Dhaka Sunday October 23, 2011

Combined effort needed to combat child malnutrition

Pankaj Karmakar and Rizanuzzaman Laskar

Stunted, sick, listless children have long been Bangladesh's misfortune “a national challenge,” in the words of food minister Abdur Razzak. But even after continuing economic growth, child malnutrition remains worse here than in many sub-Saharan African countries, standing out as a paradox in a progressive democracy.

Uganda, a sub-Saharan country known for its malnourished children, sharply improved upon the situation, and now just 20 percent of its children under five are underweight, a critical gauge of malnutrition.

In Bangladesh, by contrast, despite growth and good government intentions, the comparable number is 47 percent. This means almost half of country's children are malnourished.

Most of them do not die, but suffer a different fate, nutritionists say.

“You have to understand that it is a multi-fold problem,” says Humayan Kabir, the health secretary.

It is related to income poverty, food prices, hunger, household food insecurity and inadequate dietary intake among others, he said adding, and then there are immunisation, sanitation problems and general unhealthy behaviour of the people.

Robbed of vital nutrients as children, they grow up stunted and sickly, in a land that still runs on manual labour. Some become intellectually stunted, unable to learn or even to concentrate, inclined to drop out of school early.

“There are just too many of them in the country,” said Dr Tahmeed Ahmed, Director of Centre for Nutrition and Food Security at the ICDDR,B.

Nearly one in every three children are stunted; 10-year-olds fail to top an adult's belt buckle. They are frequently sick: chronic weakness, diarrhoea and worse are standard for many toddlers, he said.

Most disquieting, as many teachers say, many children at primary schools are below-average pupils, often, well below.

“Many of them fall asleep,” said Mohammad Al-Amin, a third-grade teacher at the Bazaar Government Model Primary School in Moulvibazar. “Their minds are slow, and they don't grasp what you teach them, and they're almost always behind in class.”

Their hunger is neither a temporary inconvenience nor a quick death sentence. Rather, it is a chronic, lifelong, irreversible handicap that scuttles their futures and cripples Bangladesh's hopes to join the rank of developed world.

The National Nutrition Programme, which began in 2004, only covered some 25 percent of the population, and therefore was ceased earlier this year, says Fatema Parveen, Director of Institute of Public Health and Nutrition.

The programme would be replaced with Tk 1,400 crore NNS programme, which aims to bring down all forms of malnutrition by giving people access to necessary information, tools and supplies, she added.

“Malnutrition seriously affects intellect” of Bangladesh's children, “and also their productivity,” said Dr Tahmeed Ahmed, one of the country's leading nutrition experts. “It is a barrier to improving our way of life.”

Most children suffer irreversible damage due to malnutrition by age 2, long before they begin primary schooling. Nutritionists contend that efforts must concentrate on the brief window of opportunity before that age.

“If you miss that period, the damage is irreversible, especially in cognition, but also in growth,” said Dr Tahmeed Ahmed.

The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), located at the city's Mohakhali, receives over 1,20,000 patients every year, and around 60 percent of the patients suffer from different forms of malnutrition.

Nushrat, a nine-month-old toddler from Munshiganj, was brought to the hospital on September 29 for what appeared to be a bad case of diarrhoea and chronic cough.

She was later diagnosed with oedema, a condition that swells parts of a body with fluid beneath the skin and is considered as a sign of malnourishment.

Her mother, who is underweight herself, could not breastfeed the young baby after three months. Nushrat's diet consisted of only ground rice and water since. shrat was later shifted to the Nutrition Rehabilitation Unit (NRU) in the hospital, where she has been receiving a healthy low-cost diet along with medication.

The nine-month-old seems well now. But the frown in her eyes hints the horror she went through in the past few days.

Bleak as it may sound, Nushrat is only one of the 5,00,000 malnourished children in the country and one of the fortunate to receive treatment.

The treatment, which consists Ready-to-use Therapeutic Food (RUTF), is costly with a full treatment costing over TK 14,000, and therefore is only available at a select few places like the ICDDR,B.

The good news is ICDDR,B is set to produce RUTF locally from next year, sources said.

However, hunger remains a big issue in the country.

