated by a low weight-for-height or presence of bilateral oedemas. This occurs as a result of recent rapid weight loss, or a failure to gain weight within a reasonably short period of time. Wasting occurs more frequently with infants and young children, often during the stages where complementary foods are being introduced to their diets (6 to 24 months), and when children are typically more susceptible to infectious diseases. Acute malnutrition can result from food shortages, a recent bout of illness, inappropriate child care or feeding practices or a combination of these factors.

According to Action Against Hunger, It is estimated that around 41 million children globally have moderate acute malnutrition (MAM). Most children with MAM live in southern Asia and sub-Saharan Africa. Furthermore, it is suggested that there are potentially 20 million children suffering from severe acute malnutrition (SAM) every year, and an estimated 0.5 million to 2 million children with SAM die each year, depending on the type of reporting mechanism.

Sixty percent of all the wasted children (both moderate and severe) in the world live in ten countries (see table below); India being the more affected with ~25 million children suffering of moderate and/or severe acute malnutrition.

(UNICEF information)

• Stunting or chronic undernutrition, resulting in growth retardation, is indicated by a low height for-age. The causes and etiology of stunting include nutrition, infection and mother-infant interaction. Stunting is a cumulative process that can begin in utero and continue until the age of 3 years after birth, compromising the growth of a child. The consequences of becoming and remaining stunted are increased risk of morbidity, mortality, delays in motor and mental development, and decreased work capacity.

Stunting is estimated by the UNICEF to affect 800 million people worldwide. 195 million children under 5 years of ages are stunted. The prevalence of stunting is highest in Africa (40%), and the largest number of stunted children is in Asia (112 million), mostly in South-central Asia (India). Ninety per cent of the overall global burden of child stunting is attributable to 36 countries (see figure below).

(HUMANOSPHERE information)

• Underweight is a composite measure of both acute and chronic malnutrition, indicated by a low weight-for-age.

In 2011, an estimated 17%, or 99 million children under five years of age in developing countries were underweight. As shown in the figure above, underweight is most common in South-central Asia (30%), followed by Western, Eastern, and Middle Africa (22%, 19% and 17%, respectively) and South-Eastern Asia (17%). The situation is better in Eastern and Western Asia, Northern Africa and Latin America and the Caribbean, where less than 10% of children were underweight.

What is well known is the fact that:

1)  Children in the poorest households are twice as likely to be underweight as those in the least poor households.

2) Children living in rural areas are more likely to be underweight than those living in urban areas.

The proportion of children under five years old in developing countries who were underweight has declined by 11 percentage points between 1990 and 2011, from 28% to 17% (see figure below). During this period of time, good progress has been made in Western Asia (reduction from 14% to 5%), Eastern Asia (reduction from 15% to 3%), Caribbean (reduction from 9% to 4%), Central America (reduction from 11% to 4%) and South America (reduction from 6% to 3%). In South-eastern Asia, underweight has declined but remains high at 17%. In contrast, underweight continues to be very high in South-central Asia (30%). This combined with large population, means that most underweight children live in South-central Asia (56 million in 2011). Actually, India has the second higher % of children aged <5 years that are underweighed (43.5%). Finally, as shown in the figure below, progress is still insufficient in Africa. One interesting point is the fact that we don’t know yet if rising food prices and the current economic crisis have affected the latest trends in some populations, it is too early to draw firm conclusions.

 

2)      The micronutrient deficiency:

Micronutrient deficiencies occur when the body does not have sufficient amounts of vitamins or minerals due to insufficient dietary intake and/or insufficient absorption and/or suboptimal utilization of the vitamins or minerals by the body. One out of 3 people (2 billion people) worldwide are affected by vitamin and mineral deficiencies, according to the WHO.

Three, perhaps the most important in terms of health consequences for poor people in developing countries, are:

• An estimated 250 million preschool children are vitamin A deficient. An estimated 250,000 to 500 000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight. Moreover, in vitamin A deficient areas, it is likely that a substantial proportion of pregnant women is vitamin A deficient.
• Iron deficiency is a principal cause of anemia. Two billion people—over 30% of the world’s population—are anemic. For children, health consequences include premature birth, low birth weight, infections, and elevated risk of death. For pregnant women, anemia contributes to 20% of all maternal deaths.

