Eating on $1.75 a day

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Invest in Nutrition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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…  

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 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.

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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….

Why millions of people choose to live in urban squalor?

As international development practitioners, we have had many occasions to visit slums in Africa or anywhere in the world. Personally, my more difficult time was in Port-au-Prince and in this specific context; poverty in the countryside has seemed to me almost Arcadian by comparison. The rural poor may lack nutrition, health care, education, and infrastructure but they can farm still in settings that not only are more bucolic, but also represent the condition of most of humanity for most of history.

With life so squalid in urban slums, why would anyone want to move there?

This is an interesting question that Charles Kenny has tried to address in his article “In Praise of Slums” published in the Foreign Policy magazine. In this new blog, we propose to describe and discuss some of his major ideas, highlight the missing aspects, if there are some and finally we will focus on one of our main centers of interest, i.e. the nutrition.

According to Charles Kenny, there are two reasons for choosing to live in urban slums

1- Because slums are better than the alternative

Most people who’ve experienced both rural and urban poverty choose to stay in slums rather than move back to the countryside. That includes hundreds of millions of people in the developing world over the past few decades, including 130 million migrant workers in China alone. They follow a well-trodden path of seeking a better life in the bright lights of the city and in this new century, the probability of living a better life is better than ever. In the case of China, world economic supremacy and extensive industrialization can explain this result. For some African countries that are currently experiencing a sustained economic growth, it can be the same.

2 – Start with the simple reason that most people leave the countryside: money

Everyone is after the same thing…. Prosperity!

Moving to cities makes economic sense. Rich countries are urbanized countries, and rich people are predominantly town and city dwellers.

According to the McKinsey Global Institute, 600 cities worldwide account for 60% of global economic output (http://www.mckinsey.com/insights/mgi/research/urbanization/urban_world). While 600 cities will continue to account for the same share of global GDP in 2025, this group will have a very different membership. Over the next 15 years, the center of gravity of the urban world will move south and, even more decisively, east. By 2025, 136 new cities are expected to enter the top 600, all of them from the developing world and overwhelmingly—100 new cities—from China.

Slum dwellers may be at the bottom of the urban heap, but most are better off than their rural counterparts. In fact, while about half the world’s population is urban, only a quarter of those living on less than a dollar a day live in urban areas. In Brazil, for example, where the word “poor” conjures images of both Rio’s vertiginous favelas and indigenous Amazonian tribes living in rural privation, only 5% of the urban population is classified as extremely poor, compared with 25% of those living in rural areas (http://www.ruralpovertyportal.org/web/rural-poverty-portal/country/home/tags/brazil).

But is it much of a life, eking out an existence in today’s urban squalor!

According to an article published in the New England Journal of Medicine (NEJM), urbanization could be an emerging humanitarian disaster (http://www.nejm.org/doi/full/10.1056/NEJMp0810878).

Why?

Because it grows too fast! To give you an example, the capital of Botswana, Gaborone, will grow from 186,000 to 500,000 inhabitants by 2020. According to United Nations Human Settlements Program (UN-Habitat), all population growth from now on will be in cities: the urban population is projected to grow to 4.9 billion by 2030, increasing by 1.6 billion while the rural population shrinks by 28 million.

According to the NEJM’s article, this transition is happening chaotically, resulting in a disorganized urban landscape. Although many expect urbanization to mean an improved quality of life, this rising tide does not lift all boats, and many poor people are rapidly being absorbed into urban slums. The UN-Habitat reports that 43% of urban residents in developing countries such as Kenya, Brazil, and India and 78% of those in the least-developed countries such as Bangladesh and Haiti live in such slums.

In fact, urbanization could be a health hazard for certain vulnerable populations, and this demographic shift threatens to create a humanitarian disaster. The threat comes both in the form of rising rates of endemic disease such as pulmonary diseases, diabetes and hypertension and a greater potential for epidemics and even pandemics like cholera. Indeed, increasing the population density in cities without proper water supplies and sanitation increases the risk of transmission of communicable diseases.

Countries like Ghana and Ethiopia because of their current and projected economic growth and the will of their governments to reduce the impact of poverty may be able to respond adequately to this demographic shift by offering not only the needed access to health services but also the necessary infrastructures like housing, and water and sanitation. These two countries are among the four African countries that are going to reach some of the MDGs in 2015. Progresses are there! Regrettably, for other countries like Haiti, it may take evermore. Kenya is another example (see below).

But slum living today, for all its failings, is markedly better than it was in Dickens’s time.

