Last month I asked why malnutrition
is still a major problem in Africa,
focusing on three underlying causes
of malnutrition using the conceptual
framework on causes of malnutrition
and death. This month I sit by the
river again, and I ask what should
we be doing, and how we can learn
from interventions that work. But I
would like to soothe you with the
nice serene picture above taken by a
good friend of mine. It is one of
those peaceful atmospheres that we
all desire every now and then.
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Malnutrition in Africa |
| What can we do right? |
It is essential to be aware that
under-5 mortality levels are high in
many countries, and that
malnutrition is associated with more
than half of these deaths. There is
no way the Millennium Development
Goals 4 (reducing child mortality)
and 5 (improving maternal health)
can be met if we omit the issue of
malnutrition, or do not address its
challenge the right way. You can
read more about the MDGs at
http://www.undp.org/mdg/basics.shtml.
Interventions that aim at preventing
malnutrition and ensuring proper
care for malnourished children are
key steps towards promoting child
survival and reducing under-5
deaths. Though there is a great
shift towards obesity and specific
micronutrient intervention, maternal
and child undernutrition continues
to place a heavy burden on low- and
middle income countries (1).
So you may ask yourself. I am a
public health nutritionist or
nutritionist who works in public
health. I am interested in
preventing children from being
malnourished in the first place or I
am interested in child survival.
What should I be doing? Let’s look
at public health nutrition-oriented
approaches used by one UN agency –
the UN Childrens’ Fund (UNICEF).
Malnutrition throughout the world
UNICEF's policies and programmes
UNICEF is committed to scaling up
and sustaining coverage of its
current high-impact nutrition
interventions in four key programme
areas. These are: infant and young
child feeding; micronutrients;
nutrition in emergencies; and
nutrition and HIV.
Infant and young child feeding
Infant and young child feeding has
two aspects: exclusive
breastfeeding, and appropriate
complementary feeding. UNICEF’s goal
is to protect, promote and support
optimal infant and young child
feeding practices (1). The picture
of the woman breastfeeding her child
above, reminds us that exclusive
breastfeeding and appropriate
complementary feeding should ensure
improved nutritional status, growth
and development, and the health, and
ultimately the survival of infants
and young children.
These strategies are based on the
1990 Innocenti Declaration on the
Protection, Promotion and Support of
Breastfeeding, the 2005 Innocenti
Declaration on Infant and Young
Child Feeding and the 2003 Global
Strategy on Infant and Young Child
Feeding. Use this link for more
information
http://www.unicef.org/nutrition/index_breastfeeding.html.
It is reckoned that about 1.4
million of the under 5 deaths in
developing countries can be
prevented by exclusively
breastfeeding for 6 months, and that
a further 6 per cent or close to
600,000 under 5 deaths can be
prevented by ensuring optimal
complementary feeding (1). Hence
actions to promote these are
crucial. Many lower-income countries
support these strategies, which is
good. But the same story cannot be
told regarding implementation. Rates
of exclusive breastfeeding up to 6
months are still low (about 50 per
cent, and lower) in many African
countries in spite of its benefits
(2).
Micronutrients
In many lower-income countries,
one-third or more of children under
5 years of age are stunted (low
height-for-age), and large
proportions are also deficient in
one or more micronutrients. Over
half of 6-9 month olds are breastfed
and given complementary foods and
only 39 per cent of 20-23 month-olds
are provided with continued
breastfeeding. Appropriate
complementary feeding is necessary
to provide the necessary energy and
micronutrients for children 6 months
and above in order to prevent
underweight (too light), wasting
(too thin) and stunting (too short).
All sorts of fruits and vegetables
are good sources of micronutrients
and can be used in preparing
complementary foods for infants.
UNICEF’s approach to improve
micronutrients status is to increase
the nutritional adequacy of
complementary foods, identifying
vulnerable groups who may require
food aid, multi-micronutrient and
lipid based supplements, and
education for improved feeding
practices. UNICEF seeks to support
policies and strategies to promote
complementary feeding and health
systems such as curricular and
training of health workers. At the
community levels, mother support
activities are encouraged.
Strategies to eliminate iodine
deficiency disorders, reduce the
prevalence of anaemia and to achieve
sustainable elimination of vitamin A
deficiencies using public health
strategies have been implemented.
Universal salt iodisation, vitamin A
supplementation, fortification of
staple foods, improvement of the
diversity of diets, and iron-folate
supplements, are among such
programmes.
