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….

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

References:

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

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

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

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

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

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

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

 

Going beyond food aid: the challenge of improving nutrition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A field guide nutrition checklist

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

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

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

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

5. Promote biodiversity and sustainable agricultural practices.

6. Give women the means to empower themselves.

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

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

Source: ACF International

“Is organic food more nutritious or safer? This is definitively not the right question.”

Stanford University researchers conducted a meta-analysis* of seventeen studies in humans and 230 field studies of nutrient and contaminant levels in unprocessed foods (e.g., fruits, vegetables, grains, milk, eggs, chicken, pork, and meat). The study, published in The Annals of Internal Medicine (http://www.ncbi.nlm.nih.gov/pubmed/22944875), concluded that “the published literature lacks strong evidence that organic foods are significantly more nutritious than conventional foods. Consumption of organic foods may reduce exposure to pesticide residues and antibiotic-resistant bacteria.” 

This conclusion has received vast media coverage – announcing that this meta-analysis demonstrates clearly that organic foods might not have more nutritious value than conventional foods and questioning the “value add” of producing and eating organic. Is organic food little more than a made up marketing scheme, another way for affluent consumers to waste money? This was the kind of questions that came to my mind when reading the articles from influential newspapers like the New York Times and the Washington Post.

In fact, there are major issues and gaps when reading both the scientific article as well as the media coverage.

One of them is the simplistic way that the media has used to report on this study. They mainly focused on the conclusion that summarized two results as a key statement. However, when reading the article, each of us can appreciate all the results (or non-results) as well as the limitations of this study and can conclude that things in nutrition science are not so simple.

The fact that the journalists have not done a critical analysis of the study and available scientific publications on the subject, or have not highlighted its limitations that are quite substantial or have not offered a fair presentation of what the study’s critics have to say is intriguing and disconcerting because a good scientific investigation can minimize the impact that this “single” study can have on our choice to eat or not organic foods. In fact, more clinical long-term investigations are needed to answer the question: “is organic food more nutritious or safer?” It will bring an important component – tangible outcomes to validate its real value in prevention and promotion. The challenges associated to scientific research of the benefice of eating organic foods will be discussed in another blog.

This is a very hot topic and we would like in this blog to ask some pertinent questions and answer them, when possible. This will help to clarify why it is important to continue to develop organic farming as well as to eat and promote organic foods not only at the local but also at the global levels.

What are the advantages of doing organic farming – locally and globally?

There are many explanations and definitions for organic agriculture but all converge to state that it is a system that relies on ecosystem management rather than external agricultural inputs. This is a system that begins to consider potential environmental and social impacts by eliminating the use of synthetic inputs, such as synthetic fertilizers and pesticides, veterinary drugs, genetically modified seeds and breeds, preservatives, additives and irradiation. These procedures are replaced with site-specific management practices that maintain and increase long-term soil fertility and prevent pest and diseases.

According to the FAO/WHO (Codex Alimentarius Commission, 1999):”Organic agriculture is a holistic production management system which promotes and enhances agro-ecosystem health, including biodiversity, biological cycles, and soil biological activity. It emphasizes the use of management practices in preference to the use of off-farm inputs, taking into account that regional conditions require locally adapted systems. This is accomplished by using, where possible, agronomic, biological, and mechanical methods, as opposed to using synthetic materials, to fulfill any specific function within the system.”

When doing organic farming, a variety of crops and livestock are cultivated in order to optimize competition for nutrients and space between species. This results in less chance of low production or yield failure in all of these simultaneously. This diversity in production can have an important impact on local food security and resilience. In rain-fed systems, organic agriculture has demonstrated to outperform conventional agricultural systems under environmental stress conditions. Under the right circumstances, the market returns from organic agriculture can potentially contribute to local food security by increasing family incomes.