According to Charles Kenny, “urban quality of life now involves a lot more actual living. Through most of history, death rates in cities were so high that urban areas only maintained population levels through constant migration from the countryside. In Dickensian Manchester, for instance, the average life expectancy was just 25 years, compared to 45 years in rural Surrey. Across the world today, thanks to vaccines and underground sewage systems, average life expectancies in big cities are considerably higher than those in the countryside; in sub-Saharan Africa, cities with a population over 1 million have had infant mortality rates one-third lower than those in rural areas. In fact, most of today’s urban population growth comes not from waves of villagers moving to the city, but city folks having kids and living longer.”

The comparison with Dickens’s time is quite powerful! Fortunately, conditions are better. It would be interesting to bring another layer of social context and to compare the living conditions of rural populations in developing countries with those of the peasants of Dikens’s time. Have they improved also? Unfortunately, we could not find any pertinent information regarding this specific point.

However, Birchenall showed in his article entitle “Economic Development and the Escape from High Mortality” (http://econ.ucsb.edu/~jabirche/Papers/development.pdf) that while mortality in cities in developed countries during the 20th century declined drastically due to health interventions, mortality in cities started to decline once death rates in rural areas were already declining. In fact, agricultural changes associated with economic development initiated the escape from high mortality and provided the conditions for higher population and higher income in the world. As food availability increased, anthropometric and epidemiological evidences indicate that people in developed countries became taller, heavier, and less susceptible to infectious diseases, especially to diseases in which nutritional status has a definite influence. According to Birchenall, the contribution of per capita income to the world mortality decline from diseases sensitive to nutrition can be as large as 45%. The contribution to the overall mortality decline and to the decline of all infectious diseases is close to 30%.

Access to health, economic development and more importantly good nutrition (quantity as well as quality) were the pillars of the escape from high mortality for the developed countries over the past two centuries. Normally, an historical analysis can show us the appropriate path to follow. Are we observing the same pattern in developing countries? This is an interesting question.

Why are the different elements that can explain a better quality of life?

The latest analyses show ed  that one of the element is a better access to services

Data from surveys across the developing world suggest that poor households in urban areas are more than twice as likely to have piped water as those in rural areas, and they’re nearly four times more likely to have a flush toilet (http://www.prb.org/pdf09/64.2urbanization.pdf).

In India, very poor urban women are about as likely to get prenatal care as the non-poor in rural areas. And in 70% of countries surveyed by MIT economists Abhijit Banerjee and Esther Duflo, school enrollment for girls ages 7 to 12 is higher among the urban poor than the rural poor.

That said, modern slum dwellers – about one-third of the urban population in developing countries — are some of the least likely to get vaccines or be connected to sewage systems (http://www.unhabitat.org/pmss/listItemDetails.aspx?publicationID=1156).

That means ill health in informal settlements is far more widespread than city averages would suggest. In the slums of Nairobi, for example, child mortality rates are more than twice the city average and higher, in fact, than mortality rates in Kenya’s rural areas. But Nairobi’s slums are atypically awful, more an indicator of the Kenyan government’s dysfunction than anything else.

In most developing countries, even the poorest city dwellers do better than the average villager. Banerjee and Duflo (http://economics.mit.edu/files/530) found that, among people living on less than a dollar a day, infant mortality rates in urban areas were lower than rural rates in two-thirds of the countries for which they had data. In India, the death rate for babies in the first month of life is nearly one-quarter lower in urban areas than in rural villages. So significant is the difference in outcomes that population researcher Martin Brockerhoff concludes that “millions of children’s lives may have been saved” in the 1980s alone as the result of mothers worldwide moving to urban areas (http://htc.anu.edu.au/pdfs/Brocker1.pdf). An interesting statement!

But who are the hungry – the rural or the urban population?

According to the latest Food and Agriculture Organization (FAO) statistics, there are 925 million hungry people in the world and 98% of them are in developing countries.  They are distributed like this:

578 million in Asia and the Pacific

239 million in Sub-Saharan Africa

53 million in Latin America and the Caribbean

37 million in the Near East and North Africa

And 19 million in developed countries

Three-quarters of all hungry people live in rural areas, mainly in the villages of Asia and Africa. Tremendously dependent on agriculture for their food, these populations have no alternative source of income or employment. This is critical when there is only one raining season. If the crops production is compromised because of the lack of rain, then the farmers may migrate to cities in their search for employment, swelling the ever-expanding populations of shanty towns in developing countries.

FAO calculates that around half of the world’s hungry people are from smallholder farming communities, surviving off marginal lands prone to natural disasters like drought or flood. Another 20% belong to landless families dependent on farming and about 10% live in communities whose livelihoods depend on herding, fishing or forest resources.

The remaining 20% live in shanty towns on the periphery of the biggest cities in developing countries. Something we need to keep in mind is the fact that the numbers of poor and hungry city dwellers are rising rapidly along with the world’s total urban population. In this context, continued efforts are needed to reduce urban disparities and inequities associated with poverty.

