In this month’s column I have chosen
to discuss malnutrition in general.
This is because some people, after
reading my last two columns, said
that though it is good to discuss
issues surrounding management of
malnutrition, this should not be the
focus. Somebody else said that the
Ready to Use Therapeutic Food (RUTF)
issue is not public health
nutrition. Now, I’m not going to
debate whether RUTF is public health
nutrition or not. Maybe readers of
this column can comment on that by
using the response facility at the
end of this column. Next month I
will discuss what’s going right, and
what we as public health
nutritionists need to do for
situation to improve to improve.
My question here, is: Why is
undernutrition still a major problem
in lower-income countries in
general, especially in Africa, and
what should we public health
nutritionists be doing to stop this
trend? I am hoping that colleagues
and other readers of this column
would take some time to share their
thoughts on practical steps we
should be taking to stop this
malnutrition menace. Do add your
comment below in the response
facility and agree or disagree with
me. We all must remember that we are
supposed to be problem solvers and
not just describers of problems.
What is malnutrition?
Malnutrition literally means ‘bad’
nutrition and therefore encompasses
both over- and undernutrition. Here
I am focusing on undernutrition.
Besides, ‘malnutrition’ is more
commonly used to refer to
undernutrition rather than
overnutrition.
Malnourished people are hungry.
Acute malnutrition is the result of
a relatively short period of
inadequate nutrition which leads to
wasting and, if severe, may also
cause retention of water and
swelling (oedema). Chronic
malnutrition is the result of
prolonged episodes of inadequate
nutrition and leads to stunting (for
more on that, please visit the
website of the International
Malnutrition Task Force at
www.imtf.orgAcute
malnutrition may be classified as
severe or moderate. Both are serious
global problems that are a
significant cause of mortality of
young children (up to 5 years of
age). Acute malnutrition can be seen
at any age but is more common in
infants and young children, and is
caused by many factors including
poor feeding practices, poor
hygiene, and illness. Inadequate
nutrition during pregnancy can
precede both acute and chronic
malnutrition.
In many low-income countries,
malnutrition is still very common.
See the Food and Agriculture
Organization of the UN (FAO) summary
in the chart below. FAO estimates
that just over 1 billion people were
undernourished worldwide in 2009.
The source is:
http://www.fao.org/hunger/en/
This is more than recorded at any
time since 1970, the first year with
comparable statistics. The numbers
in absolute terms are highest in
Asia, but in terms of proportion,
the worst rates are in sub-Saharan
Africa. In Africa, it’s estimated
that about 14 per cent of children
were born with low birthweight
between 2003 and 2008. Fourteen per
cent of children were moderately
underweight and 7 per cent severely
underweight, during this period. A
total of 10 per cent were wasted
(very thin) and 40 per cent stunted
(very short). Trends over the years
have not changed much. The source
for this information is
http://www.unicef.org/rightsite/sowc/pdfs/statistics/SOWC_Spec_Ed_CRC_TABLE
2. NUTRITION_EN_111309.pdf.
Malnutrition, Undernutrition
Underlying causes
Malnutrition is caused by inadequate
food intake and disease. In turn
this has underlying and basic
causes. Here I focus on three
underlying causes that go to explain
the current state of malnutrition
especially in sub-Saharan Africa.
Food insecurity
Food security is achieved when all
people, at all times, have physical
and economic access to sufficient,
safe and nutritious food to meet
their dietary needs and food
preferences for an active healthy
life (1). These can include simple
local staples like that shown in the
picture here of traditional maize
(corn). Food insecurity itself has
many basic causes. These include
unstable social and political
environments that frustrate
sustainable economic growth, war and
civil strife, macroeconomic
imbalances in trade, natural
resource constraints, poor human
resource bases, gender inequality,
inadequate education, poor health,
natural disasters such as floods and
locust infestation, and bad
governance (2). All of these
misfortunes are common in many parts
of Africa, so it is not surprising
that food insecurity persists in
Africa.
In many parts of Africa, poverty has
worsened, and the millennium
development goal of alleviating
poverty is not being achieved. The
HIV situation has not improved, and
many households have become food
insecure and lost livelihoods due to
HIV infection. Civil wars and
strifes are rampant, displacing
large numbers of people at a time as
well as exposing them to infections.
Africa has had more than its share
of poor governance and bad
leadership leading to instability
and decline. As if that is not all,
poor peasant farmers find themselves
at the mercy of the climate and rain
for irrigation. They are often
bedevilled with drought, which
causes poor yields and famine.
Nutrition security can be achieved
only after achieving food security.
