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.

02-20-2013quinoa

References:

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

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

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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 …

1st_Alfredo_Sabat_cartoon2006

(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).

figure 1

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:

figure 2

(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.

figure 3

(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).

WHO-Child-Stunting-map-e1280356202549

(HUMANOSPHERE information)

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

figure 6

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.

figure 7 

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).

anemia-prevalence

  • 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.

y7352e32

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.

figure 4

(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 %).

figure 5

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.

111-2k4so1b

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 …

rutf 2

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