At nowadays, the organic agricultural movements can be seen as tangible efforts to create a more sustainable development. However, these efforts are challenged by globalization, which strongly influences and impacts organic agriculture and food chains. In fact, global agriculture and food systems hold large differences between, on the one hand, industrialized farming and consumption based on global food chains and, on the other, smallholder farmers and resource poor people primarily linked in local food markets in low-income countries. This potential more sustainable development in opposition to the more conventional farming/food system gives rise to a number of questions such as:

Does global trade with organic products support a sustainable development?

Can organic agriculture contribute to global food security?

Does organic certification safeguard natural resources and improve working conditions?

Can fair trade with organic products be realized?

These questions need answers if we really want to impact the current and future food insecurity and demonstrate the viability of a sustainable global agriculture system based on organic farming.

Why are we eating organic food (or local food)? …

Because it is safe, nutritious as well as socially responsible and it allows us to reconnect with the essence of “good and tasty eating behaviors”! This is our vision at Challenged Kids International.

The discussion of these different points comes next.

Isn’t reducing exposure to pesticides and antibiotic use precisely what organic production is supposed to do?

Today, agricultural contaminants such as inorganic fertilizers, herbicides and insecticides as well as hormones and antibiotics used in conventional agriculture are a major concern all over the world. These chemicals have accumulated up the food chain where top predators (e.g. humans) can consume toxic quantities. Organic agriculture restores the environmental balance and organic foods are far safer in terms of pesticide content, antibiotic-resistant bacteria and GMOs.

And the Stanford University study corroborated partially this conclusion by finding that organic food had 30% less pesticide residue (see Wayne Roberts’ Blog for this specific point  – http://blogs.worldwatch.org/nourishingtheplanet/citywatch-getting-to-the-right-question-on-the-nutrient-benefits-of-organic-food/). Even though the pesticide levels in conventional foods in this study fall within the safety guidelines set by different environmental protection agencies, it is important to note that the health effects of the pesticides are cumulative, and that what we would consider safe at one time point might not be anymore the same over a period of 20 to 40 years of accumulation.

For example, it is well documented that:

• Herbicide residue on GMO crops may be causing fertility problems,

• Organophosphate exposure can lead to pre-term births, and both attention deficit hyperactivity disorders and lower IQs in children

This is quite scary!

Moreover, the Stanford study also noted that the risk for ingesting antibiotic-resistant bacteria was 33% higher in conventional than in organic chicken and pork but did not discuss at all the potential health outcome of this kind of results.

Why this result is so important?

Let me take one recent example to show you the potential link between ingestion of antibiotic resistant bacteria, and clinical morbidity and mortality.

As highlighted recently in the Huffington Post (as well as in other newspapers and magazines), superbugs (drug-resistant E. coli) in chickens could be an underlying cause of antibiotic-resistant bladder infections in 8 million women (http://www.huffingtonpost.com/2012/07/12/chicken-bladder-infection-superbug-uti_n_1668255.html).

In fact, chickens are injected with antibiotics from day one to help them grow bigger and faster and protect them from diseases. The problem is that these are the same antibiotics sold in the U.S. for humans to treat bladder infections, among other conditions, which means our bodies eventually become resistant to the drugs because we’re getting so much of it. McGill University researchers who have published this interesting result, had previously reported that the E. coli in the chicken was much more genetically related to those of human urinary tract infections, compared with the E. coli in the beef and pork. An interesting but implacable demonstration!

More importantly, from a public health safety point of view, this kind of results has led the USDA to routinely sterilize commercially harvested meat, a practice not necessary in organically raised animals.
Is organic food more nutritious than conventional food?

…. Yes, may be, perhaps…. It all depends on what you mean by nutritious food and its relation to seasonal food.

This Stanford University study has also showed that organic foods may have higher levels of anti-oxidants – plant phytochemicals thought to be important to human health as well as omega-3 fatty acids in organic milk and chicken, and vaccenic acid (potential anticancer effect) in organic chicken.

