By Charitha Ratwatte –

Malnutrition, micronutrient deficiency and obesity

The first Global Nutrition Report published recently by the International Food Policy Research Institute has brought out some startling facts on nutrition worldwide. A growing world economy has resulted in poverty being reduced worldwide. But the prevalence of undernourishment – a person eating too few calories to sustain an active life – has in fact fallen only by half the speed of poverty reduction.

In 1990 around two billion people were classified as living in poverty. By 2013 this had been reduced to one billion. But in the same year, 1990 one billion people were malnourished – by 2013 this number was around 0.8 billion, a far lesser rate of reduction than for poverty.

Further, micronutrient deficiency is not falling at all. For people to be healthy, they need a sufficient amount of calories, they also need nutrients – vitamins and minerals. For example, lack of Vitamin A can cause blindness, lack of iron causes anaemia. Around two billion people are estimated to suffer from some micronutrient deficiency worldwide.

Meanwhile, another nutrition status indicator – obesity – is getting worse. Between the years 2000 and 2013, the number of overweight children rose from 32 million to 42 million, more than two-thirds of them in countries which are classified as low and middle income countries.

At one time, the thinking was that there would be a time gap between hunger being eliminated and obesity developing into a problem. But this has been proved to be a myth. As countries succeed in eliminating undernourishment to a great extent – the number of people eating too many calories has unfortunately risen correspondingly!

This means that many, developing countries, including us in Sri Lanka, suffer simultaneously from all three manifestations of malnutrition – undernourishment, micronutrient deficiency and obesity. Any observer watching a cross section of Sri Lankan society at a central bus station or a railway junction or school or busy street, would notice this. Stunted children, overweight and underweight children and adults can be seen by the discerning eye.

Children going hungry

In 1974, the world held its first World Food Summit. Henry Kissinger, then America’s Secretary of State – declared that ‘No child would go hungry to bed within 10 years’. He has been proved to be totally wrong.

At the November 2014 follow up World Food Conference in Rome, statistics showed that 162 million children worldwide less than five years of age are stunted in their growth/height for age. Not only do they probably go hungry to bed at night – they could be having only one meal a day.

The rate of child wasting has not changed in the last few years, although the number of undernourished people has fallen by a fifth since 1900. The figure now stands at around 800 million people. This is notwithstanding real global growth of GDP at around 3.6% a year over the same period and a reduction by one half in the share of the population in developing countries living on less than $ 1.25 a day.

The Global Nutrition Report also brings out that every country, except China and South Korea, has a public health problem in the nature of at least –child stunting, anaemia among women of reproductive age and excessive weight among adults (obesity).

In the year 2013 the British medical journal the Lancet reported that 45% of deaths worldwide of children under five years of age were attributable to malnutrition related causes. It is estimated that micronutrient deficiencies are the reason for around one half of the disabilities suffered by children. In the USA the medical and other related costs of obesity was estimated to be between $ 475 to 2,500 per person in 2010.

Why is nutrition such a problem?

Why is nutrition such a problem compared to the advances made in poverty alleviation? The freedom of choice is one reason. In a community in which stunted growth is the norm – people will treat undernourishment as normal and spend surplus cash on the mod cons of modern living such as televisions, radios, motorcycles, etc. rather than nutritious food, especially for their children.

In the cities, high calorie food, combined with an office-based sedentary life, in air-conditioned environments is a classic recipe for obesity. Hunger and deprivation in a child’s growing up years, conditions the body to hoard whatever little fat is consumed when young. The body behaves the same way when the child grows up and consumes more fatty foods. As a result those who start life poor, are more prone to obesity in later life. A classic example is Mexico, which transformed itself from a hungry nation to an obese one in one generation! It now has the world’s worst obesity rate!

Malnutrition

The dictionary definition of malnutrition is a poor condition of health caused by a lack of food or a lack of the right type of food. Malnutrition in infants and children results in underweight babies and stunted growth, deficits in height for age in children and deficits in weight for age.

Researchers have decisively linked malnutrition and poverty, the one feeds the other and vice versa. At a conservative estimate malnutrition is said to bring about GDP losses of at least 2-3%, lead to a potential reduction in lifetime earnings for each malnourished individual. Stunting among children is linked to a 4.6 cms. Loss of height in adolescence, 0.7 grade loss of schooling and a seven-month delay is starting school.

Clearly, improved nutrition is a driver of enhanced economic growth. Paradoxically, rapid weight gain after the second year in a child has been linked to impaired glucose tolerance and obesity, in turn linked to lifetime diseases such as diabetes and hypertension.

Huge problem for South Asia

Malnutrition is a huge problem for South Asia. Let us take Sri Lanka as an example, although it is one of the better performers. For a middle income country, Sri Lanka’s maternal mortality of 46.9 per 100,000 live births, infant and under-five mortality rates of 13 and 15 per 1,000 live births and life expectancy at birth, 73 years, are good world class indicators. However, under-nutrition, 29% underweight is high.

