Food is the major concern of mankind beginning from the time of conception and extending through the entire life span of an individual. Food supplies the energy required for physical activity and other metabolic needs of the body. Nutrients are for maintaining growth of the individual and for the repair of the worn out and aging tissue. Basic constituents for synthesis of digestive juices, enzymes and hormones are derived from food.

The epidemiological and scientific consideration of nutrition is of interest not only to physiologists and physicians but also to sociologists, economists and political leaders of the state. The effects of nutrition reflect on the development of an individual and the community and therefore have major socio-economic and political implication (a). Good nutrition is the corner stone of all human progress and one of the most fundamental tests of global development [1].

On May 2, 2006 UNICEF in its Progress for Children World Report released its Report Card on Nutrition. It states that undernutrition contributes to the death of 5.6 million children under five in the developing world each year- the equivalent of 10 children a minute [2]. This report is fourth in UNICEF series which monitors progress for children towards the Millennium Development Goals (MDG), measures the world’s performance on nutrition, taking the prevalence of underweight among children under five years of age as its primary indicator [3].

Joy, despite population explosion. Photo © Zoya Zaidi

The global community promised to cut the proportion of underweight children by half between 1990 and 2015, but we are still not on track to reach that target [4]. And 146 million children are at risk from dying early because they are underweight [4], despite humanitarian promises and appeals, undernutrition remains a global epidemic related to half of all child deaths [1].

Undernutrition is the result of insufficient food intake, repeated infectious diseases and lack of care. It stunts children’s growth and development and, in girls, their later ability to bear healthy children.

“Hunger and undernutrition lead and contribute to some of the world’s most intractable problems,” says UNICEF Executive Director Ann M. Veneman. “It contributes significantly to a cycle of poverty. It hurts children in their ability to learn. It hurts children in their ability to develop and it hurts children in their ability to resist serious diseases.”

It (the report) shows that half of the world’s underweight children live in South Asia, while in East Asia, China is leading the way in reducing undernutrition [b]. Slow progress is being made in West and Central Africa, while in the Middle East; populous countries such as Iraq and Sudan are slipping backwards [4].

It is shocking to know that India has the highest number of malnourished children in the world with Madhya Pradesh being the worst effected state. About 47% of children under the age of five years in India, an astounding 57 million are under weight. Even Sub Saharan Africa is better where 33% of children are malnourished. The worst effected States in India are UP, Rajasthan, Bihar, and Maharashtra. In some of the states over 50% of children are malnourished. However Goa, Kerala, Mizoram and Tamil Nadu are high nutritional states.

Chronic Undernutrition in India-2006 57 million children are underweight; 47% are undernourished

Dwellers of the Graveyard: Notice the oedematous (puffy) face, skin changes, discoloured hairstreaks, and swollen legs of the boy suffering from protein-energy malnutrition (Kwashiorkor). Photo © Zoya Zaidi

Alarmingly, according to the report, 27% of children in South Asian countries- around 146 million – have been found to be under weight, many to a life–threatening degree. More than half of these children live in just three countries - India, Bangladesh, Pakistan. What is worse, well over half of the world’s undernourished children live in just four nations- India (57 million), Bangladesh (8 million) and Pakistan (8 million) and China (7 million).

Werner Shultink , UNICEF India’s chief of child development and nutrition program, said on the day of release of the report that no other country was worse off than India in he case of malnourished children. “ The causes for these are many: bad quality feeding, high population density, high rate of infectious diseases, high rate of illiteracy among women, high prevalence of gender inequality, low rate of immunization, high rate of birth of under weight babies, ” he said. The report has shown how the main cause for malnourishment is not so much the lack of food but social issues like early marriages and little gap between births of children, he added [5].

Although malnutrition has fallen from 70% in 1970s to 47% now, and is testimony to India’s commitment, but that does not change the fact that we are still far from our goal. And it does not even take complicated interventions to make an important difference.

In order to reach the Millennium Development Goal of reducing child undernutrition by half, the world must alter its priorities. The report card shows that reducing undernutrition is attainable if the lessons of the past 15 years are applied. The goal could not be more important: a world in which children live free from poverty and hunger [1].

Causes of Malnourishment

Malnutrition, clearly, is not a simple problem with a single, simple solution. Multiple and interrelated determinants are involved in why malnutrition develops, and a similarly intricate series of approaches, multifaceted and multisectorial, are needed to deal with it. An understanding of the complex and subtle causes of malnutrition is important to appreciate the scale and depth of the problem, the progress achieved to date and the possibilities for further progress that exist (Fig 1).

