Malnutrition in Young Children
Maternal Nutrition
The Agricultural Dimension
Seasonal Deprivation
Mental and Cognitive Development of Children
New Dietary Challenges: Chronic Diseases
Areas for Action and Ways Forward
References
Discussion
Philip James
The Commission on Nutrition Challenges in the 21st Century was established by the ACC/SCN in Kathmandu in March 1997. Its purpose is to consider how best to meet the nutritional challenges of the 21st century and to consider the role that the UN can play in meeting these challenges, taking into account the goals and commitments established at the major international conferences of the 1990s. This paper presents the preliminary findings of the Commission as set out in the draft report ‘Ending Malnutrition by 2020: an Agenda for Change in the Millennium’ (1998).
With the exception of Richard Jolly (SCN Chairman) and Ricardo Uauy (Chairman of the Advisory Group on Nutrition), the members of the Commission are completely independent of the SCN process (see Box 1). This independence has both advantages and disadvantages. The main advantage is that the Commission members perceive it as their job to speak their minds. However, there are disadvantages in that they may be preaching to the converted, and they may also be engaging in issues that the SCN has already considered in detail.
The Commission is taking a new perspective to address the persisting problem of malnutrition, and is attempting to identify whether there are other, previously unconsidered dimensions to the global nutritional problem that need to be taken into account. This paper will not therefore consider the huge problems of iodine deficiency disorders, vitamin A deficiencies, and iron deficiency anaemia, as these are already being addressed. The ACC/SCN Working Group meetings on micronutrient deficiencies (Oslo, 1998), suggest that real progress is being made in combating iodine deficiency, that progress in combating vitamin A deficiency is accelerating, but that very little progress is being made in the area of iron deficiency.
|
Box 1: Members of the Commission on Nutrition Challenges in the 21st Century · Philip James, Director, Rowett Research Institute, Aberdeen, Scotland · Mahbub ul Haq, President, Human Development Centre, Islamabad, Pakistan1 · Kaare Norum, Director and Professor, Institute for Nutrition Research, Oslo, Norway · M.S. Swaminathan, Chairman, M.S. Swaminathan Research Foundation, Chennai, India · Suttilak Smitasiri, Head, Division of Communication and Behavioural Science, Institute of Nutrition at Mahidol University, Nakhn Pathom, Thailand · Julia Tagwireyi, Director, Nutrition Department, Ministry of Health, Harare, Zimbabwe · Ricardo Uauy, Director and Professor, Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile · Richard Jolly, Chairman, ACC/SCN, Special Advisor to the Administrator, UNDP, New York, USA 1 Mahbub ul Haq died on July 16, 1998 |
Globally, over 150 million children are underweight. The distribution of underweight children by region shows that the dominant problem occurs in South Asia (Figure 1). This contrasts with the long-held view that Sub-Saharan Africa is the major crisis region of the world and perhaps reflects the way in which nutritionists often associate the nature of the problems in South Asia as being part of normal society, without recognising the presence of a vast endemic problem that needs to be tackled.
Figure 1: Total numbers (millions) of underweight children (under 5 years old) by region, 1995
Source: ACC/SCN (1996)Furthermore, a current definition of undernutrition tends to underestimate its true impact within populations because the definition is based on specifying only those at the extremes of underweight, with those classified as being malnourished falling below the lowest limit (-2 SD) of the reference population. In practice, the whole population tends to exhibit a ‘shift’ so that the majority of a country’s children may have sub-optimal growth (Figure 2).
Figure 2: The hidden impact of undernutrition
Substantial progress has been made in reducing stunting in all regions of the world except Sub-Saharan Africa (ACC/SCN, 1997). However, recent simulations by IFPRI/IMPACT projecting progress to the year 2020 suggest that continued progress, over what is quite a substantial period of time, will only be modest (Figure 3). The nutrition community has not confronted this problem in a coherent way, and it is now time to rethink the basis on which we set out analyses and plan action.
Figure 3: Projecting progress in reducing underweight in children
Source: Pinstrup-Andersen et al. (1997)
In some communities, the basis for malnutrition starts before birth, with mothers of low body mass index (BMI) on average giving birth to babies of low birth weight (Shetty and James, 1994). Although this direct relationship between maternal weight and birth weight is not a new finding, the nutritional state of women, both before pregnancy and during pregnancy, is something that should be given more emphasis, especially by major policy makers.
The amount of weight gain required by a woman during pregnancy in order to ensure giving birth to a child with normal birth weight, is set out in maternal nutrition criteria described by WHO (1995). In spite of this, there is as yet no system in society where the requirements of antenatal care, even in a crude way, are locked into the pre-existing weight and rate of weight gain of the mother during pregnancy.
Studies in South Africa and elsewhere during the 1960s and 1970s have demonstrated quite profound effects of supplementary folic acid in dramatically reducing the likelihood of low birth weight (for example, Baumslag et al., 1970). In a recent review of trials evaluating different prenatal interventions to prevent or treat impaired foetal growth (de Onis et al., 1998), folate, zinc, and magnesium supplementation during pregnancy were shown to have possible beneficial effects, with protein/energy supplementation shown to be beneficial (Table 1). On the basis of these analyses, we need to look at antenatal care in a completely new way in order to avoid the huge handicap that arises from low birth weight.