Preventing children from being
malnourished, and reducing infant
mortality, depend so much on all
such factors, and public health
nutritionists, as professionals and
as citizens, have a role to play in
all these.
Inadequate maternal and child
care practices
The period from birth to two years
of age is recognised as the
‘critical window’ for the promotion
of optimal growth, health, and
development. Failure to breastfeed
exclusively, insufficient quantity
and inadequate quality of
complementary foods, general poor
child-feeding practices, and high
rates of infections, have a
detrimental impact on health and
growth in these vital two years.
Inadequate breastfeeding, offering
the wrong foods, giving insufficient
quantities, and not ensuring that
the child gets enough food, all
contribute to malnutrition, and all
these bad practices persist in
sub-Saharan Africa and many
lower-income countries although
there is improvement in some
countries. (http://siteresources.worldbank.org/NUTRITION/Resources/Tool9-appendb.pdf).
Even with optimum breastfeeding
children can become stunted if they
do not receive sufficient quantities
of quality complementary foods after
six months of age.
For example, in Niger it is reported
that while breastfeeding is common,
exclusive breastfeeding is rare, and
children are fed water, herbal tea
and cow’s milk within a few days of
birth (3). This exposes them to
increased risks of infection,
particularly diarrhoeal diseases and
acute respiration infections (4). It
therefore not surprising that
prevalence of severe acute
malnutrition among infants less than
6 months is high in Niger. In
Nigeria a study found that the
quality of breast feeding practices
was poor and the duration was mostly
short. The use of cow's milk and the
tendency to commence supplementary
feeding before six months were also
prominent (5). Meanwhile, the
complementary foods introduced were
likely to be inappropriate.
These practices are likely to be
associated with traditional and
cultural beliefs and taboos some of
which are not helpful, together with
issues such as discrimination and
lack of empowerment, high illiteracy
and lack of nutrition education.
Unhealthy environments and
lack of access to health service
A third underlying cause of
malnutrition is lack of access to
health care, and poor environments
generally. Inadequate access to
clean water and poor environmental
sanitation exists in sub-Saharan
Africa. Malaria is endemic; one of
its causes is poor environmental
sanitation such as swamps, gutters
used as open drains, stagnant water
and poor drainage systems. Lack of
access to health facilities and care
is a major contributor to
malnutrition within a continent
where rural populations are high and
proximity to health facility
sometimes lacking. For instance in
Niger there is very low access (48%)
to formal health treatment, and a
low number of people seeking
treatment even where there is access
(3). In some countries poor quality
of health delivery, especially in
rural areas, results from lack of
adequate staffing since many health
workers would rather live in urban
areas.
Obviously, these underlying causes
require commitment from society as a
whole, not only from public health
nutritionists. But the multi-faceted
nature of the factors also imply
that we should be more than public
health nutritionists and should go
beyond providing just the scientific
evidence in order to make a
difference.
So you may ask yourself. I am a
public health nutritionist, or a
nutritionist who works in public
health. I am interested in
preventing children from being
malnourished in the first place.
What should I be doing? I don’t have
all the answers. Next month – and I
hope with your help – I will look at
some of the answers, from a public
health and a nutrition point of
view. I am also sure that some
readers have strategies and
programmes which have worked and
would like to share with others.
Please comment on what should be
done and what has worked and
hopefully, we will discuss that in
July’s blog
References
- International Food Policy
Research Institute. Reaching
Sustainable Food Security For
All by 2020. Getting the
Priorities and Responsibilities
Right. Washington DC: :IFPRI,
2002.
- Mwaniki A. Achieving Food
Security in Africa: Challenges
and Issues. Accessible at
http://www.un.org/africa/osaa/reports
- Understanding nutrition
data and the causes of
malnutrition in Niger. A special
report by
Famine Early
Warning Systems Network (FEWS
NET) July 2006. Accessible at
http://www.fews.net/docs/Publications/1001044.pdf
- Infant Feeding in
Emergencies, Module 1.
Manual for orientation, reading
and reference. Draft material
developed through the
collaboration of WHO, UNICEF,
LINKAGES, IBFAN, ENN and
additional collaborators,
November 2001.. Accessible at
http://www.ennonline.net/pool/files/ife/module1-manual-refer-ops-gv2-1.pdf
- Ogunlesi T, Dedeke O, Okeniy
J, Oyedeji G. Infant and toddler
feeding practices in the
baby-friendly initiative (BFI)
era in Ilesa, Nigeria. The
Internet Journal of Nutrition
and Wellness 2005, 1,
2.
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