In many countries, more than half of all women of reproductive age are anemic (see figure below).

• Iodine deficiency disorders (IDD) put at risk children´s mental health– often their very lives. Serious iodine deficiency during pregnancy may result in stillbirths, abortions and congenital abnormalities such as cretinism, a grave, irreversible form of mental retardation that affects people living in iodine-deficient areas of Africa and Asia. IDD affects over 740 million people, 13% of the world’s population. Fifty million people have some degree of mental impairment caused by IDD.

The figure below shows the areas at high risk of micronutrient deficiency for iron, vitamin A and iodine in the developing world. What is interesting to note is the fact that micronutrient deficiency affects a larger range of low and middle-income countries, more than the problem of underweight and/or stunting (see figure above). Globally, the problem is enormous and needs a special attention.

The two new dimensions of undernutrition:

Improving the health of mothers, newborns and children and reducing the number of preventable deaths are top priorities for many stakeholders working in both the developed and developing worlds. Improving child and maternal health is also an important strategy in the long term because it relates to the fetal origin of adult disease like hypertension, obesity, diabetes and cardiovascular disease. In this new context where we are moving from saving life to improving human development and preventing adult disease, two important dimensions of undernutrition need to be discussed independently. They are:

• Maternal undernutrition, resulting in poor nutritional status of the mother during preconception, pregnancy and post-natal stages, is indicated by a low Body Mass Index (BMI) and micronutrient deficiencies.

In nowadays, the prevalence of low body mass index (BMI <18.5 kg m-2) among women 15–49 years of age may be as high as 26.5% in Sub-Saharan Africa, 35% in South/Southeast Asia, 15.5% in Caribbean and 4% in Latin America. As shown in the figure below, India is again among the countries with the higher level of underweight women (> 20%). It is important to keep in mind that maternal short stature and low body mass index independently have adverse effects on pregnancy outcomes.

(http://openi.nlm.nih.gov/detailedresult.php?img=3182195_pone.0025120.g001&req=4)

It was really difficult to find a visual representation of the worldwide prevalence of underweight among women aged 20-49 years old. The map above shows both the prevalence of underweight and overweight in 57 low to middle income countries. What is quite interesting is the fact thatthe prevalence of overweight in young women residing in both urban and rural areas is higher than those in underweight women, especially in countries at higher levels of socioeconomic development. The best examples are Brazil and South Africa (the worse situation), the exception is India.

• Low birth weight (LBW) of newborn infants is defined as weighing less than 2,500 g at birth irrespective of gestational age (WHO). More common in developing than developed countries, a birth weight below 2,500 g contributes to a range of poor health outcomes like low fetal and neonatal mortality and morbidity, inhibited growth and cognitive development, and chronic diseases later in life. Birth weight is affected to a great extent by the mother’s own fetal growth and her diet from birth to pregnancy, and thus, her body composition at conception.

 More than 20 million infants worldwide, representing 15.5 %of all births are born with low birth weight, 95.6 % of them in developing countries. The level of low birth weight in developing countries (16.5 %) is more than double the level in developed regions (7 %).

Half of all low birth weight babies are born in South-central Asia, where 27 % of all infants weigh less than 2,500 g at birth. Low birth weight levels in sub-Saharan Africa are around 15 %. Central and South America have, on average, much lower rates (10 %), while in the Caribbean the level is almost as high as in sub-Saharan Africa (14%). About 10 % of births in Oceania are low birth weight births. Interestingly, almost 70 % of all low birth weight births occur in Asia; mainly in India, which is also the country with the high prevalence of stunting.