Table 1: Nutrition interventions to prevent intrauterine growth retardation
|
Intervention |
Number of trials |
Effect (odds ratio) |
|
Beneficial effect |
|
|
|
Protein/energy supplement |
7 |
0.77 |
|
Possible beneficial effect |
|
|
|
Zinc |
4 |
0.77 |
|
Folate |
5 |
0.6 |
|
Magnesium |
2 |
0.59 |
Source: de Onis et al. (1998)Focusing on women, a study carried out in ten states of India has shown that half the adult female population in rural areas is malnourished. Other studies in India have shown chronic energy deficiency in nearly 70% of women (Table 2). In Asia, similar levels are seen in Bangladesh and Pakistan. There are 30-40% malnourished women in Viet Nam. In Africa, the figure varies between 20 and 40% depending upon whether there has been a catastrophe, war, famine or drought.
Table 2: Chronic energy deficiency in India in the late 1980s
|
Women |
III (%) |
II (%) |
I (%) |
Total (%) |
|
10 States |
11 |
13 |
25 |
49 |
|
Hyderabad village |
10 |
15 |
33 |
58 |
|
IFPRI rural village |
16 |
18 |
27 |
61 |
|
EC rural pool |
19 |
16 |
33 |
68 |
Source: NIN (1989-90)The consequences of adult malnutrition extend beyond those of maternal risk of underweight babies. The ability of women to sustain work and their sheer physical capacity to cope are markedly dependent upon their body mass. Illness and handicap, in terms of sickness, days off work, days sick in bed and death rates, all increase with increasing malnutrition (Shetty and James, 1994). We are therefore dealing with a new dimension of malnutrition, which so far has not been incorporated into our thinking. Malnutrition in women, with its links to low birth weight, inability to sustain work, and reduced capacity to care for the family, is an area that we have not taken on board at all.
In addressing the agricultural dimension of malnutrition, the Commission has taken the population of India to give an example of the current lack of food provision. Approximately 1800 calories of food is supplied per person in India. If, however, India were a society in which people could grow to an appropriate height by virtue of being well fed during childhood, in which people were not wasted, and in which people were able to engage in all the activities that they desired, then a third more food per person would be needed (Figure 4).
Not only is there a fundamental challenge for the provision of food, but there are also the considerable problems and risks associated with the fact that, globally, we have come to rely on amazingly few types of food crops (Mann, 1997). We are becoming increasingly dependent on the mono culture, single system of agriculture with all the implications in terms of intensive production.
Many neglected and under-utilised crops, currently referred to as ‘coarse cereals’, have highly desirable nutritional profiles and should therefore be redesignated as ‘nutritious cereals’. In considering how best to ensure nutritional diversity, or ‘global nutrition security’, in addition to the number of calories produced from a crop, an eight-point strategy has been developed as an important long-term insurance policy for agriculture (see Box 2).
A new approach of measuring and comparing weights and heights of both children and mothers has been developed in order to prioritise village, regional and national policies for combating malnutrition (James et al., 1999). Figure 5 shows a schematic representation of this new approach. If mothers are thin, they may simply not have enough food. It is not surprising therefore that thin mothers are associated with thin children, as the problem is a fundamental problem of food security and household provision of food on a daily basis. But the model also illustrates other scenarios. Adequately fed mothers may have thin, malnourished children, and this raises a number of issues in relation to UNICEF’s concern for caring.
Figure 4: Projected food needs of the Indian population
Source: IDECG (1992)Figure 5: A new approach to prioritising village, regional and national policies
Source: James et al. (1999)
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Box 2: Global nutrition security (Swaminathan, 1998) 1. Re-focus national priorities in agricultural research to allow for crop diversity as well as the intensity of production 2. Recreate the demand and market for a wide range of crops 3. Develop processed foods based on a mixture of nutritious crops 4. Include minor crops in national food security measures 5. Redesignate ‘coarse cereals’ as ‘nutritious cereals’ in order to alter the image of such micronutrient rich crops in public perception 6. Promote conservation of a wide range of food crops 7. Promote breeding efforts designed to increase the micronutrient content of crops like rice, wheat and maize 8. Promote mixed cropping and multiple cropping sequences
which provide space in the cropping system for under-utilised but nutritionally
desirable crops |
Seasonal fluctuations in the annual provision of food can have significant effects on adult and infant malnutrition. Analyses reveal that weight changes of adults alter in response to seasonal shortages of food, and that these food shortages are induced by complex interactions of climate and soil (Ferro-Luzzi et al., 1994). Recent studies in The Gambia have shown that seasonally-induced adult body weight changes are linked to low birth weight, a greater propensity for neonatal death, childhood stunting, anaemia and the risk of permanent brain impairment. These effects on children born during and after seasonal deprivation can, however, be combated by food supplements: supplementation of pregnant women during the hungry season has been shown to result in a substantial shift in birth weight and a marked reduction in the proportion of children with low birth weight (Ceesay et al., 1997). This seasonal impact of deprivation currently affects millions of women of normal body weight and is additional to the 200 million malnourished women of reproductive age.
Seasonal deprivation also has profound long-term implications. Comparison of adult survival curves in The Gambia for those born in the harvest season and those born in the hungry season shows a remarkable effect due to season of birth (Figure 6). The premature deaths of those born during the hungry season are due both to increases in deaths from infections and to increases in deaths during childbirth. The implications are that if seasonal deprivation were eliminated overnight, the burden of physical survival and reproductive capacity would still remain for another 50 years.
