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!

OCIC article

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 28th 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.

 stunting-in-children_50291a07a181b

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:

 graph 1

 (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:

graph 2

  (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).

 figure 9 article 3

 

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.

 figure 3 article 3

 

 (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).

 figure 1 artice 3

 

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). 

 figure 10 article 3

 

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).

figure 5 article 3 

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.

 figure 7 article 3

 

 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.

 figure 8 article 3

  

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

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….