To summarize:

Undernutrition is a major issue, the numbers talk by themselves:

• 2 billion people worldwide are micronutrient deficient
• 870 million undernourished people in the world
• 800 million people worldwide are stunted
• Asia and the Pacific have the largest share of the world’s hungry people (563 million)

• 195 million children under 5 are stunted
• 99 million children under 5 worldwide are underweight
• 61 million children suffered from acute malnutrition, including 20 million suffering from severe acute malnutrition
• 20 million children are born with restricted intrauterine growth or prematurely
• Every year at least 3.5 million of children under 5 die from malnutrition-related causes

• Women make up a little over half of the world’s population, but they account for over 60% of the world’s hungry
• 468 million women aged 15 to 49 years (30% of all women) are anemic, at least half because of iron deficiency

Tackling the issue of undernutrition in the word will need significant progress in India because:

• 230 million people go hungry daily (~1/3 of the worldwide undernourished people)
• An estimated 40% of the world’s severely malnourished children under 5 live in India

• 60 million children are underweight
• 48 % children under 5 are stunted
• Half of the country’s children are chronically malnourished and 80 % are anemic
• 30 % of children are born with low birth weight
• Child malnutrition is responsible for 22 % of the country’s burden of disease
• At least half of infant deaths are related to malnutrition, often associated with infectious disease

• More than 90 % of adolescent girls and 50 % of women are anemic

References:

http://www.fao.org/docrep/016/i3027e/i3027e.pdf

 http://www.unicef.org/nutrition/training/2.3/2.html

 http://ccafs.cgiar.org/bigfacts/undernourishment/

 http://jn.nutrition.org/content/129/2/529.full.pdf

 http://blogs.scientificamerican.com/observations/2011/12/08/stunted-growth-from-common-causes-threatens-childrens-later-achievement/

 http://www.childinfo.org/files/low_birthweight_from_EY.pdf

 http://gamapserver.who.int/gho/interactive_charts/mdg1/atlas.html

 http://www.who.int/gho/mdg/poverty_hunger/underweight_text/en/index.html

 http://www.actionagainsthunger.org/impact/nutrition

 http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/0,,contentMDK:20916955~pagePK:146736~piPK:146830~theSitePK:223547,00.html

 http://www.cini.org.uk/childmalutrition.pdf

 http://www.unicef.org/infobycountry/india_statistics.html

 http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_12-en.pdf

 https://www.wfp.org/hunger/stats

 http://articles.timesofindia.indiatimes.com/2012-01-15/india/30629637_1_anganwadi-workers-ghi-number-of-hungry-people

 

Understanding the different dimensions of malnutrition to maximize human capital development (Part I: Introduction)

Malnutrition (over (bad) and undernutrition) is a global issue not only in the developed world but also in the developing countries. Its outcome is catastrophic in both cases. A simple act … feeding ourselves and our children appropriately seems to be not so easy. Why? There are many reasons that I won’t discuss today in this blog. In fact, I would like to focus on the different dimensions of malnutrition (hunger and undernutrition) and its consequences in the context of international development, mainly because it is currently the “on fire” issue that needs to be addressed. For a lot of stakeholders including us, nutrition and food security represent the cornerstone for progress on other development fronts such as employment, education, the environment and health and in achieving a quality future for humankind.

Over the past five years, the fight against undernutrition and hunger is finally receiving the attention that it deserves:

• Through the publication in the Lancet of a series of papers related to child and maternal undernutrition in 2008, which drew together evidence on key problems and proven solutions in nutrition (the next series will be launched in May 2013),
• Followed by a number of initiatives, among other the endorsement of the ‘Scaling Up Nutrition’ Framework (SUN) by various stakeholders (2009). The SUN Framework calls for the implementation and scaling up of two complementary approaches. The first one is direct effective nutrition-specific interventions, focusing on pregnant women and children under two with short-term direct interventions such as the promotion of good nutritional practices, micronutrients, and complementary feeding. The second is a broader multi-sectoral nutrition-sensitive approach that tackles the determinants of undernutrition by promoting agriculture and food security, access to and consumption of nutritious foods, improving social protection, care practices and ensuring access to health care,
• To the recent Rome meeting consultation on post-2015 development agenda co-led by the Food & Agriculture Organization (FAO) and the World Food Program (WFP) that calls for food security and nutrition to be the central element in future development efforts not just for developing countries but for the global community as a whole.

Although the prevalence of malnutrition in developing countries is decreasing, it is still a major problem for many children. Understanding the problem and consequently formulating intervention programs at the local and national levels is a motion in progress but it still remains a complex and difficult issue.

The first reason being that the process of malnutrition expresses itself in different forms and with variable consequences.