These results corroborate our reading of other scientific articles that have already proved some benefits of organic food and farming. To reinforce this statement, six articles have been published just this year on the nutritional value of organic foods showing interesting results like:

(1) Organic broccoli maintained higher concentrations of bioactive compounds (ascorbic acid and phenolics) and antioxidant potential during storage than conventional broccoli, with higher potential health beneficial effects (http://www.ncbi.nlm.nih.gov/pubmed/22936597),

(2) Organic cropping systems result in spinach with lower levels of nitrates and higher levels of flavonoids and ascorbic acid (http://www.ncbi.nlm.nih.gov/pubmed/22393895),

(3) Organic growing increased the level of antioxidant compounds such as carotenoids, phenolic compounds and vitamin C in sweet bell pepper (http://www.ncbi.nlm.nih.gov/pubmed/22368104),

(4) The organic growing system affects tomato quality parameters such as nutritional value and phenolic compound content (http://www.ncbi.nlm.nih.gov/pubmed/22351383),

(5) The concentrations of several nutritionally desirable compounds in milk (β-lactoglobulin, omega-3 fatty acids, omega-3/omega-6 ratio, conjugated linoleic acid and/or carotenoids…) decreased with increasing feeding intensity (organic outdoor ≥ conventional outdoor ≥ conventional indoors) (http://www.ncbi.nlm.nih.gov/pubmed/22737968; http://www.ncbi.nlm.nih.gov/pubmed/22430502)

Evaluating the health benefits of eating organic foods is a relatively new research focus (less than 10 years of investigation). The number of publications is increasing significantly each year and we can expect more sophisticated research projects and as a result, more and more interesting results will be available to demonstrate the benefit of eating organic foods.

Moreover, the long term health impact of eating organic foods is not currently appropriately addressed. The duration of the human studies ranged from two days to two years. Most of the health effects will take a lot longer than that to show up.

According to the Stanford University article, this kind of clinical investigations won’t be possible because it is too expensive. Past (the SUVIMAX 1 study in France) and current experiences (the SUVIMAX 2 and Nutrinet studies in France, the Raine study in Australia and the Ontario Birth Study here in Toronto, Canada) to name some of them show that this is possible to investigate long-term effects if there is the political will to go in this direction.

Finally, the interface between food, nutrition and health is a complex issue. It depends from where you come from, your education and how you value the importance of good foods and/or health as well as the tradition and culture around food and culinary practices.

For CKi, nutritious food is more than the number of calories or the quantity of macro- (protein, carbohydrate…) and/or micronutrients (minerals and vitamins), it also relates to its social component (eating together, discussing and sharing food), the taste of food, the use of our five senses and finally, the impact that colorful and tasty foods can have on our brain and ultimately on our overall well-being.

Nutrition is a complex phenomenon, like an interactive game where pleasure can play a significant role. Unfortunately, we have lost this dimension in our “super speed” world.

A few years ago, I switched to organic and/or local food because I wanted to reconnect with my roots (French culture around food). The result has been more than positive. I have rediscovered the taste of foods: seasonal fruits and vegetables where I am sure to find the best nutritional value as well as locally produced meat, eggs, cheese and bread. As a result, I am eating less meat and refined carbohydrates but more grains, fruits and vegetables; I also cut completely junk foods. When I am cooking real foods and I am eating good cuisine, I have a lot of pleasure and I feel full not only in my stomach but also in my mind – a great sensation of satiety. I also know that I contribute socially to the sustainability of the global food security. This is also why it is important to eat organic and/or local foods!

Over time, we can expect that unbiased analysis coupled with modern-day science is likely to show with increasing clarity that growing and consuming organic food, especially in conjunction with healthy diets rich in fresh, whole foods and seasonal fruits and vegetables is one of the best health-promotion investments we can make today as individuals, families, and a society.

* In statistics, a meta-analysis refers to methods focused on contrasting and combining results from different studies, in the hope of identifying patterns among study results, sources of disagreement among those results, or other interesting relationships that may come to light in the context of multiple studies.