In a similar way, by comparing blood glucose levels in adults born at different times during the second world war Dutch famine, Ravelli and colleagues (1998) have recently shown that foetal nutritional deprivation leads to high susceptibility to diabetes in later life. We are therefore programming a health budget 40 years hence if we continue to neglect maternal nutrition.
Studies by Sally Grantham-McGregor and her colleagues in Jamaica (1991) show the remarkable effect of different treatments for stunted children on development quotient (Figure 7). Supplementation with food markedly improves the development quotient. An even more remarkable finding is that in the absence of supplementation, the provision of stimulus and care - encouraging the children to interact with society and explore their environment - results in a greater improvement in development quotient. When supplementation and care are combined, children essentially catch up with non-stunted children in their development quotient.
Furthermore, evidence is now emerging to suggest that children who have received maternal care, interaction and nurturing during early childhood have a higher intellectual ability in secondary school.
Figure 6: Survival curves according to season of birth in rural Gambia
Source: Moore et al. (1997)
Figure 7: Development quotient of stunted children treated differently
Source: Grantham-McGregor et al. (1991)
Diet-related chronic diseases not only afflict affluent society, but are now also the scourge of the developing world. In numerical terms, diseases of the circulatory system and cancers are greater in the developing world than in the developed world (Figure 8). Cancer is enhanced by overweight, and Figure 9 shows the high proportion of overweight people in some developing countries. An extraordinary transition is occurring - from the malnutrition of India, to the huge problems of chronic disease in Colombia, for example. There is a global pandemic of obesity (WHO, 1998). In the Pacific Islands, for example, three quarters of adults are clinically obese and half are diabetic (Table 3).
Figure 8: Causes of death in the developed and developing world, 1999
Figures in bold are percentages and figures in brackets refer to the number of deaths in thousands.Table 3: The epidemic of obesity in Asia and the PacificSource: WHO (1997)
|
Country |
Year |
Age group |
Prevalence of Obesity (%) |
|
|
Men |
Women |
|||
|
India |
1988/90 |
Adults |
0.5 (mixed) |
|
|
Japan |
1993 |
20+ |
1.7 |
2.7 |
|
China |
1992 |
40+ |
2.2 |
5.2 |
|
Australia |
1989 |
20-69 |
9.3 |
11.1 |
|
Western Samoa - whites |
1991 |
25-69 |
41.5 |
59.2 |
|
Western Samoa - blacks |
1991 |
25-69 |
58.4 |
76.8 |
Source: WHO Collaborating Centre, Rowett Research Institute, ScotlandFigure 9: BMI distributions in adult populations (male and female)
Source: WHO (1995)In looking where the problem of heart disease is most prevalent, the ex-USSR, Czech Republic, and Hungary come top of the league table (1992 figures) according to the Cardiovascular Epidemiological Unit (1994). Undoubtedly, this is primarily caused by environmental and dietary factors. In Norway, a decrease in death rates due to coronary heart disease in the 1980s was preceded by a progressive reduction in total and saturated fat intake and with an increase in polyunsaturated fat consumption. The situation in Norway during this century demonstrates that with a coherent public health strategy, and not simply adult education and individual behavioural management, the course of coronary heart disease can be changed.
One of the effects of dietary change is illustrated in Figure 10, which shows that as the fat content of the diet in Denmark increased from 1935 to 1985, so did the prevalence of obesity in 18-year-old recruits. In Brazil, middle-aged women are the first group in the population to become overweight - indeed, in almost every part of the world, women are more obese than men. Not only therefore are women handicapped in the rural under-privileged part of society by underweight, but as soon as one sees a shift in dietary patterns and physical activity, women are again handicapped.
The current regional estimates of diabetes will undoubtedly escalate over the next few years diverting health resources unless a new approach to addressing this problem is found (WHO, 1997).
In order to devise coherent strategies, priorities for action need to be set to reduce maternal malnutrition, low body weight, numbers of stunted children and all the issues related to diet-related chronic disease (Box 3). Furthermore, the priorities need to be set in relation to the magnitude of the problem and the level of population risk. This approach has been applied to the major micronutrient deficiencies, where four levels of population risk have been selected (Table 4).
Figure 10: Secular trends in dietary fat and the prevalence of obesity in Danish army recruits
Source: Lissner and Heitmann (1995)
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Box 3: Areas for action 1. Micronutrients: Vitamin A, Iron, Iodine 2. Maternal nutrition: avoidance of low birth weight 3. Adult malnutrition: household security 4. Obesity: maternal nutrition; physical activity; diet with major intersectoral policies 5. Cardiovascular disease: major dietary policies in addition to consumer education 6. Cancers: major reappraisal of horticultural needs, farming,
transport and refrigeration policies for increased vegetable and fruit
consumption especially in urban areas. |
|
Level of population risk |
Subclinical signs of deficiency (%) |
||
|
Iron |
Vitamin A |
Iodine |
|
|
IV (severe deficiency) |
³ 80 - 100 |
³ 20 |
> 99 |
|
III (moderate to severe deficiency) |
³ 50 - < 80 |
³ 10 - < 20 |
³ 50 - < 99 |
|
II (mild and widespread deficiency) |
³ 30 - < 50 |
³ 2 - < 10 |
³ 20 - < 50 |
|
I (mild and clustered deficiency) |
< 12 |
< 2 |
< 20 |
Source: IOM (1998)We have a dilemma. We need targets, but we also need to go to countries. But how do we go to countries and capture the imagination of political leaders and financiers, whilst at the same time, have a discerning plan involving interagency cooperation? This is where we are rather inept in the way in which we put across our proposals.
