24 April 2009

Hunger and Undernutrition

The July 2008, id21 insights, issue # 73 is about Improving the nutritional status of women and children. The editorial begins by reminding us that a high global food prices would make large proportions vulnerable in Sub-Saharan Africa and South Asia. Even in the absence of rising food prices there was an increase in child undernutrition indicating that income growth is not the answer for all ills.

Despite the understanding that reducing child undernutrition (particularly that of the adolescent girl) is paramount in addressing a number of Millennium Development Goals (MDGs), one wonders Why is undernutrition not a higher priority for donors? Andy Sumner, Johanna Lindstrom and Lawrence Haddad point out that one-third of the children in Sub-Saharan Africa and South Asia are undernourished. What is more, the proportions are increasing in the former. In prioritizing undernutrition they suggest the following. The community of research institutes in nutrition, think-tanks and international Non-Governmental Organizations should put up a strong case. There isa a need to link undernutrition to a failure of governance. The proportion of children underweight could be a more potent measure than poverty.

Nicholas Alipui suggests that Strong public-private sector partnerships can help to reduce undernutrition. There is a clear need for well-focused and strategic partnership between the private and public players. There is scope with regard to Ready-To-Use Therapeutic Foods (RUTFs) for six plus months children suffering Severe Acute Malnutrition (SAM). However, care should be taken to note that this should be not be considered as a substitute for breast feeding, as is being marketed by some private players. Two other related papers in this are that of Community-Based Management of Severe Acute Malnutrition, A Joint Statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children's Fund (UNICEF), 2007, and Infant and Young Child Feeding and Care by the UNICEF.

The success of salt iodisation has helped reduce iodine deficiency disorder like cretinism, mental retardation and premature birth in 70 per cent of the population as against 20 per cent in the early 1990s. Other related documents in this are Micronutrients - Iodine, Iron and Vitamin A and a 2004 Copenhagen Consensus Challenge Paper Hunger and Malnutrition by Jere R. Behrman, Harold Alderman and John Hoddinott.

In The price of hunger: The relationship between poverty and food intake David Mepham indicates that undernutrition is a symptom and cause of poverty. Halving people with less than one dollar a day would go a long way but it should also be complemented with halving the number of people suffering from inadequate food consumption. Income poverty and inadequate consumption are related and particularly so in large parts of Sub-Saharan Africa and South Asia where average per capita per day returns turn out to be less than the cost of a healthy diet. Poor diet can impair growth and development affecting achievements in schooling and productivity in adulthood and thereby extending deprivation to the next generation. Thus, undernutrition and poverty need to be tackled together and also complemented with nutrition education.

"Malnutrition concerns not enough food, too much food, the wrong types of food, and the body's response to a wide range of infections that result in malabsorption of nutrients, or the inability to use nutrients properly to maintain health. Clinically, malnutrition is characterised by inadequate or excess intake of protein, energy, and micronutrients such as vitamins, and the frequent infections and disorders that result" (World Health Organization).

In Africa, 30 per cent of children are malnourished because of low birth weight and growth faltering in the post-natal period. John Mason and David Sanders indicate that The persistence of child malnutrition in Africa worsens during droughts, conflicts, economics crisis and HIV epidemic. Accelerating globalization is affecting poor farmers. Removal of tariffs income support to farmers in developing countries would increase export opportunities for poorer farmers. Improvements in child nutrition would augur well for reducing child mortality, morbidity and enhancing intellectual development. These are further elaborated in the Impact of Drought and HIV on Child Nutrition in Eastern and Southern Africa and Community Health and Nutrition Programs in Disease Control Priorities in Developing Countries 2nd Edition, edited by Dean T. Jamieson et al, 2006.

The poor Nutrition for mothers and children by Isatou Jallow is in contravention with Article 25.2 of the Universal Declaration of Human Right by which motherhood and childhood are entitled to special care and assistances. Non-exclusive breastfeeding in the first six months is an important risk factor for child mortality and disease burden. Maternal short stature and iron-deficiency anaemia that account for one-fifth of maternal mortality can be attributed to poor nutrition. The World Food Programme can address these concerns while also conveying to communities that (i) child care is not the sole responsibility of women, (ii) improving mother and child nutrition will have positive impacts on the whole society and (iii) there is a need to link mother-child nutrition programme with school feeding and other such programmes to advocate the relevance of nutrition thought an individual's lifecycle. A suggested reading is Halving Hunger: It Can Be Done.

Barbara Macdonald raises the question Why have donors committed so few direct investments to eliminate child undernutrition? Despite some encouraging new initiatives, the constraints identified are (i) the lack of effective coordination amongst the key international and state organisations responsible for reducing undernutrition, (ii) gaps in evidence about the impacts of nutrition interventions, including rigorous evaluation of current programmes, and (iii) the daunting challenge of insufficient trained people to design, implement and evaluate programmes. It also brings into focus two recent publications. (1) 'Maternal and Child Undernutrition Series', The Lancet 371, edited by R. Horton, January 2008, (link for registered users). (2) Vitamin and Mineral Deficiencies Technical Situation Analysis: a Report for the Ten Year Strategy for the Reduction of Vitamin and Mineral Deficiencies', Food and Nutrition Bulletin, 28(1) supplement 2, edited by T. Sanghvi, M. van Ameringen, J. Baker and J. Fiedler, 2007, (link for registered users).

The most important question is What can be done to accelerate progress against undernutrition? Ricardo Uauy drawing from his coauthored paper Effective International Action Against Undernutrition: Why has it Proven so Difficult and What can be Done to Accelerate Progress? in The Lancet suggests four areas. (1) Stewardship and guidance: International organisations must work together to create evidence-based simple, consistent and prioritised guidance. (2) Aid and investment: Increase aid for direct nutrition intervention and better target the neediest group. A case of comparison is that though Disability Adjusted Life Years from undernourishment would be similar to that from Human Immunodeficiency Virus (HIV), aid to latter is almost 20 times greater. (3) Direct service provision: During disasters and conflicts impact of nutritional intervention programmes need to be documented and evaluated for their efficacy (including cost-effectiveness). These will create operational standards as also better coordination mechanisms to improve emergency response. (4) Strengthening resources: To address the shortage of skilled personnel funding need to re-orient training and research to more programme-relevant topics to help increase nutrition interventions.

The issue also provides some useful links of:

Global Alliance for Improved Nutrition – GAIN

Micronutrient Initiative

Save the Children

School Feeding global website

Towards 4 + 5 - Research Programme Consortium on Maternal, Newborn and Child Health

UNICEF - United Nations Children's Fund

United Nations System Standing Committee on Nutrition

World Food Programme

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