References:

http://www.ncbi.nlm.nih.gov/pubmed/22944875

http://www.anh-usa.org/new-junk-science-study-dismisses-nutritional-value-of-organic-foods/

http://grist.org/food/organic-food-may-not-have-a-big-nutritional-edge-but-how-much-does-that-matter/

http://www.ncbi.nlm.nih.gov/pubmed/12094634

http://www.ifoam.org/growing_organic/1_arguments_for_oa/environmental_benefits/environmental_benefits_main_page.html

http://www.icrofs.org/pdf/darcofIII/globalorg.pdf

http://www.fao.org/organicag/oa-faq/oa-faq1/en/

http://www.huffingtonpost.com/2012/07/12/chicken-bladder-infection-superbug-uti_n_1668255.html

 

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/

Save the child …. Give breast milk!*

The World Breastfeeding Week is celebrated every year (August 1st to 7th) in more than 170 countries to encourage breastfeeding and improve the health of babies around the world. It commemorates the Innocenti Declaration made by WHO and UNICEF policy-makers in August 1990 to protect, promote and support breastfeeding (http://www.unicef.org/programme/breastfeeding/innocenti.htm).

As we all know, the first two years of a child’s life are particularly important, as optimal nutrition during this period will lead to reduced morbidity and mortality, to reduced risk of chronic diseases and to overall better development. Indeed, infant and young child feeding is one key area (or the cornerstone) to improve child survival and promote healthy growth and development.

The situation

Malnutrition is responsible, directly or indirectly for about 33% of deaths among children under five. Well above two thirds of these deaths, often associated with inappropriate feeding practices, occur during the first year of life. In fact, despite compelling evidence that exclusive breastfeeding prevents diseases like diarrhea and pneumonia that kill millions of children every year, global rates of breastfeeding have remained relatively stagnant in the developing world, growing from 32% in 1995 to 39% in 2010 (see map below to get an idea of the level of exclusive breastfeeding per country).

In reality, breastfeeding rates in the developing world have been declining until recently. This decline has been attributed to changing socioeconomic factors and the perception that infant formula is superior to breast milk. To give you a concrete example and according to UNICEF Pacific Representative, Dr. Isiye Ndombi: “In the Pacific, breastfeeding rates dropped for a number of reasons, either because mothers were being integrated into the workforce, were not supported by their spouses or were not making informed decisions about the long-term benefits breastfeeding would bring to their children. Exclusive breastfeeding (i.e breastfeeding from birth to six months) are about 40% in Fiji, Tuvalu and Vanuatu, and 31% in the Republic of Marshall Islands.”

“It’s a global trend”, says Elisbeth Sterken, national director of INFACT Canada, a non-profit agency concerned with issues around breastfeeding (http://www.infactcanada.ca/). The impact of bottle-feeding infants is different culture to culture but the long-term impact would be the same – a high incidence of obesity and metabolic diseases. Why?

For example, “in Western cultures, bottle-fed babies begin life with nutritional deficiencies that may lead to health and obesity issues later in life”, she said.

In fact, it was a real surprise to read in a book entitled “Let them eat junk” that baby formula can contain 60% more sugars than regular milk. In fact, a bottle-fed baby consumes 30,000 more calories over its first eight months than a breast-fed one. That’s the calories equivalent of 120 average chocolate bars. Given how early our tastes are formed, it is not surprising that “several research studies have shown correlations between bottle-feeding and subsequent obesity. And the problem continues in baby foods, against efforts to limits the high level of added sugars.

Is it possible to advocate for an improvement of the nutritious value of baby formula and change the current trend?

The task seems tricky. Lobbying power from food companies is huge! The battle is unequal, something similar to the idea developed by Jean de la Fontaine in one of his poems. What union can there be between a clay pot and an iron pot? Because when they collide against each other, the clay pot will be broken.

