Sunday, 11 August 2013

The quiet killer

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August 1-7: World Breastfeeding Week 

Just as the 19th century was the century of the British Empire and the 20th, the century of the strongest superpower, the 21st century is spoken of as the Asian Century, the century when Asian politics and culture will be the dominant one.

In the last two decades, South Asia has seen unprecedented economic growth. The World Bank reports that during this time, the no of poor - those living with less than $1.25 a day – came down from 61% to 36%. Even with all this progress, South Asia has 571 million poor, which is 44% of the developing world’s poor.

As for India, since 2007, it is, as per World Bank standards, a middle-income country. Yet, in 2013, the same standards pronounce it home to a third of the world’s poorest people.

And so, in this country, the desperately poor are, still, everywhere.
People like me, the privileged lot, rarely come into contact with them - unless our profession or vocation demands it. We are, however, often in touch with those who are illiterate or inadequately educated; those who, as a result, can never aspire to what would be considered a decent job. And so, all along, I’ve been convinced that ‘the’ best, long-term investment you can make in a child’s future is education.

Until, I started reading up for this post about nutrition and found out that food is the need of the hour and that it comes way before education.
Seems pretty obvious, you’d think. So let me explain why this was a real discovery for me.

Why focus on nutrition?

We all know that hunger has to be met before a person can be educated. What many of us don’t know, however, is that giving adequate, nutritious food to expectant mothers or their babies is the single most crucial support we can offer to give a child a fighting chance at leading a healthy, meaningful life.
And more importantly, that no matter how much help, of whatever kind, we extend after that crucial initial period, irreversible damage has already been done; the sort that has widespread consequences, usually carried over into the next generation.

Josette Sheeran, former head of the UN’s World Food Program (WFP) to fight hunger, explains this vividly in her TED Talk on hunger. Josette shows through slides (of brain scans taken by Chilean nutrition expert, Dr. Monckeberg Fernando Barros) that malnutrition can cut the volume of the brain by as much as 40%, and prevent the synapses of the neurons from forming properly.
Which, she goes on to say, translates into the malnourished child’s earning potential as an adult being cut in half. No wonder then, that the top most position among the millennium development goals of 2000 (that shifted the focus away from GDP or economic growth as a yardstick for progress), was the goal of ‘eradicating extreme poverty and hunger’.

Golden Interval

While explaining the effects of malnutrition, Josette talks about the critical finding of a team of experts brought together by The Lancet in 2008 to work on a series on maternal and child undernutrition. (This was a follow-up to their child survival series of 2003). The team compiled all the research on the topic of maternal and child nutrition and came up with evidence that showed that there was a 1000 day Golden Interval from the time of conception to two years when adequate nutrition, or the lack of it, could ‘make or break’ a child.

Key messages 

The other key messages of the series were:

Undernutrition is the largely preventable cause of over a third—3.5 million—of all child deaths.

Stunting, severe wasting, and intrauterine growth restriction are among the most important problems.

After age 2 years, undernutrition will have caused irreversible damage for future development towards adulthood.

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The series pointed out the urgent need for scaling up interventions for nutrition and showed that, ("according to strict criteria around admissible evidence") breastfeeding counselling, vitamin A supplementation, and zinc fortification have the greatest benefits".


In June of this year, The Lancet returned to this urgent issue in the second part of their undernutrition series, reinforcing their message of 2008 with ten nutrition-specific interventions with an emphasis on supplementation.


The numbers for South Asia and India
  • Half of the world's malnourished children live in just three countries - Bangladesh, India, and Pakistan; of these, one in three live in India.

  • Contrary to popular perception, in Bangladesh and India, the proportion of children malnourished is very significantly higher than in even the poorest countries of the sub-Sahara. (see Asian enigma)

  • The prevalence of underweight among children in India is amongst the highest in the world, and nearly double that of Sub-Saharan Africa. (news report on 'Indian enigma')

Response from India 

The Indian response to The Lancet recommendations was not positive. A few days after the publication of the 2013 series, an open statement to the Indian Government was released by a group of renowned scientists and policy makers, expressing their reservations about making future policy decisions in the country based on the recommendations.

Stating that “the series should not be allowed to become an opportunity for commercial exploitation of malnutrition,” the team mentioned:

influential links that some authors had with the food products and micronutrient industry,

a bias for the selection of product based solutions (particularly Ready to Use Therapeutic or Supplementary Foods and single or multiple micronutrients) without taking risks into consideration

that relevant, contemporary and high-quality evidence from India and South Asia has been  excluded or ignored

the potential dangers in privatisation and unregulated marketing of commercial foods

that important evidence with nutritional implications (such as literacy, sanitation, hygiene etc) has not been modelled during prioritisation of the interventions

the lack of attention to overnutrition in India.

Why the ICDS is not effective enough

Some time back, the World Bank had expressed the view that food supplementation was not the answer for India’s malnutrition problems. The concerned report says,

“India’s main early child development intervention, the Integrated Child Development Services program, has been sustained for about 30 years and has been successful in many ways. However, it has not yet succeeded in making a significant dent in child malnutrition. This is mostly due to the priority that the program has placed on food supplementation rather than on nutrition and health education interventions, and because of the fact that the program targets children mostly after the age of three when malnutrition has already set in. 
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…The focus should be on those ICDS components that directly address the most important causes of undernutrition in India, specifically improving mothers’ feeding and caring behavior, improving household water and sanitation, strengthening the referral to the health system and providing micronutrients.

What the Cochrane evidence says 

This year, there have been three Cochrane reviews and one protocol which looks at various aspects of underunutrition, including a comparison of traditional food with Ready-to-Use Therapeutic Food (RUTF). (Currently, the evidence does not clearly favour RUTF over traditional food.)

Schoonees A, Lombard M, Musekiwa A, Nel E, Volmink J

Published Online: June 6, 2013

Lazzerini M, Rubert L, Pani P

Published Online: June 21, 2013

Dangour AD, Watson L, Cumming O, Boisson S, Che Y, Velleman Y, Cavill S, Allen E, Uauy R

Published Online: August 1, 2013

(The Independent's report on the reviewDirty water and poor hygiene stunting growth of millions)

Shafiq Y, Saleem A, Lassi ZS, Zaidi AKM

Published Online: June 21, 2013

Anna Joseph
Anna is the South Asian Cochrane Centre's  Communications Officer.