The Long Shadow of Childhood Undernutrition
In some of the previous chapters of this lecture, we’ve spoken of how maternal mortality and child mortality are influence also by the state of nutrition during pregnancy, prior to pregnancy and what happens to children in terms of their own nutritional status and probability of their succumbing to illness before the age of five. So we now recognize that childhood under-nutrition is a very critical element in global health. Not surprisingly it was positioned as one of the millennium development goals to be targeted for a substantial reduction in the prevalence of childhood under-nutrition across the world. Even a report as recent as the global nutrition report of 2014 lists that about two billion people are estimated to be deficient in one or more macronutrients, when we are really talking about macronutrient deficiency, we are really talking about ultimately being under-nourished due to deprivation of calories or energy. But we also now recognize that it’s not just calories or energy, it’s the quality of diet that matters in multiple ways. So we are looking at nutritionally balanced diets as well. And that is where we find the problems are probably even more than this particular estimate. We also know that about more than three billion people are afflicted globally with micronutrient deficiencies, whether it’s iron deficiency, vitamin A deficiency, or iodine deficiency, or a combination of all of these. When we look at the global profile of low birth weight and under-five malnutrition and look at what the magnitude is in different parts of the world in comparison to the standard, conventional, geographical atlas, the picture is really very different. Countries of south Asia, particularly India and its neighboring south Asian countries like Bangladesh and Nepal have a huge burden of under-nutrition, as do some of the countries in sub-Saharan Africa. Whereas in many other parts of the world, childhood under-nutrition is no longer a challenge and indeed, does not figure as a part of their own agenda for implementation of the millennium development goals. Despite all the progress that has been attained because of the millennium development goals and even to some extent the period preceding that, we have seen that there are huge disparities, even among the low and middle income countries in terms of the prevalence of underweight in childhood. While Brazil, China and Thailand have been models of great success with prevalence less than 10%. Indeed in Brazil, about 2%. In the countries of south Asia we find the picture very different. India, even in 2011 in a global nutrition report of the World Health Organization was reported to have 43% underweight below the age of five years. Bangladesh, 41% prevalence. And Nepal, 39% prevalence. Even in sub-Saharan Africa, which is better off than south Asia, there was a 28% prevalence of underweight children under the age of five. And these have profound effects. There is impaired physical growth, particularly linear growth among these children who are underweight and under-nourished. There’s a much greater susceptibility to infections, whether it is measles or respiratory infections or diarrheal diseases. Most of the infections can take a toll and even chronic infections like tuberculosis are far more often in the setting of under-nutrition. At the same time, it has an impact on cognitive and intellectual functions. The brain power of these children is substantially reduced as compared to what their potential would have been if they were well-nourished. And while it is certainly a tragedy for the child, in terms of not being able to obtain their full developmental potential, it’s also a huge problem for the countries in terms of the cumulative loss of brain power which they could have otherwise utilized for productive growth. At the same time, because education is also affected of these children because under-nourished children are sickly. They don’t learn very well. And they do not advance well to higher education; therefore their employment opportunities are also substantially decreased. They have reduced ability to participate in sports and other recreational activities and therefore their ability to really be important members of a large peer group, whether in schools or in society is also decreased over a period of time. But even more importantly this link carries on to pregnancy also. Imagine a girl child who’s under-nourished and anemic, growing on to become an anemic and rather underweight adolescent with a limited pelvic size. And when that adolescent girl then becomes pregnant soon thereafter we find that the small pelvic size also results in a small placental size that creates a problem in terms of the pregnancy outcome for the mother, but in the same time the reduced blood flow also results in under-nourished children, particularly when the baby in the womb is not able to get enough blood flow from the small placenta. So it has an impact on the mother, it has an impact on the child. And you may have maternal mortality or child mortality, particularly neonatal mortality, or you may even have a child who has been born successfully but is small size and then there is a further penalty to be paid thereafter. There are also a fair amount of negative effects on the risk of adult chronic disease like cardiovascular disease, diabetes, and even to some extent, some cancers. There are intergenerational effects not only between the child who becomes the mother and her own child, but sometimes these intergenerational effects can spill over to subsequent generations as well. So there is this intergenerational disadvantage of childhood under-nutrition that can carry on to subsequent generations. And we see this long shadow of childhood under-nutrition being cast into adult life when we look at the impact of rebound adiposity in a child who has been born small in size and low in birth weight, but gains in weight between the ages of two and twelve years. That doesn’t actually translate to an increased muscle mass. It translates much more into body fat, especially fat deposited in the abdomen and around the vital organs in the