Fig. 1 Causes of malnutrition (Source: UNICEF 1997)

Mal nourished sub-normal girl, with puffy face and apathetic look of Kwashiorkor, the extreme form of protein malnutrition. Photo © Zoya Zaidi

Immediate causes

The interplay between the two most significant immediate causes of malnutrition - inadequate dietary intake and illness - tends to create a vicious circle: A malnourished child, whose resistance to illness is compromised, falls ill, and malnourishment worsens. Malnutrition lowers the body’s ability to resist infection by undermining the functioning of the main immune-response mechanism. This leads to longer, more and more severe episodes of illness. Infection causes loss of appetite, malabsorption, and metabolic behavioral changes. These, in turn increase the body’s requirements for nutrients. Children who enter this malnutrition-infection cycle can quickly fall into a potentially fatal spiral as one condition feeds off the other (Fig.2).

Fig.2 The vicious cycle of malnourishment (Source: Andrew Tomkins and Fiona Watson, Malnutrition and Infection, ACC/SCN, Geneva 1989)

Underlying causes

Three clusters of underlying causes lead to inadequate dietary intake and infectious disease: inadequate access to food in a household; insufficient health services and an unhealthful environment; and inadequate care for children and women.

Household food security

This defined as sustainable access to food of sufficient quality and quantity- including energy, protein and micronutrients- to ensure adequate food intake and healthy life for all members of the family.

Household food security depends on the access to food- financial, physical and social- distinct from of availability. Poor families cannot afford food, and therefore are food insecure, for them therefore food security is often extremely precarious.

Women have a special role to play in maintaining household food security. In most societies, they are solely responsible for preparing, cooking, preserving and storing the family's food - and in many societies they have the primary responsibility of producing and purchasing it. Their awareness about quantity and quality of food and hygienic methods of preparing it, along with their own health is therefore extremely important.

‘My little brother’- Elder children look after their younger siblings, in the absence of their mother-already over-burdened with too many children, household work and working in the fields. Photo © Zoya Zaidi

Health Services, Safe water and Sanitation

An essential element of good health is access to curative and preventive health services that are affordable and of good quality.

Access to United Nations Development Programme (UNDP) varies widely, but in as many as 35 of the poorest countries 30 to 50 per cent of the population may have no access to health services at all [6].

The lack of access to safe and adequate water supply, proper sanitation and unhygienic conditions in and around homes, as well as unhygienic handling of food causes poor environmental health, leads to spread of infectious disease, most significantly childhood diarrhoea.

Also, women and children are usually responsible for fetching the water needed for domestic use, a task that drains considerable time and energy. Depending on how much the distance to the water source is shortened, it has been estimated that women could conserve large reserves of energy, as many as 300 to 600 calories a day (6). In the arid state of Rajasthan, India, women some times walk 6-8 miles daily to fetch water, with 4-5 earthen pitchers precariously balanced on their heads.

Bathing in the Nallah (drain). Photo © Zoya Zaidi

Progress has been made in improving access to safe water. But more than 1.1 billion people lack this fundamental requirement of good nutrition. As for sanitary waste disposal, the world is actually losing ground, with the rate of coverage falling in both rural and urban areas. Only 18% of rural dwellers had access to adequate sanitation services at the end of 1994, and over all some 2.9 billion people lack access to adequate sanitation [6].

What can be done?

Adequate food intake

Is of course of paramount importance: An average term infant requires 100 Calories/kg of body weight. 8-10% of these calories should be obtained from good quality protein. The first year of life is the most crucial period of development of a child (a)

Breast-feeding

Human milk is the ideal nourishment for infant’s survival, growth and development. It contains all the nutrients a baby needs to thrive, it also passes on critical antibodies from mother to baby and protects against illnesses like diarrhoea, and pneumonia- two of the major causes of infant mortality in the developing world [1].

There is a high concentration of a) secretory Ig A (an antibody found naturally in the human gut), b) lysozyme (a digestive enzyme), c) specific inhibitory substance for viral infection and anti staphylococcal factor, d) Lactoferin (an iron containing protein) is less than 50% saturated with iron, and this does not make milk a suitable medium for growth of enterobacteria (diarrhoea causing bacteria of intestine), low pH of breast milk (or higher acidity), f) high level of bifidus factor protects the baby from infection with Escherichia coli (an intestinal bacteria causing diarrhoea). Breast milk also improves the response to vaccination. Formulas and other substitutes carry a high risk of infection, particularly in unhygienic conditions in which they are prepared, and can be fatal to the infant.

For instance cow’s milk- the usual substitute of mother’s milk in developing countries- India in particular- contains more proteins that are not easily digestible by the infant as apposed to mother’s milk that has fewer proteins, which are easy on digestion and place lower solute load on kidney. Kidneys have less capacity to concentrate urine in the first week of life; premature infants tolerate the breast milk better, especially in the neonatal period. High protein content of cow’s milk can also lead to cow’s milk allergy and Lactose intolerance (a form of milk-allergy). Moreover high active lipase (a fat dissolving enzyme) content in the mother’s milk promotes digestion of fats and provides free fatty acids that facilitate absorption of calcium. The fatty acid content promotes brain growth and protects from arteriosclerosis in later life (a).