If we are going to develop a global compact (see Box 4), we will need to take on a completely new approach, recognising that if we are going to take on some of the major global challenges, we have a whole array of conditions to account for. We have to be far more flexible, coherent, policy-driven and action-motivated than we ever have been in the past. We need to prioritise, but need to be coherent, integrative and effective in order to combat this array of challenges.
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Box 4: A new global compact for nutrition 1. Formulate a Social Compact · Prime Ministers/Presidents2. End childhood malnutrition by 2020 3. Develop national regional views of principal issues 4. Implement locally developed action plans with coherent inter-agency collaboration with subsidiarity of decision making. 5. Use nutritional wellbeing as a critical marker during
financial readjustments |
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Tim Frankenberger (CARE): In any sustainable development activity it is important to not only have civil society and government working together, but also the private sector. What is your perspective on the private sector in this activity?
Ricardo Uauy (Commission): The report that has just been presented is a conceptual framework. The action side is only just starting, and this is one of the stages of the action side. Parallel to this technical report there will be two levels of activities. One that will involve high-level political leaders and community leaders who would influence the decision-making process-including the private sector, and one that will be linked to the human rights approach. In this aspect, the Commission has contacted high-profile leaders like Mary Robinson. We are at first creating a consensus that is based on the technical side. This is a process that hopefully will continue in the months ahead, enrolling the contribution and the reaction of political leaders, social leaders, of community leaders, of business leadership around the world. The process is only in a first draft stage.
Rainer Gross (GTZ): I appreciate very much that the obesity factor has been taken up. All the surveys in Latin America suggest that obesity is not just an aspect of women but it is an aspect of poor women. Similar patterns are also seen in South-East Asia, and particularly in the country where I am working - Indonesia. I would conclude therefore that not only undernutrition, but also overnutrition, is a problem of the whole society, and not just a problem of individuals. I would like to refer you to an excellent recent overview in Scientific American, which presented some exciting news on the biochemical insights regarding the interaction between stress and obesity. We are learning a lot about this issue and I think we have to address the problem in relation to poverty. What I miss in the report, is the interaction between environmental pollution and nutrition. With the new wave of chronic or non-communicable diseases, in particular in developing countries, we have to address this problem.
Philip James (Commission): I agree. We are beginning to have tremendous concern about the environmental problems in, for example, Central Europe.
Roger Shrimpton (UNICEF): I would like to give a UNICEF response to the Commission’s report. Firstly, I would like to say that UNICEF sees the fulfilment of the right to good nutrition as the principal challenge to the United Nations system for the new century. This is the central message of the State of the World’s Children 1998, and a long-held agency position. We, therefore, welcome the creation of the Commission and the charge given to it by the SCN and its member agencies. We now welcome the Commission’s report, which is a thought-provoking reflection on the complex and compelling problem. It is all to the good that a distinguished panel of scholars and practitioners share with the international community, through the SCN, the visionary ideas and recommendations embodied in the report. Discussion of the report is also in the spirit of improving on this draft as a guide for interagency collaboration to advance the fulfilment of nutrition rights. We hope that the report will be an important tool in keeping nutrition as a high priority for all agencies, even amidst competing priorities and in the challenging environment of UN reform. UNICEF welcomes in particular the suggested focus for action on the reduction of stunting through the central strategies of reduction of low birth weight, and improved infant feeding. Recognising maternal care as the key to combating stunting in the next generation highlights the connectedness of nutrition actions through the life cycle. Maternal care for nutrition is a neglected element of policy and programmes, even as the recognition of the importance of birth weight and nutrition in very early child development has increased. In the constructive spirit, we would like to point out four aspects of the report that we think could be strengthened, making it even more useful for all of our agencies.
The first one is related to historical underpinning. We feel that the report could be stronger if it better reflected the recent history of consensus building that the SCN agencies have been through, both in the SCN and in the International Conference of Nutrition of 1992. The principles in the ICN declaration are still relevant, and the process by which they were reached should not be minimised. Furthermore, the extensive exercise conducted by the ACC/SCN to understand how nutrition has improved by drawing lessons from real experience in several countries was also an important consensus-building exercise. These lessons learned, presented in the SCN document How Nutrition Improves, also represent a consensus on a number of factors that should figure in any discussion of strategies. Among these is the importance of the status of women, which should be embodied in all nutrition-related action and advocacy. Advocacy in favour of governments spending on basic social services and mobilisation of communities are also parts of those elements. Structuring the report more closely on the range of lessons already articulated in the SCN documents would have provided some continuity to this analytical base.
The second issue is around the nature of the malnutrition problem. One aspect of the consensus captured in the ICN was about the nature of the problem of malnutrition and its causes. In particular, it was agreed at the ICN that care for nutrition in households, particularly care of women and young children, was treated on a par with household access to adequate food and to health services and a healthy environment as determinants of malnutrition. The ICN background paper on care for nutrition explained clearly the phenomenon by which child malnutrition exists, even in the face of adequate health services, sanitation, and household food security. These ideas are no less relevant today than in 1992. The Commission report is weak in its consideration of the elements of care for nutrition as well as for links to food security and health.