A second reason making malnutrition a complex problem is that the primary causes – the interaction between insufficient food supply (quantity and quality) and the frequent recurrence of infectious diseases – are determined by a multitude of factors of different natures. This complexity – of its expressions, effects, and causality – makes it difficult to get a global vision and understanding of the problem.  

As we are moving in a new era where tackling the problem of malnutrition (hunger, undernutrition and bad nutrition) could be one major focus in the post-2015 development agenda, it is important to better understand the pathophysiology of malnutrition and the factors that influence the growth process in preschool age to help to better direct actions.

During the next few weeks, we will try to answer these questions:

What are the different dimensions of malnutrition (i.e. hunger and undernutrition), the causes, the consequences, and the proposed strategies/solutions to make undernutrition “the world’s number one solvable problem”?

We will focus more specifically on stunting (a not so well known complex aspect of malnutrition with long term impact), micronutrient deficiencies (one of the most cost effective solutions to tackle some specific consequences of malnutrition), the long-term consequences of undernutrition in the context of child and maternal health, the importance of protein intake for human capital development. Finally, we will try to summarize the most appropriate strategy that would use a combination of direct effective nutrition-specific interventions and a broader multi-sectoral nutrition-sensitive approach that tackles the determinants of undernutrition.

Time to move to the next blog….

Can antibiotics save the life of malnourished children? Yes it can but …

Malnutrition is a major health problem in low- and middle-income countries, particularly in children less than 5 years of age. Recent estimates suggest that 3.5% of children worldwide, or nearly 20 million, are severely malnourished. Severe acute malnutrition (SAM), characterized by a weight of less than 70% of the median weight for height and/or by visible severe wasting and/or by the presence of nutritional oedema, is a life-threatening condition. In the absence of appropriate treatment, case-fatality rates in hospitalized children (inpatient) range from 30% to 50%.

In many poor countries, the majority of children who have severe acute malnutrition are never brought to health facilities. In this circumstance, only an approach with a strong community component can provide them with the appropriate care. Evidence shows that about 80 % of children with severe acute malnutrition who have been identified through active case finding, or through sensitizing and mobilizing communities to access decentralized services themselves, can be treated at home (outpatient). The other 20 % needs to be transferred for inpatient treatment. Current estimates suggest that about 1 million children die every year from severe acute malnutrition.

In the early 2000s, malnutrition got a squishy new peanut-flavored enemy. Kids fed a calorie-rich paste of peanuts, sugar, milk, and the whole alphabet of vitamins and minerals recovered at rates nearly twice that for previous treatments (fortified milk formulas). The ready-to-use therapeutic food (RUTF) has some advantages: it is a ready-to-use paste which does not need to be mixed with water, thereby avoiding the risk of bacterial proliferation in case of accidental contamination. It can be stored for three to four months without refrigeration, even at tropical temperatures.

However, some 15% of the severely malnourished children still didn’t recover on RUTF and died. A new study in Malawi recently published in the New England Journal of Medicine (NEJM) reports on the potential of using antibiotics as part of the management of severe acute malnutrition to diminish this “non response” to nutritional treatment.

To summarize the study and its main results: the malnourished children enrolled in the study were treated at home and received antibiotics or placebo during the first 7 days plus RUTF for a period of one month. Overall, 88.3% of the children enrolled in the study (RUTF ± antibiotics) recovered from severe acute malnutrition. Among them, the rate of weight gain was significantly increased among those who received antibiotics. Furthermore, the overall mortality rate was 5.4% but antibiotics plus RUTF cut mortality by 36 to 44 % compared to RUTF alone. This means that for every 100 children treated, two to three lives could be saved; treating a million could save more than 20,000. One of the potential explanations of the observed improvement in recovery and mortality rates is the fact that antibiotics decreased the potential development of sepsis during nutritional treatment.

Interestingly, the authors also looked at the baseline characteristics of the children enrolled in the study and how these parameters can affect both survival and nutritional recovery when treated with antibiotics and RUTF.