Nutrition in emergencies
UNICEF’s third approach for
promoting nutrition focuses on
emergencies. It is estimated that
about 35 million refugees and
displaced people are in the world,
90 per cent of whom are women and
children. Malnutrition increases
during emergencies because people
become displaced, livelihoods are
lost, sanitation problems become
pronounced due to congestion in
refugee camps, breakdown of health
system is likely, lack of clean
water results, and mothers may find
it difficult to breastfeed. The
result is acute malnutrition.
If the emergency situation is
prolonged, then chronic malnutrition
also becomes an issue. In
emergencies, UNICEF assesses the
nutritional and health needs of
affected populations, protects and
supports breastfeeding, especially
exclusive breastfeeding by providing
safe havens for pregnant and
lactating women, provides essential
micronutrients, supports therapeutic
feeding centres for severely
malnourished children, and provides
food for orphans.
Nutrition and HIV
On nutrition and HIV, strategies
adopted by UNICEF include providing
voluntary, confidential testing and
infant feeding counselling for
pregnant women, helping governments
develop infant and young child
feeding policies that encourage
early and exclusive breastfeeding
and include HIV guidelines,
protecting breastfeeding, and
promoting optimal infant feeding in
hospitals.
UNICEF also addresses the
nutritional needs of the growing
number of HIV-positive pregnant and
lactating women and children who are
infected with the virus, orphaned,
or living with an HIV-infected
parent. The aims of these strategies
are to prevent mother-to-child
transmission of HIV in
breastfeeding, and to provide care
and support to infected mothers and
HIV exposed and infected children.
Malnutrition and its persistence
What works?
These strategies are
effective only if they are properly
implemented. One of the Panel 1
Series Key Messages of The Lancet
series on maternal and child
undernutrition states that
‘Effective interventions are
available to reduce underweight,
stunting, micronutrient
deficiencies, and child deaths.
Among the currently available
interventions reviewed,
breastfeeding counselling,
appropriate complementary feeding,
and vitamin A and zinc, have the
greatest potential for reducing
child deaths and future disease
burden related to undernutrition.
Interventions to reduce iron and
iodine are important for maternal
survival and for children’s
cognitive development, educability,
and future economic productivity’
(3).
We can conclude from the above quote
that these strategies do work. Given
this, then either they are not being
implemented, or there is something
wrong with how they are implemented.
Maybe these interventions are not
provided in a timely manner, or
large (nationwide) scale
implementation is lacking, or there
is lack of political will, or they
are not implemented in a sustainable
manner.
What do I think?
In my opinion, counselling pregnant
women, and education on the vital
value of exclusive breastfeeding
during antenatal visits need to be
intensified. The baby- friendly
hospital initiative needs to be
protected. The importation and
promotion of breastfeeding
substitutes should be strongly
discouraged, through legislation.
Moreover, many cultural
misconceptions still persist. It is
common among certain cultures for
mothers not to give colostrum or
give herbal mixtures in the first
days of the child’s life. Some women
still think breastmilk does not have
enough water. Other mothers do not
sill accept the fact that breastmilk
flows as the child suckles and are
tempted to mixed feed because the
child cries. Yet still others also
think that bottle-feeding is a
status symbol, an indication of
prosperity. These issues need to be
addressed.
What is appropriate complementary
feeding? In my experience, teaching
and demonstrating to rural mothers
with the help of a mother-support
group how to prepare thick (not
watery) cereal porridges and to
fortify with palm oil, peanut paste,
soya milk and fish powder are simple
but effective ways of promoting
appropriate complementary feeding.
I believe that food based approaches
such as fortification of commonly
eaten foods should be required by
law throughout African countries,
and that non-compliance should be
identified and punished. Imported
foods, especially oil and cereals,
should also be fortified. If not,
micronutrient deficiencies will
continue to be with us. There are
countries where food fortification
has worked, such as in Morocco where
flour is fortified with iron and
bread made from the fortified flour
is commonly eaten at almost every
meal.
The causes of malnutrition are
multi-faceted. Tackling malnutrition
should involve all sectors including
health, agriculture, water and
sanitation, transport, and rural
government. We must know how to
collaborate and bring the various
sectors round the table when we plan
for interventions because all are
needed.
Global consensus
Having said all this, malnutrition
will be properly tackled only when
nutrition becomes a priority at all
levels, from global through national
to local and household. As rightly
put in the executive summary of
The Lancet Series, nutrition is
a central component for human,
social and economic development, and
prevention of malnutrition is a
long-term investment that will
benefit the current generation and
their children.
I believe that efforts at national
levels will be effective if there
are agreements at the global level
that prevent exploitation and which
do not force countries to only do
what donor agencies expect them to,
even if these are not in the
country’s interest. On the other
hand, these global pressures are
also necessary because they may
compel national commitment and
promote political will.