The third issue is about the centrality of rights. As the Secretary-General has noted categorically, all activities of the United Nations must be based on, and reflect, a human rights approach. The report would be stronger and more credible as a UN document were human rights more central to this analysis and recommendations. To call for a new social contract for nutrition for example, ignores the well-established body of human rights instruments that form the basis for the work of the United Nations and already constitutes a social contract for nutrition. The report would do well to call for a strengthening of the focus on nutrition in the existing processes by which States Parties report on their human rights obligations to the relevant United Nations bodies. There is great scope for making nutritional concerns more pronounced in this reporting and the SCN, as well as member agencies, have a clear role to play in this regard.
The fourth issue is around the scope of priorities for nutrition problems. There is no question that non-communicable chronic diseases related to nutrition and other factors are a growing problem, both in developing and industrialised worlds. There is also convincing evidence that reducing low birth weight and undernutrition in its many forms in the early months of a child’s life reduces that child’s risk of suffering from a number of chronic diseases in adulthood. UNICEF believes that this should be a principal strategy for the SCN agencies to address the problems of chronic diseases in adulthood as it is consistent with a wide range of other objectives, including reduction of stunting. Approaches that aim first at the problems of undernutrition more directly associated with poverty, disenfranchisement and poor access to resources and basic services at the household level are necessarily those that should be of most concern to our central agencies and to the SCN.
The fifth and last item concerns follow-up processes. UNICEF appreciates the report’s conclusion that regional strategies are necessary and useful to combat malnutrition. Nonetheless, regional nutrition strategies already exist in many cases, although we agree they can be strengthened. Existing regional meetings should be used to articulate and advocate the agenda of the Commission report, but a new series of regional meetings would be burdensome for government partners who have already participated in the formulation of regional agendas related to nutrition. We hope that our constructive consideration of the report, together as SCN member agencies, will result in a common commitment to some key principles and actions that will move forward the fight against global malnutrition.
Mike Golden (University of Aberdeen and ACF): The startling data that has just been presented shows how devastating stunting and wasting are - in both children and adults - and how the legacy of past failures is building up for the future. The data have all been observational and epidemiological. Philip James has shown us that we are in a terrible state, but he has not shown us what we can, or should, do about it. In 1982, George Beaton reviewed supplementary feeding programmes - over 200 of them. On reading that report and looking at the original papers, it is quite clear that the supplemental feeding programmes were universally unsuccessful. Looking at the programmes that have occurred since 1982, which I have reviewed, the supplemental feeding programmes have, by and large, also been unsuccessful. We still have the problems of stunting and wasting and we don’t have a successful strategy to implement, we don’t know what to do about the problem or, in biological and physiological terms, why the problem occurs.
I would like to ask the Commission whether they have considered the underpinning science - the causation of stunting; the causation of thinness in adults; the causation of low birth weight. Has the Commission come across any successful programmes at all? I am reminded of data published by Michael Gracy on Australian Aboriginals, which described four decades of nutritional surveys, showing that the nutritional state today is no different than it was four decades ago. During that time, public health measures were put in, children were vaccinated, and there were social security and food security. But these have had zero effect on the weight and the height of the Aboriginal populations. Clearly the strategies that we have had in the past have been failures. So why do we persist with the same strategies? I suggest this is because we need to do something because of the magnitude of the problem, but we do not know what else to do.
We can talk about addressing these problems, and we can all see that we have a major problem, but I do not see that we know what to do about them. I do not see that there has been an investment in nutritional science to understand the causation of stunting, of low birth weight or of thinness in adults, so that we can formulate reasonable strategies based on science.
It is axiomatic that we cannot apply what we do not know!
Ricardo Uauy (Commission): There is always room for more science. The Commission feels that the body of science that has emerged over the last 15 years at least allows us to move forward. In the Third Report on the World Nutrition Situation you will find that science has made an impact in programmes, and that progress is being made. The missing link to strengthen action is not the need for more science - we will always need more science - but the need to apply the science that we know and the science that is emerging. At present, the bottleneck is in the application of science at the programme level, especially at national level. Successful pilot projects around the world have demonstrated that we can advance. We don’t have all of the answers, but at this point I think there is enough knowledge to put into action, while at the same time, we generate new knowledge. Hopefully, by putting this knowledge to work we will learn how to make these programmes more effective. So your point is well taken. But at present, the call is for action in terms of reducing stunting. If you look at the progress, many of the countries around the world are making dramatic progress at improving stunting with an integrated approach where the three components of the agencies are present-care, food security, and health.