Without any surprise – the more vulnerable are the children and the women!

An estimated 146 million children in developing countries are underweight – the result of acute or chronic hunger (UNICEF, 2009).  All too often, child hunger is inherited: up to 17 million children are born underweight annually, the result of inadequate nutrition before and during pregnancy. Furthermore, if we look specifically the urban situation: research indicates that urban infants suffer growth retardation at an earlier age than their rural counterparts, and that urban children are more likely to have rickets. While the urban diets are often more varied and include higher levels of animal protein and fat, rural diets may be superior in terms of calories and total protein intake. Average food consumption is lower and estimates of undernutrition generally higher in urban areas. However, physical malnutrition in children is markedly worse in the rural population, possibly because urban dwellers, of whatever social group, have lower energy demand than subsistence farmers.

Several associated factors account for nutritional deprivation among slum dwellers. One problem is the inability to adapt to new staples and a new structure of food prices. Food purchases of the urban poor are heavily dependent on competing demand for unavoidable non-food expenditure such as transport to work, housing and remittances to relatives in the countryside. The urban poor seldom have easy access to central markets due to public transport costs and are thus compelled to buy their food in small quantities from local shops at higher prices. They may have little time to prepare food, no suitable space for cooking and no money for fuel. As a result, the poor often rely mainly on small-scale local vendors to prepare meals with little regard for hygiene or food safety. When I was in Port-au-Prince, I saw a gigantic accumulation of white containers in the different canals and rivers that cross the city – demonstrating the importance of the “take-out  system” despite the high level of poverty.

On the other side, women are the world’s primary food producers, yet cultural traditions and social structures often mean women are much more affected by hunger and poverty than men. A mother who is stunted or underweight due to an inadequate diet often give birth to low birth weight children.

According to UNICEF, around 50% of pregnant women in developing countries are iron deficient. Lack of iron means 315,000 women die annually from hemorrhage at childbirth. As a result, women, and in particular expectant and nursing mothers, often need special or increased intake of food.

One major issue in urban undernutrition identified by most UN agencies is that of time constraints on urban women. They are more likely to be household heads, particularly in Latin America, and often lack social support networks found in rural areas. For many low-income female workers who leave home early in the morning and return late at night, bottle feeding of infants has become an absolute necessity. But commercial milk powders are often unhygienically prepared, creating a positive threat to infants’ health. In some urban communities, large scale introduction of bottle feeding has already changed the type and incidence of protein-energy malnutrition. Marasmus, a severe form of protein-energy deficiency, is becoming more frequent among younger children in urban areas. In four Bangkok slums, the prevalence of protein-calorie malnutrition was attributed to failure to breastfeed, early weaning and inadequate artificial feeding.

Slum life remains grim.

HIV prevalence rates are twice as high in urban areas of Zambia as they are in rural areas, for instance, and the story is worse with typhoid in Kenya. Slum residents are also at far greater risk from violence, outdoor air pollution, and traffic accidents than their rural counterparts. And the closer conditions in slum areas get to a state of anarchy mixed with kleptocracy, the more health and welfare outcomes tend to resemble those of Dickensian Manchester.

But all things considered, slum growth is a force for good. It could be an even stronger driver of development if leaders stopped treating slums as a problem to be cleared and started treating them as a population to be serviced, providing access to reliable land titles, security, paved roads, water and sewer lines, schools, and clinics.

As Harvard University economist Edward Glaeser puts it: “slums don’t make people poor — they attract poor people who want to be rich. So let’s help them help themselves”.

Definition: What is a slum?

A slum household is a household that lacks any one of the following five elements:

Access to improved water

Access to improved sanitation

Security of tenure

Durability of housing

Sufficient living area

Resources:

http://www.foreignpolicy.com/articles/2012/08/13/in_praise_of_slums

http://www.mckinsey.com/insights/mgi/research/urbanization/urban_world

http://www.nejm.org/doi/full/10.1056/NEJMp0810878 http://econ.ucsb.edu/~jabirche/Papers/development.pdf

http://www.ifpri.org/publication/why-child-malnutrition-lower-urban-rural-areas-0

http://www.wfp.org/hunger/who-are# http://www.fao.org/hunger/en/

http://whqlibdoc.who.int/publications/2012/9789280646320_eng_full_text.pdf

If you would like to read more interesting articles from Charles Kenny,

go to: http://charleskenny.blogs.com/

It is possible to improve food security in Sahel!

Where is located Sahel?

We have all heard about Sahel, but we don’t really know where it is located and how this region is large? Check the map below for more information.