This aspect of the study’s analysis was not discussed in the two articles published in Mother Jones and the New York Times that I have read. In fact, this kind of analysis helps to understand the residual 4.5 % mortality rate and the potential “non response” to antibiotics and RUTF for a specific population. It highlights also the importance to perform a good clinical diagnostic and a socio-economic analysis to better understand the family situation and identify the children at risk before enrollment. Finally, it shows the necessity to continue to invest in prevention strategies.

For example, the study showed that the children who recovered were significantly older and were more likely to have their father alive and still at home. In fact, the authors found that younger age, marasmic kwashiorkor*, greater stunting, poor appetite, HIV exposure or infection, and a cough before enrollment were associated with an increase risk of treatment failure, including an increased risk of death.

Investing in prevention strategies is critical. Exclusive breast feeding during the first 6 months, and continuing breast feeding and promoting improved complementary feeding practices for all children aged 6–24 months — with a focus on ensuring access to age-appropriate complementary foods (where possible using locally available foods) can prevent malnutrition at a younger age. This strategy can also ensure healthy growth and development, minimizing the incidence of stunting. In Malawi, the rate of exclusive breastfeeding is quite high (71% in 2010 vs 44% in 2000) when compared to other Sub-Saharan African countries but there is still room for improvement.

Furthermore, HIV can be a key limitation of the benefit of antibiotics and RUTF in the treatment of severe acute malnutrition. In the context of Malawi, an estimated 11% of the adult population is infected with HIV and the prevention of mother-to-child transmission of HIV is still low (~30% in 2010). Indeed, only 40% of eligible HIV+ pregnant women received ART in 2010. In the study published in NEJM, only 31.6% of the children were tested for HIV, and those who were known to be HIV seropositive, especially if not receiving ART, had the higher risks of treatment failure and death.

In fact, the World Health Organization (WHO) recommends the use of ARTs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period. Furthermore, WHO recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARTs during that period. This approach reduces the risk of HIV transmission and improves the infant’s chance of survival by boosting the immune system, reducing energy loss and improving child’s appetite to food. In this condition, the HIV-positive children who receive ART can respond appropriately to RUFT in the treatment of severe acute malnutrition. Moreover, the main challenge lies in increasing the availability of treatment in resource-limited countries. The expansion of ART and Preventing Mother-to-Child Transmission (PMTCT) of HIV services is currently hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV-specific interventions within broader maternal and child health services. More works  need to be done in this direction…

Finally, the study published in NEJM concluded that further studies are needed to evaluate long-term outcomes of routine antibiotic use (like drug resistance) in children with uncomplicated severe acute malnutrition and to determine whether a specific high-risk target population can be better defined. We are waiting for more results and new recommendations…

 

* A malnutrition disease, primarily of children, resulting from the deficiency of both calories and protein. The condition is characterized by severe tissue wasting, dehydration, loss of subcutaneous fat, lethargy, and growth retardation.

 

References:

http://www.who.int/bulletin/volumes/89/8/10-084715/en/index.html

http://www.nutriset.fr/Downloads/PFE-RUTF-Increasing-access.pdf

http://www.unicef.org/publications/files/Community_Based_Management_of_Sever_Acute__Malnutirtion.pdf

http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/

http://www.who.int/mediacentre/news/releases/2009/world_aids_20091130/en/index.html

http://www.countdown2015mnch.org/reports-and-articles/2012-report

http://www.nutritionj.com/content/11/1/60

 

Going beyond food aid: the challenge of improving nutrition

Food security programs are shifting their focus from quantity to quality, but what is the best approach?

Article published in the Guardian, December 2012 – http://www.guardian.co.uk/global-development-professionals-network/2012/dec/03/food-aid-improving-nutrition

This is a great article … then we hope you will enjoy it. It highlights the importance to focus on quality (diversity in foods, indigenous staples…) and not anymore (or not only) on food quantity (calories) – A vision for program development shared by Challenged Kids International.  

Food security and malnutrition remain some global development‘s biggest challenges. Latest UN figures show that 870 million people were chronically undernourished between 2010–12; the vast majority of whom, 850 million, live in developing countries. Yet despite this the UN’s Scaling Up Nutrition (SUN) movement said in it’s report that 2012 was the year “when chronic under-nutrition moved from the side-lines to the centre”. It argues that the international community has now realized the need to shift focus from simply food quantity, to one of food quality. In a word: nutrition.