Basil Hetzel (ICCIDD): My comment is related to our experience in meeting the gap between available knowledge and its application, which has just been alluded to by the panel. I offer this experience as being relevant to other problems. How has the progress with iodine deficiency disorders been achieved? I submit that it has been achieved, first of all, as a result of the level of scientific knowledge. This permits the available technology to be applied, and the understanding of the problem as a major cause of brain damage (considered by WHO as the major preventable cause of brain damage in the world today), to be widely accepted. The second step was the establishment of an international NGO, which I have the honour of chairing. George Beaton made the comment in his ‘history’ that the establishment of this NGO in relation to the SCN was indeed a critical step. That NGO has been able to work in the UN system in advocacy. It has been able to reach countries. It has developed various strategies at the global, regional, and country levels. The remarkable progress that we have seen has resulted from collaboration between agencies in the UN system, the multilateral agencies, the bilateral agencies, the NGOs, the private industry (the salt industry) and finally, the world service club, the Kiwanis who have raised US$ 25 million towards the campaign so far. I offer the model of the International Council for Control of Iodine Deficiency Disorders (ICCIDD) as one where there has been the establishment of a global partnership. That global partnership has brought about a very dramatic improvement in the situation and control of iodine deficiency as a cause of brain damage in the last decade. I believe this model deserves consideration by the Commission and by the SCN in relation to other problems.
Tom Marchione (USAID): I look forward to taking the Commission results back to the Bureau for Humanitarian Response in Washington, which is in charge of an US$ 800 million food assistance programme where food supplementation plays a large part. In response to Michael Golden’s comments, if one looks at the SCN publication How Nutrition Improves, indeed you will see that there are examples where one can have an impact on child malnutrition through programmatic approaches. However, I would also like to support his view that there be an emphasis on programming and how to do it. We have set a goal of reducing general malnutrition by one half and I think we have to focus on how we go about achieving that goal, if not by the year 2000, then shortly after that.
Philip James (Commission): Concerning Mike Golden’s issue, i.e., trying to create a substantive body of knowledge and a capacity within developing countries, we have actually been discussing that here in Oslo with the IUNS. There is a real need for us to go from our near colonialist approach where we essentially, dare I suggest it, seduce the most able in developing countries into UN or NGO organisations. We are very troubled by the need to nurture a powerhouse of intellectual analysis and independent national thought within particular countries, and I think that we do see programmes where we are absolutely convinced that this is the right approach. It would be so much better if that were done in a coherent way with the local institutes full of their vigorous analysis of what’s needed on a national basis. I would very much hope that as we develop this report we will see that in some way we need to lock that process of nurturing and capacity building, which Dr Brundtland mentioned, into the whole mechanism by which we achieve change.
Anna Ferro-Luzzi (Italy): I enjoyed your presentation, and the way it brought together a whole picture. In this respect, I appreciated particularly one aspect of it, namely the concept that malnutrition should not be seen only as expression of food deprivation, but also as a consequence of unbalanced diets. As you pointed out, this problem is not limited to developed countries. The developing country burden in chronic diet-related diseases such as obesity, cancer, and ischaemic heart disease, is already great, and is bound to increase exponentially in the near future with an ageing population and change in lifestyle. The problem we face today is the difficulty of persuading policy makers and academia in developing countries that these aspects should be taken into serious consideration. The same applies also to donors - be it governments or agencies - who are very reluctant to put chronic diet-related diseases on their agenda. I would warmly wish that the next draft of the report include advice on the strategies and arguments needed to increase the awareness on this aspect, perhaps emphasising the economic benefits of early prevention of chronic diseases.
Julia Tagwireyi (Commission): One of the areas for discussion is ‘how to do it’. If you look at the successful case studies that have been developed, there is certainly a lot of information. But we have not extended the ‘how to do it’ in terms of how we sustain the political commitment to nutrition in a way that makes it politically expedient for the politician to support nutrition and to make it beneficial in economic terms. It is all very well to have well-conceived programmes but they just remain on paper. If we don’t manage their scarce resources, how would I, as head of nutrition, make an argument so that my minister of finance sees it as economically possible or expedient to invest in nutrition? I think the ‘how to do it’ in that aspect is a bit deficient and I think that here we can learn. There are a lot of agencies that have been past masters at this and I think we need to harness those experiences. The ICCIDD is one. UNICEF has also been quite successful in engaging policy makers. We have to move from science to practice. We have to engage in political dialogue. If we do not make a coherent enough argument for making nutrition an investment, then we can have good science and the best programme design, but we won’t get very far. This is where we have to move to when we look to the 21st century.
Judy McGuire (World Bank): What we have is a partial analysis of the problem. We have a far more coherent epidemiological presentation than a presentation of the rest of the issues. It is partial because even with the epidemiology, which is well represented, we really don’t know what to do about it. Take the case of low birth weight, which is absolutely critical. There is a very serious debate as to whether you can intervene at all in pregnancy, whether you can deal with adolescent girls, or whether you have to really start with the zero to 2-year-olds and improve their growth. It is an inter-generational problem, so even at that level of diagnosis we don’t have much. Also, there is no political or economic analysis here. I would maintain that poverty, more than anything else, is driving these nutrition problems and I find it to be a severe vacuum that there is no assessment of poverty anywhere in this analysis. The agricultural analysis does not refer to IFPRI’s 2020 Vision. I am hoping that the whole symposium will give us a fuller picture. Suttilak’s presentation hopefully will focus on behavioural change. Behaviour and care may not be covered, but behavioural change is certainly not covered and what we are talking about is far more than just diagnosing the problem as an epidemiological problem.
Gro Nylander (National Hospital and the National Coordinator of the Baby Friendly Hospital Initiative in Norway): Thank you for summing up some of the knowledge about the devastating effect of malnourished mothers and their small children. One would expect that the malnourished mothers of these small children would have a lower chance of lactating plentifully and successfully. Would you care to comment on what is the difference between children who are given a chance of a proper catch-up weight after birth compared to children who stay malnourished?