This is the measure of non-income face of poverty, proportion of people who suffer from hunger. It has two indicators, the prevalence of underweight among children under five and proportion of the population below a minimum level of dietary energy consumption. In India it is estimated that nearly half of the small children are malnourished, this is higher than in most parts of sub-Saharan Africa.

Eradicating poverty and hunger by 2015

The first of the eight Millennium Development Goals is to eradicate poverty and hunger by 2015. Sri Lanka, a MDG study concluded, may be among countries able to achieve several of health MDGs, and the income poverty MDG, under certain conditions, i.e. to halve the proportion of people living on less than a $1 a day, but not the non-income poverty target, the nutrition MDG.

Some time ago Meera Shekar of the South Asia Division of the World Bank conducted an interactive discussion connecting Sri Lanka, India, Nepal, Pakistan, Bangladesh and Afghanistan, on Scaling Up Nutrition (SUN) in South Asia. Worldwide 29 countries have alarming levels of malnutrition, primarily in Asia, Africa and Latin America.

In five South Asian countries, the percentage of underweight children among the under-fives are over 40%. Taking into account data from 1960 to 2007, for Sri Lanka, one of the better performers, it reduces very gradually from 38% in 1977 to only 21% in 2006. This is with our other social indicators being at virtual first world levels!

Sri Lanka is, paradoxically, faced with the worldwide problem of both under nutrition and overweight, which is on the rise, among high income groups and this makes the population susceptible to the high risk of cardiovascular diseases, diabetes and other non-communicable diseases. Over 20% of Sri Lankan women are overweight and the trend is increasing.

There is a clear correlation between nutrition and poverty, so with poverty levels supposedly going down, malnutrition should also reduce, in theory. Under nutrition in Sri Lanka affects very young children and mothers, often during pregnancy, leading to low birth weight. Early damage caused to children’s cognitive and growth potential is tragically, irreversible, whatever is tried as remedies, thereafter.

Not rocket science

Meera Shekar showed that the window of opportunity for improving nutrition standards is very small. It ranges between the pre-pregnant mother and until the newborn is 18 to 24 months old. Recent research shows that a large part of the damage is caused to the foetus while in the womb, before birth.

Meera Shekar emphasised that what has to be done is known, it is not rocket science. At one time it was thought that the solution for malnutrition was providing more food or providing dietary supplements. But today it has been established that better nutrition is a result of an integrated set of policies covering a wide range of activity, not necessarily restricted to diet alone.

Dirty drinking water and bad sanitation causes illness which prevents the body from absorbing supplements. India’s open defecation is a special problem. Women giving birth at a young age could result in underweight babies. Spacing of pregnancies is essential.

The mother-to-be must be given supplements of multiple micro nutrients, iron foliate, and iodine through iodised salt, calcium supplements and protection from air pollution caused by cooking fires. For the newborn baby, compulsory breast feeding is essential. For the baby and child, improved supplementary feeding, zinc in management of diarrhoea, vitamin A fortification and supplementation and insecticide-treated mosquito nets.

The interventions are known, the delivery is the problem. Studies have shown that programs such as giving out vitamin A supplements or zinc treatment for diarrhoea have been very sporadic in implementation and not sustained.

Sri Lanka

Fortunately, Sri Lanka has a well-proven model for delivery. The Nutrition Fund of the Sri Lanka Poverty Alleviation Project, funded by the World Bank (CREDIT 2231-CE) managed by Janasaviya Trust Fund (1991 to 1998) focused on training mothers to recognise malnutrition in them and their children, sensitised them to long-term debilities which it caused and trained them to prepare more nutritious foods to combat malnutrition.

Nutrition Fund Director Dr. Priennie Ranatunga and her team trained mothers to recognise under nutrition and to appreciate that a malnourished mother will give birth to an underweight girl child, who in turn, due to lack of nourishment, will give birth to malnourished children in the future and that it was within their power to take action to break this vicious cycle.

Educating females, daughters, mothers, grandmothers helps break the cycle of a malnourished young mother giving birth to an underweight baby. A repeated birth without spacing worsens the problem. Sri Lanka’s record of almost all deliveries taking place in hospitals is a huge advantage.

This is in stark contrast to the present method of distributing food supplement Thriposha, which is issued to pregnant mothers and underweight babies. In a poor household this is naturally shared among the whole family, if the mother is not sensitised of her and her child’s special needs. Dr. Ranatunga trained mothers to plant, grow, harvest, produce and process their own alternative food supplements in their home gardens.