abdomen. And this sets the stage through metabolic programming for onset of high blood pressure, early onset of diabetes, and heart disease in, in these children as they grow into adulthood. And even in fairly early adulthood, you can find diabetes and heart attacks claiming a huge toll of health on these children. And we have evidence of this from multiple countries, but here is an example from India, from what’s called the New Delhi Birth Cohort. And this cohort that’s been followed up from birth to adult life what was determined was that while in the first two years of life the children in the lowest birth rate range were reasonably well protected against acquiring a lot of body fat, by the time they cross two years of age and started having a compensatory nutritional intake, their percentage of body fat markedly increased. And it is these children who had low birth weight under the age of two, but who had rebound adiposity or relative obesity. It was not actually obesity or overweight, it was relative obesity compared to their low birth weight in the beginning who turned out to have much higher incidence of diabetes by the time they became adults. So it was this problem that set the stage for adult diabetes. And it’s not surprising therefore to see that India, which had such a huge burden of childhood under-nutrition in the earlier pictogram, now in this pictogram also it has one of the highest burdens of diabetes in the world. So these are fairly interlinked, at least in the south Asian subcontinent. But these effects are not only limited to the life of one child or even the offspring of that child. When we look at a woman who is now pregnant and who is carrying the consequences of her own impaired nutrition from childhood, we must recognize that the female fetus that is in the womb also is having eggs which will result in her own children when she becomes a mother later on in life. And those are also affected in terms of their gene expression by the childhood under-nutrition that the mother suffered. So at least three generations are linked by this intergenerational transmission of nutritional disadvantage. And perhaps even more as we understand epigenetics, we recognize that some of these disadvantages can be carried into multiple generations. So we need insure that childhood under-nutrition is corrected, not only because we want to protect the present generation or the immediate next generation, but truly in the spirit of sustainable development we want to prevent some of these disadvantages accruing to as yet unborn generations. There are interventions that we need to adopt in order to insure that childhood under-nutrition can be successfully tackled by countries. And some of these are nutrition-sensitive interventions. They do not lie in the form of nutritional supplementations or specific nutrition related or diet related interventions, but they have a profound effect on nutrition because they impact the level of nutrition both in terms of intake as well as in terms of absorption and utilization. Water for example is absolutely important. Unless you have clean drinking water, you can get diarrheal disease and that can wash out a good part of the nutrition that has been taken in. For the same reason, sanitation and hygiene are absolutely important, because infectious diseases, because of poor sanitation and hygiene, again, can drain away much of the limited nutrition that children in low and middle income countries get. And at least 50% of under-nutrition in India has now been ascribed to lack of sanitation. In terms of agriculture and food security, that becomes absolutely important, because we do need to produce enough dietary diversity through crop diversity as well as healthy food products to ensure that every citizen has calorically adequate but also nutritionally appropriate diet at each stage of life. And therefore these systems are to become better aligned to the need of nutrition of all society but particularly from the point of view of preventing child under-nutrition which is such a crying shame. Now we need social safety nets because if there are huge income disparities and also in terms of access to diets because of poor living conditions in low income communities, then we are going to see under-nutrition being perpetuated. So we do need some social safety nets as well. We need a greater focus on early development of children. We need focus on better schooling. Again, education fosters better nutrition. At the same time, midday meal schemes in different countries are also helping to improve some of the nutritional problems, especially micronutrient deficiencies among children. And we need child protection. We need maternal and mental health to be looked at, because if the mother is mentally stressed, she cannot feel a young infant or even the growing child properly. We need women’s empowerment. Having more income and more social status and political power for women insures that children grow up much better. At the same time we need access to health and family planning services because if you have an early pregnancy in an under-nourished adolescent girl being pushed into early marriage. And of the subsequent spacing of pregnancies also is very small, you are bound to get children who are under-nourished. And that is going to have an adverse influence later on as well. So we do require a large number of nutrition sensitive interventions. But we also need to incorporate nutrition specific interventions such as insuring adequate food and nutrient intake at each stage of life as appropriate to that age. And the specific requirements which may vary based on the level of physical activity, based on whether the person is at that point in time undergoing an illness or not and so on. Now we also particularly need to focus on promotion of exclusive breastfeeding at least for the first six months of life. That is absolutely mandatory for good nutrition as well as building of the immunity of the child. And this is very critical but unfortunately not widely practiced even in low and middle income country settings where one would have considered it to be a traditional cultural norm. But it is not. And