Just one example to demonstrate this unequal battle: the Thai introduced a proposal to reduce the levels of sugars in baby foods from the existing maximum of 30% to 10%, as part of the global fight against obesity. The proposal was blocked by the US and the EU, where the world’s largest sugar corporations have their home offices. This is one among other examples of the lobbying power of the sugar companies.

And what happens in the developing countries?

In developing countries the impact is more dramatic”, Sterken said. An estimated 1.5 million formula-fed babies die each year because families in developing countries can’t afford the formula and dilute it, use contaminated water to mix it, can’t properly sterilize bottles, or supplement with sugared tea, thereby depriving their children of nutrition, and introducing deadly bacteria into their food.

Another important problem is related to the high level of urbanization in sub-Saharan Africa.

Slums in sub-Saharan Africa are expanding at a fast rate, and the majority of urban residents now live in slum settlements. And in fact, urban poor settlements or slums present unique challenges with regards to child health and survival.  The slums are characterized by poor environmental sanitation and livelihood conditions. Contrary to the long-held belief that urban residents are advantaged with regards to health outcomes, urban slum dwellers tend to have very poor health indicators. Then it is not a surprise to observe thaturban mothers are less likely than rural ones to breastfeed -and more likely to wean their children early if they do begin. Low rates of breastfeeding may be attributed in part to cultural practices, access to and utilization of health care facilities, a lack of knowledge about the importance of the practice, but more importantly to the reality that poor women in urban settings who work outside the home are often unable to breastfeed.

This is an important point, how can we help women who work in developing countries to act sppropriately?  It is a necessity for them to be able to breastfeed because it is good for their babies but they also need to economically survive. A dilema!

Does malnutrition affect the quality of mother’s milk?

The 2008 Lancet Nutrition Series highlighted the remarkable fact that a non-breastfed child is 14 times more likely to die in the first six months than an exclusively breastfed child. Breast milk meets a baby’s complete nutritional requirements and is one of the best values among investments in child survival as the primary cost is the mother’s nutrition. In this context and knowing the high incidence of food insecurity in the developing countries, it seems important to ask if malnutrition (or poor nutrition) can affect the quality of mother’s milk and compromise the potential benefit of breastfeeding where it is most needed, i.e. the developing countries.

In fact, a review of the literature showed that mild or moderate malnutrition rarely affects the amount or quality of breast milk that a woman produces. The mother’s dietary intake will not generally increase how much breast milk she can produce in a day. Her nutritional status before and during pregnancy are important for milk content, but generally this has only of marginal impact since her body will ensure that the breast milk receives the available vitamins and minerals. If her diet remains inadequate for a long time, the milk may contain fewer vitamins and fats as her own body stores are used up. However, her breast milk continues to be nourishing for her child, and provides anti-infective factors that help to protect the child against infections. No breast milk substitute contains these protective factors.

The response at the micro and macro levels

It’s hard to believe that something as natural, healthy and cost-free as breastfeeding needs to be promoted by health and nutrition specialists. But as World Breastfeeding Week began on Aug. 1, breastfeeding specialists want to draw attention to the many benefits of breastfeeding to mother and baby and curb the trend toward bottle-feeding infants with commercially prepared formula.

In 2002, the WHO and UNICEF have developed a Global Strategy for Infant and Young Child Feeding (http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/), which recommends that infants start breastfeeding within one hour of life, are exclusively breastfed for six months, with timely introduction of adequate, safe and properly fed complementary foods while continuing breastfeeding for up to two years of age or beyond.

Moreover, the WHO and the United Nations Children’s Fund jointly developed a code for marketing infant formula to curb aggressive marketing campaigns, especially in developing countries (http://www.who.int/nutrition/publications/code_english.pdf). However, its impact over the past 30 years has been limited because of a series of alleged violations and boycotts.

What do we need to do to reinforce exclusive breastfeeding globally?

An international governance is needed to step in and replace the voluntary marketing code. It will help to address and correct unethical marketing that could be put in place by makers of breastmilk substitutes.

It is also necessary to develop national policies that support maternity leave, not only in developed, but also in developing countries.

