Children are humanity’s investment in the future. They are the most vulnerable section of our society. Malnutrition is associated with over half the deaths of children between 6 months and 5 years of age in the developing countries. According to some statistics, five million children die every year due to malnutrition- one child every six seconds.
Malnutrition refers to all deviations from adequate nutrition including under-nutrition resulting from inadequacy of food relative to need and over-nutrition resulting from excess of food relative to need, both being equally harmful. Obesity is an example of over nutrition. Malnutrition in children leads to permanent effects and to their having diminished health capital as adults.
Nutritional adequacy is one of the key determinants of the quality of human resources everywhere. Despite the rapid progress that has been made in the technology of food production and processing, global malnutrition continues to be a major area of concern for public health and welfare. Undernutrition and malnutrition remain prevalent in the poorer countries, particularly in South Asia and Africa, where food production is not keeping pace with population growth. The problem of malnutrition in developing countries encompasses a spectrum of deficiencies of which the most devastating is a deficiency of one or more of the 3 micronutrients: iron, vitamin A and iodine. Together they contribute to a great deal of morbidity and ill health, growth retardation, reduced levels of physical and developmental activity in children and lower productivity in adults. The basic cause of these deficiencies is lack of adequate intake through the diets, compounded by poor bio-availability as in the case of iron. Other environmental factors such as parasitic infestation and chronic infections aggravate the deficiencies by impairing absorption and increasing the requirements. Vitamin A deficiency is one of the most frequent nutritional deficiency disorders in the world. WHO has estimated over 250 million children worldwide to have deficient vitamin A stores.
Almost half of these problems are a feature of South Asia where malnutrition is a social problem of staggering dimensions. According to the Global Hunger Index, South Asia has one of the highest child nutrition rates in the world. South Asia is home to well over one fifth of the world’s population, making it both the populous and the most densely populated geographical region in the world. Even though it has experienced high economic growth during the last decade, it still has the highest rates and the largest numbers of undernourished children in the world. More than one third of all child deaths are due to malnutrition mostly because malnutrition increases the likelihood of dying from other diseases. In South Asia 72 children are born every minute and 29% malnourished children will not reach their full growth and cognitive potential due to an inadequate diet.
In the public imagination, the home of the malnourished children is Sub-Saharan Africa but the league tables clearly demonstrate that the worst affected region is instead South Asia. Just over 30% of African children are under weight compared to the corresponding figures for South Asia which is over 50%.
Measured by absolute numbers, it is to be expected that problems of poverty will be concentrated in South Asia simply because of the sheer size of its populations (India alone has %0% more people than 47 countries of sub-Saharan Africa put together!). But when the proportion affected is also far higher, as is the case with child malnutrition, then the centre of gravity of the problem shifts still further. That is why half of the world’s malnourished children are to be found in just 3 countries: Pakistan, India and Bangladesh.
The population of Pakistan has surged from 34 million in 1947 to an estimated population exceeding 180 million in 2012. Maternal and child health and survival remain a major challenge. Directly or undirectly, the concurrent vicious cycle of malnutrition contributed to almost 35% of all the under-5 deaths in the country. Over the past 20 years, there has been little change in the prevalence of malnutrition in the population despite more food availability and an overall increase in calorie intake per capita. In Sindh alone, while the emergency standard in 15%, the southern Sindh has reached 21-23% -the worst condition of malnutrition in the world over the years.
The most prominent method/tool for measuring child nutrition is anthropometry. It is the use of body measurements to assess nutritional status. Over the past 20 years there has been substantial progress in the standardization of anthropometry making use of height, weight and Body Mass Index (BMI) with respect to age. This gives us three measures namely stunting (height-for-age), body weight (weight-for-age) and wasting (weight-for-height).
Stunting is the anthropometric index of height-for-age referring to shortness that is a deficit or linear growth that has failed to reach genetic potential as a result of poor diet or disease.