we also need to promote the right complimentary feeding practices and responsive feeding practices when the children require food. So all of these actually are built in in earlier infancy and childhood. In fact while exclusive breastfeeding is required up to six months, continual breastfeeding should be carried on as long as possible even up to two years, if it’s possible. At the same time, good feeding practices are very important in the growing child. When we talk about the catch up growth happening because of compensatory nutritional feeding, getting ultimately converted not into real good, linear growth with muscle mass, but into a lot of body fat, we must recognize that high carbohydrate diets with low physical activity may be responsible for that. So we need better diets which also are combined with rigorous physical activity in the children, which can ensure that the catch up linear growth is translating into actually a better physical stature in terms of linear growth, but also more muscle mass rather than just body fat. So we need to pay attention to what kind of food we are giving. At the same time, caregiving and parenting practices are important in the entire area of child nutrition, control of infectious diseases is critical because we said; diarrheal diseases can drain away nutrition. Other infections can also reduce the appetite, reduce the absorptive capacity. So control of those infectious diseases, even treating intestinal worms which actually make the child malnourished, that’s also very important. Now we need to look at multiple micronutrient supplementation as a possible additional element, though that cannot be the sole pathway for good nutrition. We have to depend upon natural foods for good nutrition. The use of ready-to-use therapeutic foods has been recommended, particularly in treatment of severe forms of childhood under-nutrition. This is a little controversial because it appears to be pushed sometimes by the industry. But they may have a limited space in the treatment of the severe forms of malnutrition. In terms of the impact of various programs, we have also seen success stories which we can learn from and other countries can emulate. Thailand has been a poster child for such a success. If you see what has happened in the three Southeast Asian countries of Thailand, Philippines and Indonesia, between 1980 and 1990, Thailand had a marked decrease in the prevalence of underweight children. There was a bit of a spike thereafter when all of these countries were facing economic challenges because of some of the financial crises that their country’s faced but nevertheless we noticed that Thailand’s success continues to be commendable. And this has been a feature ever since thereafter. Indonesia has shown a slower growth, but even there we are finding a considerable amount of success. Philippines on the other hand till recently hasn’t had much success, but now it’s beginning to record some gains. What succeeded in Thailand and what is it that we can learn from there? That Thailand adopted the basic minimum needs approach, which looked at some of the social determinants like housing and environment. They brought in family planning and reproductive health services. They encouraged community participation. They also utilized spiritual and ethical development as a platform for promoting healthy nutrition and good eating habits. So they combined all of this and the effective linkages between services in various sectors with community level action mediated by community mobilizers who were interfacing with families, brought nutrition from the abstract policy level into very much of the home habit. Now when you look at how the Thailand model worked, they looked at services and brought in government, NGO action into health, education, agriculture and other sectors. But they also brought in facilitators who worked with community mobilizers, provided supervision, training, information and support. And these mobilizers acted with the families and that interface involved counseling, organizations, supplies, referral for prenatal care, child care practices, growth monitoring, supplementation of micronutrients when needed. All of this happened at the community level. And the communities also became active participants in planning, implementation and monitoring. So this has been Thailand’s prescription for a successful program which reduced childhood under-nutrition in a very short space of time. And that is where other countries can actually learn from. What we recognize now is that childhood under-nutrition is not an aberration that comes in because of poor feeding in the limited space between birth and five years of age. It is sometimes a carryover effect of poor nutrition during pregnancy. It sometimes is a carryover effect of the poor nutrition that the mother herself had as a child and as an adolescent. But we also recognize that there are factors in infancy and early childhood which again need better attention, particularly to reduce the risk of various ill health conditions which can affect the child but also trying to prevent some of the later problems of adult chronic disease. And the stage there is set between birth and two years and between two years and twelve years. We also need to look at adolescence as a very important period of life. We don’t want anemic mothers resulting from anemic adolescent girls. We want to make sure that they also have good nutrition so that they can grow up well and bear healthy children later on. Even male adolescents too require healthy nutrition rather than becoming obese or having poor nutrition otherwise. This again needs to be carried over into adult life because again, if nutrition suffers in pregnancy, the child is bound to suffer again. So the idea of building nutrition into a life course model is absolutely critical. Even if we target childhood under-nutrition and monitor specific metrics related to childhood under-nutrition, when we plan programs and frame policies, we have to have the life course model. And we have to look up, look upon it as a multi-sectorial societal responsibility. And that is where it fits into sustainable development.