The Sahel (in orange) is the ecoclimatic and biogeographic zone of transition between the Sahara desert (in yellow) in the North and the less arid Savannah (in green) in the South. It stretches across the north of the African continent between the Atlantic Ocean and the Red Sea. The Sahel covers parts of the territory of (from west to east) Senegal, southern part of Mauritania, Mali, southern part of Algeria, Niger, Chad, southern part of Sudan and Eritrea.

What characterizes the Sahel region right now?

The Sahel region suffers from recurrent drought events, temperatures easily crawl into the 100s. Food insecurity, hunger, death are common. Widespread drought, high food prices and poor harvests have put more than 18 million people in a situation of starvation and over a million children at risk of severe malnutrition.

But, despite this dramatic scenario of food insecurity – low rainfall and general food scarcity, some farmers have had a bumper rice yield this year. This surplus rice is no accident.

Is it a miracle?

Not at all! Over the last three years ACDI/VOCA (http://www.acdivoca.org/site/ID/home), an economic development organization, has helped some 10,000 farmers in the northern Segou region of the Sahel region located in Mali to make the transition from semi-nomadic livestock herders to sedentary farmers and landowners through the Alatona Irrigation Project, funded by the Millennium Challenge Account (MCA – an innovative and independent U.S. foreign aid agency that is helping lead the fight against global poverty (http://www.mcc.gov/pages/about).

Like for the majority of the African countries, the inhabitants of this region depend on natural rainfall to grow crops or create viable grazing grounds. For these pastoralists, one year of low rainfall, like last year, could wipe out their animal herds and create a human disaster. Indeed, it can force them to sale their livestock on which they depend for survival at a fraction of their value because it is done in response to a crisis situation. Resettling in a new village and retraining these herders has helped them transition from a subsistence lifestyle into commercial agriculture, resulting in family economic stability and regional food security.

How did they achieve these objectives – family economic stability and regional food security?

Each of the resettled families will receive title to five hectares of irrigated land (which is significantly superior to the average farm size of one hectare that a large majority of the farmers own in Mali), new housing and improved access to fresh water supplies, primary education for children, and health clinics.

Improving the quality of life of the whole family and breaking the intergenerational poverty cycle are important!

Working with local organizations, ACDI/VOCA helps train the new farmers to grow rice with careful irrigation, soil conservation and fertility practices. The farmers are also diversifying and selectively marketing second-season cash crops.

More specifically, ACDI/VOCA is organizing the distribution of agricultural starter kits to ensure success for first-time rice farmers. The kits include oxen, plowing equipment, wagons, fertilizer and certified seed. ACDI/VOCA will also provide kits for a second dry season vegetable crop exclusively for women farmers. In addition to rice, farmers are exploring markets for shallots, potatoes and forage crops for livestock feed.

Perhaps most importantly, these new farmers are learning water management, hydraulic systems, irrigation and drainage techniques as well as the best practices in terms of maintenance of a network of canals.

Access to water, appropriate equipments, technologies, savoir faire and local capacity building for long-lasting outcomes as well as diversification of the production are the keystone of any successful farming project!

As a result, Alatona farmers are producing 5.2 tons per hectare and making on average $1,000 per hectare in a country where average annual incomes are measured at $700 per year.

Everybody thought we herders were incapable of successfully developing the land that the project has given us,” Demba Diallo, a chief of one of the resettled villages remarked. “With all the positive impacts we are seeing, we are organizing ourselves to better overcome defeats.”

This project is designed to go beyond food subsistence and move into agribusiness, where farmers can invest in small threshing machines, de-hulling machines and motorized tractors.

Infrastructure development projects like the Alatona Irrigation Project can help foster food security and alleviate poverty through economic growth. And the components of this winner ticket are replicable through a holistic and integrated approach that needs to include:

A Variety of Services 

It integrates financial services, irrigation development and women’s gardens into its agricultural training program. It fosters sustainability by helping producers form farmer organizations that have market advantage whether buying farm inputs or selling the crops. 

The ownership of the Land for the farmers

The agricultural land in the project is being cultivated under a land title system, which is a first for the region. Now farmers own the land and have incentives to make improvements. As decision-makers, they put in crops the market demands.

 

Challenges still exist for the Alatona Irrigation Project, such as maintaining long-term soil fertility, sustaining the canal infrastructure, transferring know-how to younger generations and coping with the current political instability in Mali.

Sources:

http://www.huffingtonpost.com/anja-tranovich/food-security-solutions-sahel_b_1651153.html

http://www.acdivoca.org/site/ID/maliMCA-ASDA

If you would like to read more of the series of articles published by Huffington post to call attention to the crisis in the Sahel, go to:

http://www.huffingtonpost.com/news/sahel

You will find some really interesting articles….