Philip James (Commission): It’s quite intriguing. In an IDECG symposium 2 or 3 years ago, Prentice showed that the physical capacity of mothers to keep generating milk is truly astonishing at surprisingly low body weights. But of course what you are then doing is requiring that such a woman is able to substantially increase her food intake if she is not to suffer personally. The evidence that children can catch up from low birth weight is true, but as I look at the evidence, it is not as good as it should be. What we don’t understand is whether the failure of low birth weight children to catch up is in part a reflection of the mother’s problems, too. There is no doubt that the breastfeeding issue is enormously important, but as several have commented, we have quietly neglected some of the big issues surrounding the weaning processes. That is something that we ought to certainly include. But we are clear that it would be much better to avoid low birth weight if at all possible.
Ricardo Uauy (Commission): I think the answer from developing countries is very clear. Low birth weight is associated with decreased prevalence of breastfeeding and decreased successful breastfeeding. It is associated with high risk of malnutrition and there is the potentiating effect of low birth weight on malnutrition, stunting and both mental and physical development. This means that you have to consider both the mother and the infant. The literature of developing countries is very strong in indicating that one potentiates the other, both in terms of physical and mental handicap.
Fernando Viteri (University of California, Berkeley and UNU): The Commission states institutional strengthening and building as one aspect on how to act. It also agrees on the importance to empower governments and nations to take action. It is important in this regard not only to create a governmental will to act, but also to provide each country with a critical mass of well-trained people who can support, promote, and sustain action by the government. In this regard it is important for the UN agencies and other institutions to commit more funding and more opportunities for training scientists from the developing world, in nutrition and many other related disciplines, either locally though regional institutions or through international cooperation. My plea is to increase the capacity of institutions by increasing the number of scientists so that we can create a critical mass at the country level.
Julia Tagwireyi (Commission): The issue of capacity is particularly relevant to Sub-Saharan Africa. It is no secret that in terms of capacity-programme planning, research, and so on - Sub-Saharan Africa is very limited. We have received several different kinds of support over the years - it has not been a total vacuum - but some of that support has not been very empowering or sustainable. Some of our best-trained Africans are outside Africa. In looking ahead to a new vision for institutional and capacity building, we should look at a model that helps to keep our best people working on the worst problems in the globe, which are in Sub-Saharan Africa. We need your best teams to work on the problems we have, and I welcome the new initiative by UNU. I know that under the new leadership of Dr Garza we will see more investments in Africa. We don’t have the capacity to sustain all these very good interventions. The numbers aren’t there to even do some of this work. So this needs to be a serious focus in any strategy to make an impact on the malnutrition problems in Sub-Saharan Africa.
Ricardo Uauy (Commission): This is a very neglected area, and I think we all share the responsibility. People from developing countries share the responsibility in accepting projects that leave nothing after they are completed. It is not enough to have teams come in and then leave with the project, with a publication, but with nothing on the ground. I challenge all of us to consider what is left after our donors leave a project. I also suggest that perhaps a levy should be placed on each project to create a fund for institutional development. Nobody wants to take charge of building capacity. Everybody wants to do his or her project. This is demanding of very limited human and institutional resources. The Advisory Group on Nutrition (AGN) has looked at the issue even of training refugee workers in Africa. At the present time they have to be trained at the London School of Hygiene and Tropical Medicine. This needs to be reassessed and I think the IUNS initiative and the donors should consider doing something about this at the earliest possible time.
Elisabet Helsing (Board of Health, Norway): I feel that the work is not quite finished and I join the concerns expressed by Julia Tagwireyi and Anna Ferro-Luzzi that the plans for action still have some way to go. I am particularly concerned that as we approach the double burden of disease we do not start talking in two different terms of solutions. We need to be clearer about the need for comprehensive food and nutrition policies.
Urban Jonsson (formerly Regional Director for UNICEF in South Asia): Both the report and the presentation have emphasised the remarkable difference in nutritional status between South Asia and Sub-Saharan Africa. Someone said that we need to have a correct diagnosis before we can have a solution. Any report about the global nutrition situation today will have to be precise about the remarkable fact that in spite of more food per capita, higher income, and many other better things such as health services, South Asia has a 50% higher prevalence of malnutrition than Sub-Saharan Africa. We also know that this is associated with a very high prevalence of low birth weight in South Asia. My position is that this is related to the different forms of exploitation of women in South Asia and Sub-Saharan Africa. Very little has been said about the extreme importance of the subordination, exploitation, and marginalisation of women in societies. This will explain not only differences between South Asia and Sub-Saharan Africa, but also the differences within these continents.
I think that this reflects the need to bring down the analysis of causes to what I call a structural, basic level that relates to the macro-economic and macro-political aspects. I know that this is controversial, but I don’t think one can avoid it in a report that attempts to describe the situation in totality.