Thriposha deliveries are never on time, poor pregnant and lactating mothers have to make repeated visits to the clinic to collect their allocation. There is under supply and rationing, timely deliveries are constrained by factors like lorry availability, and lack of funds for overtime for drivers, it is a bureaucratic nightmare for DMOs. Some remote areas hardly get deliveries. Mothers turn up for the clinic and go away frustrated.

Four important strategies

The JTF Nutrition intervention’s success was based on four new and important strategies.

(1) Involvement of community organisations, which have delivered development packages to poor communities with no disciplinary blinkers for decades in Sri Lanka. Their incisive understanding of the problems of the poor and their holistic approach to development, (which includes even areas such as culture, values and spiritual development), gives them credibility and asserts their ‘interiority’, thus reducing the social distance between themselves and the people. By the end of 1994, around 40 community organisations had commenced in-depth nutrition projects in about 160 Divisional Secretary areas.

(2) Innovative approach to human development. The highest powers of a human being are those of ingenuity and creativity. Human development therefore requires that brain development proceeds unimpeded. The human foetus and infant (0-12 months) have the highest state of brain development, with 3.5% of the brain being developed, it is estimated, at around 3.5 years of life. While brain mass is correlated to nutritional wellbeing, brain stimulation is affected by the child’s environment. The JTF’s Nutrition program used a simple ‘ weight/age’ index to measure nutritional status of children, trained mothers to source and feed children with supplements, and supported early childhood education.

(3) Quantification and use of indicators. Voluntary nutrition workers on the program carefully monitored the nutrition of status of children in the village, the access to pure water, the access to latrines etc. and maintained a score card to enable the participants monitor their own household scores and support was provided to take initiatives which would help to improve the score, for e.g. a community water supply scheme through the JTF’s own participatory Community Projects Fund. A base line score card was prepared and communities shown how they could improve their score and at the same time attain higher mother and child nutrition scores, which were predetermined through participatory process.

(4) Implementation in a small homogenous geographic area. Community interventions have to be local. Interventions are multifaceted – adult education, preschools, latrine construction and use, water supply schemes, agricultural wells, wells for drinking water, cultivating, processing of supplementary foods, etc. These have to be authentic and sustainable community efforts. A classic case of Schumacher’s ‘Small is Beautiful’. The approach of the JTF’s nutrition program was participatory with bottom up planning and sequenced, realistic achievable stage by achievable stage.

Successful intervention

The Implementation Completion Report of the World Bank, on Sri Lanka’s Poverty Alleviation Project, implemented by Janasaviya Trust Fund, (JTF) dated 15 June 1998, has this to say on Nutrition Fund intervention:

‘The activities of the Nutrition Fund were the most successful. It covered over one fifth of the population within the conflict-free zones of Sri Lanka, and was operational in 18 of the 25 Districts. About 68 Partner Non-Government Organisations were involved, in over 1,600 Grama Niladhari divisions, with a beneficiary participation of 89% of the target population. The outreach was approximately 700,000 mothers and 2.7 million children, well in excess of the Staff Appraisal Report target. Success can largely be attributed to innovative interventions focusing on behavioural factors. Reliance on participatory approaches succeeded in enhancing nutrition awareness and improving feeding practices.’

At the time of project closure, at over ¾ of the sites at which the nutrition program was being implemented, serious malnutrition had been reduced by more than 15%, based on reporting and record keeping by the participating community organisations.
This model clearly worked. Sri Lankan women, especially the young, are literate. They can be reached by newspapers, radio, TV. The grandmother, mother and girl child should be targeted by an aggressive outreach program if this cycle of under nutrition, malnutrition and irreversible damage to children’s cognitive and growth potential is to be broken.

Sri Lanka’s current problems on child and maternal malnutrition are further compounded by fact that a healthcare system, infrastructure and budget, which has evolved to respond to health hazards caused by communicable diseases in a young population, is today struggling to treat a rapidly ageing population, suffering from non-communicable diseases and other geriatric illnesses.

Addressing under nutrition in South Asia

Meera Shekar’s presentation has clearly shown that addressing under nutrition in South Asia in general and in Sri Lanka, in particular, will require strategies to:

(a) Reduce income inequalities (b) improve access to safe water and sanitation (c) reduce food insecurity (d) scale up direct nutrition interventions (e) use the successful participatory delivery mechanism well proven in the Janasaviya Trust Fund’s Nutrition Intervention and (f) revise and reform the government healthcare expenditure and infrastructure to reflect the preventive and curative health demand realities of today. For the malnutrition conundrum, there is a well proven delivery system for the necessary interventions.

The Millennium Development Goals target of 2015 is almost on us. Some nations will tap themselves on the back with some self-satisfaction, and others will have to admit that the Nutrition MDG is still “a work in progress”. What is needed is a nutrition-friendly approach right across Government. It will be interesting to see whether any manifestos of candidates at Sri Lanka’s presidential election will reflect this!