Underweight is the anthropometric index weight-for-age which represents body mass relative to age influenced by the height and weight of a child. The WHO, on the basis of worldwide data had recommended that newborns with birthweight less than 2500 g may be considered to fall in the LBW category-carrying relatively greater risks of perinatal and neonatal morbidity and mortality and substandard growth and development in later life. Most birth weight is an indication that the infant was malnourished in the womb and/or the mother was malnourished during her own infancy, childhood, adolescence and pregnancy. Underweight children account for over 33 percent in Afghanistan, 41 percent in Bangladesh, 43 percent in India, 39 percent in Nepal, 31 percent in Pakistan and 22 percent in Sri Lanka.
More than half of the world’s low birthweight babies are born in South Asia.
Wasting is the outcome of chronic dietary or disease. More than a third of children under five years of age in East and South Asia are stunted. Eighteen percent of babies are born with a birth weight that is too low. Twenty seven percent of under fives weigh too little for their age. Thirteen percent of under fives are wasted, while nearly half of pregnant women and pre-school children are anemic.
Other indicators include head circumference-for-age, arm circumference-for-age, subscapular skinfold-for-age, triceps skinfold-for-age, motor development milestones, weight velocity, length velocity, head circumference velocity etc. Other biochemical and clinical parameters include eye examination, evaluation of goiter, evaluation of anemia, clinical estimation of morbidity and blood and urine tests.
There are other socio-economic factors that have significant influence and help determine the nutritional status of a region. These include poverty, unemployment, level of education, food security, maternal education/awareness and their nutritional status, child’s age and gender, breastfeeding trends and other cultural, social and psychological factors influencing diet.
Poverty significantly reduces the standard of living robbing people of a healthy lifestyle and quality of life. Infants living in poor households are more likely to experience food security which includes not having enough to eat, having inadequate diet.
Three South Asian nations — Bangladesh, Bhutan and Nepal — are characterized as least developed country. Poverty is commonly spread within this region. According to the poverty data of World Bank, more than 40% of the population in the region lived on less than the International Poverty Line of $1.25 per day in 2005. The poor will be more exposed to risk factors including environmental toxins, inadequate nutrition, maternal depression, parental substance abuse, trauma and abuse, violent crime, divorce and low quality child care, substandard housing and unsafe neighborhoods.
Exactly how an infant is fed is crucial to growth in the early months of life. Breastfeeding is vital for a good and complete nutrition of infants. A child of this age needs to be exclusively breastfed; breastmilk not only meets all a child’s nutritional needs but also offers considerable protection against disease through its inherent immunological properties by minimizing chances of infection through unclean water and contaminated foods. However, around 60% women in South Asia are aware that breastfeeding prevents the child from diseases followed by better growth.
Complementary feeding denotes the giving of foods in addition to a continued intake of breast milk between about 6 months and 24 months or beyond. Breastmilk cannot provide all the required nutrients beyond 6 months. If other foods are introduced too late, the child’s growth will deteriorate; if they are introduced too early, growth will be threatened through infection. The critical difference would appear to be the timing of the introduction of other foods. First it is important to try to feed even small amounts to a child in illness. Second, to continue giving food and fluids (especially breast milk) when a child is ill and third, a child should be given an extra meal a day for at least a week after an illness so that he or she can catch up on the growth lost.
Complementary feeding practices in Pakistan differ regionally. Extremely reduced rate of exclusive breastfeeding with premature introduction of complementary feeding was widespread. Bottle feeding appeared universal in most places after 3 months. Use of formula delayed introduction of family foods and inadequate total intakes were evident.
Another important determinant of child nutritional status is the health and well being of the mother. However much a mother may love her child, it is all but impossible for her to provide high-quality child care if she is herself malnourished, poor and oppressed, illiterate and uninformed, anemic and unhealthy, has 5 to 6 other children and is without the necessary support either from health services or from her society or from the father of her children. During the pregnancy itself, the average woman should gain about 10 kilos in weight. Evidence suggests that most women in Asia probably gain just a little more than 5 kg.
This leads to another important factor which is the availability of information and awareness regarding child nutrition.Many at times the caretakers are operating on their own unreliable perceptions and social or cultural norms. The women of South Asia often face restrictions that prevent them even from leaving the household, let alone seeking other opportunities for improving their own lives and their child’s. This, therefore, restricts transmission of new knowledge about health matters and child care that could have otherwise been generated through interaction and discussions with other parents or authorized sources. Unless parents, national policy makers and leaders are aware of the importance of good nutrition they will not take steps to promote it.