Flavio Valente (Global Forum on Sustainable Food and Nutritional Security, Brazil): I would like to see if we could move ahead with some other issues in this discussion. I like the urgency that the Commission puts into its report. The decision by the World Food Summit to reduce by half the number of malnourished by the year 2015 is understood by civil society as a very low mark. We would like to achieve this as soon as possible. UNICEF and ICN have already shown the importance of treating human beings as whole. When you do that - when you feed them, when you give them care and health care - they grow and they become healthy human beings. The problem is that this has not convinced governments. That is why civil society has placed so much importance in the new approach of the UN. First, in working together, and second, the heavy emphasis on human rights. We need to discuss bridging historical gaps and economic gaps within society. Working with nutrition for many years I have seen that even if children recover from their malnourished status when they are young, if they are then placed in a deprived situation, they cannot recover. I think the same is true for nations.
I would also like to ask the SCN to make an effort to bring into the nutrition discussions some of the international organisations that are dealing with this from the other end, such as the World Trade Organization. They really don’t think too much about the impact of their policies. Perhaps if they were here, discussing these issues with you, they will start to see the impact of their policies.
Richard Orraca-Tetteh (University of Ghana): I like this holistic approach to the nutrition problems in the world and I think the suggestion made by the ICCIDD is very interesting. To give an example of what we did in Ghana, we saw the iodine problem as being important in our area. We wrote a project that the Canadian International Development Agency (CIDA) supported. Now we have salt iodisation in the country. This was based upon local people trying to get things done, and this leads to the question of capacity building. I have been in Ghana as a nutritionist since 1959. We do not have the necessary support for training. We need to look at capacity building and we need the support to train more people from various parts of Africa who will stay and work in Africa.
Asbjorn Eide (World Alliance for Nutrition and Human Rights): The descriptive part of the draft report is very useful. The insight, for instance, on the question of intra-household food allocation and the South Asian puzzle I think is very interesting. As Urban Jonsson and others said, the analysis of causes needs to be much deeper. I would like to address very briefly what you have been saying about the human rights aspects and about the use of a social contract, a global contract or a nutrition contract. It is very important to take into account the existence of a number of mechanisms - legally binding mechanisms. For instance, the Convention on the Rights of the Child has 191 ratifications today - four more than the number of United Nations members. They are legally bound to address nutrition of the child. I am not saying that you are reinventing the wheel, but you should at least take that part of the system more fully into account in your further thinking. There is also the Convention of Elimination of Discrimination Against Women, which is also binding on a great number of states. The Working Group on Nutrition, Ethics, and Human Rights of the SCN has produced a paper that reviews the development of human rights within the UN. Let me finally remind you that after the World Food Summit in 1996, there was a mandate explicitly given to the High Commissioner for Human Rights to take the lead role in working with the various agencies. I know that FAO and others are already in close collaboration with the High Commissioner for Human Rights, and that again is something that you should follow with close attention. I think that the scientific insights that you can give will be of very great help so I look forward to future cooperation.
Cutberto Garza (UNU): In answer to Julia Tagwireyi, the United Nations University is very much committed to capacity building, especially in Africa. Discussions have already begun and we hope to sit down with those of you who have stayed in Africa, to develop a long-term plan for capacity building in that region. We also have plans to initiate a similar type of effort in the newly independent states of the former Soviet Union. We are very pleased to have your support in this, and invite the other UN agencies, NGOs, bilaterals, and multilateral to help us in this endeavour.
George Beaton: I have been associated in one way or another with the SCN for many years. I see the present effort as something relatively new for the SCN and, in that regard, I congratulate and thank you for what you did not do. You did not offer prescriptions for action. Instead, what you are asking the people in this room to do is something that the SCN was established to do but has actually done very seldom. You have asked us, nay, challenged us, to begin a discussion among ourselves about what we can collectively do if we agree on the problem. If this can happen, it may be the single most important contribution of this Commission as we move toward the 21st century.
Graeme Clugston (WHO): We welcome the report, which is very thought provoking. Your presentation focused on science and newly emerging issues, particularly the critical issues of low birth weight and maternal malnutrition and the forgotten role of adult malnutrition, stunting and survival. May I just add two or three comments.
Firstly, there is a global movement underway, which has been generated by events over the last decade such as the World Summit for Children, the International Conference on Nutrition and the World Food Summit. These were very carefully planned initiatives that identified emerging key issues and the strategies to address them. I think the issues that the Commission has highlighted need to be fed into this process.
Secondly, the importance of capacity building which many have mentioned, and which is at the very forefront of WHO’S action, is fundamental because sustainable and permanent reduction of malnutrition depends on it. Capacity building includes such things as infrastructure strengthening, training, human resource development, and strengthening of national nutrition policies and strategies. It is often not highly visible work, particularly on the international scene, but it is crucial. The Commission may be unaware that WHO, UNHCR and WFP do indeed run workshops in Africa for training people in emergency forecasting and management.
Thirdly, the key emerging issues should not ignore, overlook or underplay the importance of IDD, vitamin A deficiency or iron deficiency anaemia, and the models that they provide for addressing some of the other newly emerging issues. Other key issues that I think ought to be strengthened in the report include household food security and caring, food safety and quality, breastfeeding promotion, and the crucial issue of complementary feeding.
Finally, apart from nutrition as a human right, the report needs to wrap all this up with a greater emphasis on nutrition and development, ensuring that nutrition itself and its elements are included in national development policies and poverty eradication policies at the national level. Again, I think this alludes to what sort of action is needed at country level. I look forward to hearing the other presentations and appreciate the stimulus of both your presentation and the report. I suggest building these things into the ongoing framework of ICN follow-up that is already in place, to further strengthen the momentum in countries, regions, and globally.