Finally, ‘Reducing maternal and
child undernutrition will require
improved coordination between
national agencies and international
organisations. Additionally, the
international nutrition system
requires significant reform in order
to be effective: a new global
governance structure is needed to
provide greater accountability’.
This is the last and crucial key
message of The Lancet series.
There are many parts of Africa where
several non-government organisations
are working together in the same
geographical location and doing
similar interventions but one does
not know what the other is doing.
This only leads to re-inventing of
wheels or duplication as well as
wasting already limited resources.
Some of these programmes are not
sustainable anyway since they fold
up in 3-5 years without adequately
empowering the communities to
continue. Lack of coordination also
means that there are no
opportunities for agencies to learn
from one another’s experiences in
order to avoid mistakes made by the
other and thus do what works.
Malnutrition acute and
chronic
More RUTF stuff
Where do ready-to-use therapeutic
foods fit into this? They are
important, they are a breakthrough
in large scale management of
malnutrition, and they are
effective. One of their
characteristics which makes them
very effective is their low water
content, which ensures that they do
not get easily contaminated, have
long shelf life and are nutrient
dense.
This is in contrast to parts of
Africa where children are given
watery porridges with high water
content and low nutrient density,
and where the water may be
contaminated. The diet of the
general population especially in
West Africa is also mainly root
crop-based rather than cereal based.
Cereal based foods have lower water
content than root-based foods, and
this decreases the risk of low
nutrient density.
But ready to use therapeutic foods
should be used only to manage
malnutrition in emergencies and as a
short-term approach. They must not
replace family foods and balanced
diets. We must not medicalise
malnutrition. We should promote
nutrition rather than manage
malnutrition.
Prevention is better than cure
Looking at the causes of
malnutrition it is clear we should
focus on prevention rather than on
‘management’. The presence of
malnutrition in children signifies a
failure on our part as professional
and scientists, and also a systemic
failure.
This implies that we should prevent
children from become malnourished in
the first place. This is why
ready-to-use therapeutic foods
should not be our focus. Public
health nutritionists working in
Africa and in all other
low-resourced countries and settings
should endeavour to tackle the
factors that lead to the situation
where we need to treat or ‘manage’
malnutrition – for at that point, we
would have failed already. Indeed,
the term ‘manage’ sounds quite
negative. Why manage a problem when
you can prevent the problem in the
first place?
If the debate is centred on
ready-to-use therapeutic foods, and
generally on treating malnutrition,
we will make minimal impact. The
debate should be on how to prevent
malnutrition. Instead of debating
whether we should produce
therapeutic foods locally or
commercially, in Africa or as
imported say from Europe, we should
be thinking about how can we
eradicate food insecurity, improve
care and feeding practices for
children and infants, and
successfully advocate adequate
public health access and safe
environments, so that we do not end
up ‘managing’ malnourished children.
To achieve this, it is necessary to
strengthen programmes and
interventions that aim at preventing
malnutrition. These include
exclusive breast feeding and
appropriate complementary feeding,
food fortification, school feeding
programmes, supplementary feeding,
community based growth monitoring,
nutritional surveillance, nutrition
education, and behaviour change
communication.
We must also address the factors
that underline poor feeding
practices, food insecurity and poor
health and environment. Even when we
have to manage malnutrition, the
community mobilisation and screening
aspects need to be emphasised since
these are more prevention-based. And
when malnutrition needs to be
managed in the hospital, we should
pay attention to support for
families and carers, so that they
are empowered in order to prevent
the recurrent of malnutrition.
A world free of malnutrition? Yes,
it is possible.
References
- UNICEF in Action UNICEF
www.unicef.org
- WHO. Infant and young child
feeding data by country.
http://www.
who.int/nutrition/databases/infantfeeding/countries/en/index.html
- The Lancet series on
Maternal and Child
Undernutrition. Executive
summary” IAEA
http://www-tc.iaea.org/tcweb/abouttc/tcseminar/Sem6-ExeSum.pdf
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Request and acknowledgement
You
are invited please to respond, comment, disagree, as
you wish. Please use the response facility below.
You are free to make use of the material in this
column, provided you acknowledge the Association,
and me please, and cite the Association’s website.
Please cite as: Annan R. Promoting Nutrition
and preventing malnutrition: What has worked and
what should we be doing. [Column] Website of the
World Public Health Nutrition Association, July
2010. Obtainable at www.wphna.org
The opinions expressed in all contributions to
the website of the World Public Health Nutrition
Association (the Association) including its journal
World Nutrition,
are those of their authors. They should not be taken
to be the view or policy of the Association, or of
any of its affiliated or associated bodies, unless
this is explicitly stated.
This column is reviewed by Geoffrey Cannon.
regvies@yahoo.com
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