For most poor families, the real food problem is not lack of food on the table but the inordinate costs in terms of money, time and energy of putting it there: measuring that there is too little of any of these resources left over to invest in other aspects of life. A high percentage of household expenditure allocated to food is an indicator of household food security. The means to achieve household food security may compromise the ability of the family to provide adequate care for its young children.
Frequency of disease is dependent especially on safe water and sanitation. The vast majority of South Asians do not have access to sanitary methods of waste disposals. Child mortality due to gastroenteritis and water borne diseases is extremely high in the region.
Over the period of 2000-25 rural population of developing world is projected to increase from 2.95 billion to 3.03 billion and simultaneously, urban population is projected to double from 2.02 billion to 4.03 billion. In the long run, economic development brings higher standards of living and better diets but in the short term it’s a different story. Among the most important relationships between urbanization and nutrition is the shortening of the period of lactation which invariably results.
There are other cultural, social and psychological factors that influence the nutritional status in the region such as social status. In South Asia, food is often distributed according to the status fixed by relationships rather than to nutritional needs. Among young children, boys often have higher priority than girls as they get to eat first and the best. The way in which the food is served also holds significance as well. Often social obligations influence the quality of diet as well.
There are often psychological associations to various foods e.g. diets of pregnant women in some countries are restricted because people believe it necessary to ensure a small baby and easy delivery; beliefs that certain food or certain combinations of food have good or bad effects on people especially whether the food is hot or cold in nature.
Furthermore, laws and regulations regarding food also influence nutrition such as through regulation of land tenure, slaughtering of animals and marketing. The good quality food may all be used for commercial purpose leaving rural families with lower or poor quality food.
Malnutrition is worsening in developing countries like Pakistan, Bangladesh, Nepal and India because of the impacts of climate change – particularly on water resources, a key input for producing food for more than a billion people in the region. Climate change and rising temperatures have now badly disturbed food production patterns and have deepened food insecurity. Malnutrition is particularly increasing in the countries where large populations are dependent on rain-fed subsistence farming. Climate change, growing use of food crops as a source of fuel and soaring food prices are three major challenges that threaten efforts to overcome food insecurity and malnutrition according to Impact of Climate Change and Bioenergy on Nutrition a joint report by International Food Policy Research Institute (IFPRI) and the UN Food and Agriculture Organization.
Recent research reaffirms the crucial contribution of good nutrition to human development. Community-based nutrition initiatives may lead to a more general empowerment of communities. The challenge is to implement what we know and to research what we do not. Unless national policy makers and leaders are aware of the importance of good nutrition, they will not take steps to promote it. In educating the population as a whole, aim will be to help people to obtain the best diet possible within their own cultural and economic environment. Such education is not easy. The processes by which changes in food habits occur or can be induced are still insufficiently understood. Food habits, although they may have originated by historical accident, become closely interwoven with the emotional and cultural life of people and are passed on through succeeding generations by the social training given to the young. World Bank’s South Asia Region Sector Manager for Health, Nutrition and Population Julie McLaughlin said GDP lost to malnutrition in many developing countries can be as high as two to three percent. Malnutrition slows economic growth and perpetuates poverty through direct loses in productivity from poor physical status and indirect losses from poor cognitive function, deficits, schooling and losses owing to increased health costs. Direct investments in nutrition have the potential to improve nutrition outcomes much faster. Well nourished populations spend less on health care, freeing resources for investment and growth.
For Pakistan, the annual losses are over 5% of GDP. Many UN agencies, particularly the UNDP, UNFPA, UNHCR and UNICEF have begun operationalising a “human rights approach” to development. Upgrading information technology will promote awareness and discussions. New information technology provides several opportunities for accelerating the reduction of malnutrition.
Vast amount of nutritional information and data is already available on internet which also provides a forum for debate on issues that require discussion. Such easier access to information makes it easier to hold institutions, pressures to improve information increase. The only problem is the lack of awareness of the availability of these facilities and how to make use of them. A large number of people on the South Asia don’t know how to access these resources and are unable to benefit from this. Therefore the situation needs to be handled at a macro level starting from the roots and tackling the very existence of social norms and misconceptions that hinder progress.