Yet only slightly more than one third of all infants in developing countries are exclusively breast fed for first six months of life, an absolute prerequisite for healthy growth of the infant [1].

Trace elements

Iodine: Iodine is present in the secretion of thyroid gland; Lack of iodine can lead to increased secretary activity of thyroid glands leading to endemic goiter. Brain damage due to iodine deficiency, is leading cause of preventable brain damage in children - but a tiny teaspoon of iodine consumed over a lifetime is all a child needs to be protected. Iodine is commonly added to table salt. Iodine is present in abundance in seafood; an adult requires about 150 microgram of iodine per day.

Vitamin A: Any yellow fruit or vegetable; for example peaches, squash or carrots contain vitamin A. But, in fact, meat is the most readily available source of vitamin A. Lack of vitamin can cause, Xerophthalmia (dryness of eyes), Padagra like skin condition, and Keratomalatia (injury to sclera due to dryness) leading to night-blindness.

‘Rag-pickers’- Notice Padagra-like skin changes on the hands of the child with sugarcane. Photo © Zoya Zaidi

Iron: Iron is absolutely critical to women, particularly during their childbearing years.

Loss of blood during menstruation and the high demands of iron during pregnancy deplete women's iron reserves. Iron deficiency -anaemia -causes complications during pregnancy and is a leading cause of maternal deaths worldwide. Red meat is the best source of iron. Vegetables like spinach also contain iron but it is harder for the body to use iron from these sources. Fortifying common household foods like flour and breakfast cereals with iron are a good way to ensure that children and families get what they need (1).

Country’s economy

Good nutrition is linked to a country’s economy. When populations are well nourished it means higher individual productivity, lower health care costs and a healthier economy.

What is being done in India?

Water and the power of women in India

In the UNICEF-assisted Sanitation, Water and Community Health project in the Rajasthan district of India, five women from neighboring communities maintain the villages’ hand pumps. UNICEF helped a local non-governmental organization (NGO) train these rural women to keep their villages’ water flowing. In what has traditionally been a male-dominated environment, the women are now recognized for their important roles in society [7].

Aganwadi’s in Maharashtra

In Maharashtra the infant mortality rate has dropped from 48 to 42 [per 1,000 live births], marginal but nevertheless significant. To begin with, a lot of emphasis is placed on reporting deaths. The government machinery can act on it if there is information that there has been an increase in deaths in an area. Teams, including Anganwadi (NGO) workers, have been asked to step up the process of surveying and registering newborn children. Volunteers are constantly tracking their weight so that it does not fall below the minimum normal limit of less than 2.5 kg in India. Also, several government departments are working together to protect people from disease. For example, bleaching powder is supplied to the villages to prevent water contamination [8].

In conclusion I would like to say that as the world 'stood up for hunger' on 16th October to mark the World Food Day, India hung its head low in shame- 63% of its children on that day went to sleep on empty stomach [9]. Ironically, starvation deaths hit the headlines but hunger the precursor of death and starvation goes unnoticed. This is because it is difficult to visualize and depict hunger. It is a wake up call for us; time has come to spruce up our act, tighten our belts and make laws and legislations concerning this issue and implement the already existing schemes. We must treat this as an emergency, only then would we be able to alleviate the suffering of our children, improve their physical and mental health; because these children are our tomorrow, and in another 10-15 years to come, will be old enough to run the affairs of the nation. Are we going to face the challenges of the new millennium on empty stomach?

REFERENCES

[1] www.unicefusa.org/site/apps/nl/content2.asp?c=duLRI8O0H&b=39256&ct=2342501

[2] www.unicef.org/progressforchildren/2006n4/

[3] unp.un.org/details.aspx?entry=E06087&title=Progress+for+Children%3A+A+Report+Card+on+Nutrition

[4] www.unicef.org.nz/media/news/news1146533041.html

[5] TOI daily, May 12th 2006.and web.worldbank.org/ WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/ 0,,contentMDK:20916955~pagePK:146736~piPK:146830~theSitePK:223547,00.html

[6] www.unicef.org/sowc98/silent4.htm#figure5

[7] www.unicefusa.org/site/apps/nl/content2.asp?c=duLRI8O0H&b=1172421&ct=2563095

[8] www.hinduonnet.com/fline/fl2219/stories/20050923005601000.htm

[9] forum.atimes.com/topic.asp?TOPIC_ID=1766

[a.] Essentials of Paediatrics by OP Ghai; pp 46, Ed. 3rd 1993, publishers Interprint, India

[b.] www.povertymap.net/mapsgraphics/thumbnail/undernutrition.jpg

[c.] Map © Zoya Zaidi- figure source: forum.atimes.com/topic.asp?TOPIC_ID=1766

Fig I and 2 www.unicef.org/sowc98/silent4.htm#figure5 (6)


Copyright ©2006 Zoya Zaidi. About The Author