There are, however, differing views as to how best to increase nutrition levels.

Monique Mikhail, policy adviser on sustainable agriculture at Oxfam, welcomes initiatives such as SUN, which has 28 developing country government members. But she and many others in the NGO community fear that international efforts to target government agricultural policies often result in more cereals to be sold as export, rather than the locally-produced diverse foods needed to improve nutrition.

“A lot of the discourse out there is pushing this large-scale, mono-culture model, without realizing the impacts of that on communities”, says Mikhail. “Land is being taken away from small-scale producers.” The World Bank identifies five ‘pathways’ that link food production to nutrition: subsistence-oriented production, income-oriented production for sale in markets, increased agricultural production, empowerment of women to control household food and health, and macroeconomic growth. But in practice, one is favored over another.

According to SUN, a 2005 Ethiopian health survey found that chronic malnutrition was highest in its most agriculturally productive regions. The inference was large-scale production can lead directly to export, or simply a lack of local food diversity.

It is a problem that Samuel Hauenstein Swan, senior policy adviser, Action Against Hunger, recognizes  “Malawi promoted corn – it didn’t dramatically improve the food security of the people, but it dramatically improved the exports. They are one of the big maize exporters now. But did that reduce the numbers of stunting? Not really … ministers of agriculture are still focused on these very few grains [while] nutritious crops like sweet potatoes are not easily commercial.”

NGOs working on the ground, therefore, are increasingly promoting small-scale food production within communities. Cristina Ruiz, humanitarian program unit manager, Africa, at Christian Aid, has recently returned from two years in the Sahel region of Africa – one of the world’s most malnourished regions. “We start by working with communities to do a capacity assessment, which lasts for two or three days in a community, conducting an in-depth analysis of the risks and threats they face and the capacity they have in the community to deal with that”, she explains. “Out of that comes an action plan for how they could improve their resilience to those risks.”

The Sahel’s staples of millet and maize, of low nutritional value and severely diminished by years of drought, are now supplemented by market gardening, says Ruiz. “We help them to grow vegetables they can eat but also sell as a cash crop locally. That has been the biggest change and the biggest success. You need water to do that – so we have been providing bore holes and solar pumps.”

Mikhail also advises that development professionals look to small-scale farming when addressing malnutrition. “Small-scale livestock is also incredibly important. Consuming more meat, milk and protein contributes greatly to your overall nutritional status in a way that allows you to absorb vitamins from the other vegetable products,” he says.

Crucially NGOs seem to be finding more success by concentrating their efforts on women. The FAO argues that when women have control over household income, more money tends to be spent on items that improve nutrition and health. Mikhail agrees: “The important role that women play as carers, food producers and providers is the critical nexus for improving agricultural production, increasing production, as well as improving the quality and nutrition at consumption … I think where we had mainly fallen short in the past was that we hadn’t focused directly on women.”

Hauenstein Swan believes that food security remains dominated by calorie intake and food aid. But he says the knowledge now exists to move beyond that towards resilience, empowerment and hardier, more nutritious staples such as sweet potato, QP Maize and golden rice, rather than allocating vast amounts of land for export crops. “On the global level”, he says, “you can’t escape nutrition now when you talk about food security.”

A field guide nutrition checklist

1. Identify the scale and cause of undernutrition. Collect information about the magnitude of undernutrition, its causes and severity. Then identify and target the most vulnerable groups, especially pregnant mothers and children under two.

2. Assess food consumption patterns. Gain an understanding of what the community eats, where they obtain food, and the nutritional gaps.

3. Assess the level of government commitment. Look at the national nutrition strategy and policy framework and the level of current/planned budget to roll that out, including local representation and extension services.

4. Identify care and health practices. This includes informal care – mothers, siblings, fathers – as well as formal health care services in the area.

5. Promote biodiversity and sustainable agricultural practices.

6. Give women the means to empower themselves.

7. Promote the production and consumption of meat, dairy products and fish (where available).

8. Reach out through multiple channels. Home visits, agricultural extension services, nutrition counselling, women’s groups, dramas and storytelling. These could be combined with other essential health services such as immunization.

Source: ACF International