And finally, it is important to work at the community level. One of the strategies could be to train low-income mothers as breastfeeding counselors and assist communities in forming mother-to-mother support groups (something similar to Saving Help Group). This strategy will increase the understanding of the risks of not breastfeeding and finally, it will reinforce the practice of exclusive breastfeeding among mothers.

In fact, if the exclusive breastfeeding rate was increased significantly, as much as 13% of all deaths of children younger than 5 years could be prevented that could represent around 1 million children under five in the developing world each year. Moreover, the promotion of breastfeeding could avert 21.9 million disability adjusted life years (8.6%).

What do we mean by exclusive breastfeeding?

“Exclusive breastfeeding” is defined as giving no other food or drink – not even water – except breast milk. It does, however, allow the infant to receive oral rehydration salts (ORS), drops and syrups (vitamins, minerals and medicines). Breast milk is the ideal food for the healthy growth and development of infants; and it’s also an integral part of the reproductive process with important implications for the health of mothers.

Then, what are the benefits? Just a recap….

Exclusive breastfeeding for six months has many benefits for the infant and the mother, says the WHO. “Chief among these is protection against gastro-intestinal infections which is observed not only in developing but also in industrialized countries. Early initiation of breastfeeding, within one hour of birth, protects the newborn from acquiring infections and reduces newborn mortality. Finally, the risk of mortality due to diarrhea and other infections can increase in infants who are either partially breastfed or not breastfed at all.”

Breast milk is also an important source of energy and nutrients in children 6 to 23 months of age. It can provide one half or more of a child’s energy needs between 6 and 12 months of age, and one third of energy needs between 12 and 24 months. Breast milk is also a critical source of energy and nutrients during illness and reduces mortality among children who are malnourished.

Adults who were breastfed as babies often have lower blood pressure and lower cholesterol, as well as lower rates of overweight, obesity and type-2 diabetes.

Breastfeeding also contributes to the health and well-being of mothers. It reduces the risk of ovarian and breast cancer and helps space pregnancies — exclusive breastfeeding of babies under six months has a hormonal effect which often induces a lack of menstruation. This is a natural (though not fail-safe) method of birth control known as the Lactation Amenorrhea Method.

Moreover and from a sustainable point of view, exclusive breastfeeding contributes both directly and indirectly to sustainable development. Evidence has clearly shown that exclusive breastfeeding for the first six months of a baby’s life not only improves their future growth and educational achievement, but also significantly reduces national health costs and helps prevent chronic malnutrition. Breastfeeding helps to prevent a number of diseases in childhood and later in life. It offers protection from infections, allergies and adult-life chronic conditions like hypertension, diabetes, obesity, cardiovascular diseases and cancer that rob the national budgets of millions of dollars.

Breastfeeding needs to be valued as a benefit which is not only good for babies, mothers, and families, but also as a saving for governments in the long run.

* The theme for this year’s celebration is “Understanding the past, planning the future: Celebrating 10 years of WHO/UNICEF’s Global strategy for Infant and Young Child Feeding”. It has the slogan “Save the Child, Give breast milk”.

Resources:

http://allafrica.com/stories/201208060231.html http://allafrica.com/stories/201207051232.html

http://www.scoop.co.nz/stories/GE1208/S00003/make-breastfeeding-easier-for-mothers-says-unicef.htm

http://www.guelphmercury.com/news/local/article/771868–world-breastfeeding-week-aims-to-promote-benefits-curb-bottle-trends

http://www.unicef.org/nutrition/index_emergencies.html http://helid.digicollection.org/en/d/Js8230e/1.3.1.html

http://www.biomedcentral.com/1471-2458/11/396/

http://www.nbcchicago.com/investigations/series/target-5/target-5-sugar-baby-formula-139339308.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/

http://www.nutraingredients.com/Industry/Infant-formula-marketing-code-has-failed-says-expert

Book: Let them eat junk, how capitalism creates hunger and obesity – Robert Albritton