A 2011 ActionAid report has ranked Bangladesh as one of the most vulnerable countries to hunger with “devastating predictions” over the coming years.

It said skyrocketing food prices would continue to have a severe impact on the poor people's ability to buy enough food, which does not bear well for the country's already high level of malnutrition.

Therefore, more nutrition education programme for parents might do a better job than large and politically popular feeding programme in fighting the rampant malnutrition in the wake of food crisis, suggests the World Bank (WB).

It says programmes should shift their emphasis from directly providing food to changing the behaviours of mothers for example, to breast-feed exclusively for the first six months of life or seek quick treatment for their children's diarrhoea. Improvement of sanitation and health care is also needed.

“The origins of malnutrition often lie in the way infants and young children are fed, not the quantity of food available,” it added.

Meanwhile, Bangladesh government has taken an ambitious project called the Health Population Nutrition Strategic Development Programme (HPNSDP) recently to address the issue of under-nourishment. It has also formed an operational plans.

However, lack of coordination among different government bodies and organisations remain a big issue, nutrition experts said.

This is a multi-sector issue and should receive focus from all the relevant authorities including the health ministry, food ministry, women and children affairs ministry, local government bodies, among others, they say.

Most of all, the issue needs to receive the Prime Minister's attention, as nothing would be implemented until the initiative comes from the very top, they added.

'It's a multifold problem'

Humayun Kabir, Secretary, Ministry of Health and Family Planning, talks to The Daily Star

Bangladesh government aims to reduce children's underweight rate in the country in the next five years, said Humayun Kabir, secretary at the ministry of health and family planning.

It also aims to reduce the rate of stunted children from 43 percent to 38 by 2016, and hold the rate of night blinding at 0.04 percent.

“The government has a vision to eradicate malnutrition among both women and children,” the health ministry official said adding, “It is more than just a general objective, it is a constitutional obligation.”

He said a massive five-year project to improve the general health, sanitation and nutrition situation in the country was approved at the Executive Committee of the National Economic Council (Ecnec) this August, and a considerable part of the project deals with malnutrition.

Around eight percent of the resources of the Health Population Nutrition Strategic Development Programme (HPNSDP) have been allocated to the National Nutrition Service (NNS).

The NNS programme, which is a continuation of the governments past efforts to contain under-nourishment, aims to “institutionalise nutrition and bring it to the mainstream”, the health secretary said.

But the malnutrition situation which showed little improvement over the past decade, pushing up the number of malnourished children to half a million shows it will not be easy to meet this goal.

The country currently holds six percent of the world's total underweight children, just behind India and Pakistan in the list of top ten countries with the most number of underweight children.

Nutrition experts have called it the effects of a vicious cycle, which starts with social and economic problems leading to maternal malnutrition, and results in child malnutrition.

“You have to understand that it is a multi-fold problem,” said Humayun Kabir, the health secretary.

It is related to income poverty, food prices, hunger, household food insecurity and inadequate dietary intake among others, he said adding, and then there are immunisation, sanitation problems and general unhealthy behaviour of the people.

“Many mothers, for example, do not breastfeed their child for six months like they are supposed to,” said the health secretary, “and many families do not have access to the supplementary foods required for the babies”.

The result is the present malnutrition situation in the country, he said, adding that the government has taken the matter with “utmost importance”.

Apart from large projects, the government has also taken several action plans addressing breastfeeding, supplementary feeding, combating iron and vitamin A deficiencies, he said.

Some results are already here, the secretary stressed adding, there is now a noticeably visible change in the behaviour of the general people and there has been notably decrease in infant mortality.

“But the malnutrition problem is a multi-fold problem and needs to be addressed accordingly,” said Humayun Kabir.

Other ministries and government organisations also need to chime in to face the situation, as the health ministry cannot address it all by itself, he added.

'This is a vicious cycle'

Dr. Tahmeed Ahmed, Director, Centre for Nutrition and Food Security, ICDDR,B, talks to The Daily Star

More than 40% of the country's children are malnourished, and are at risk of growing up to be sickly adults with impaired intellectual capabilities, said Dr Tahmeed Ahmed, a leading nutrition expert in the country. This huge burden of childhood malnutrition is even worse than some countries in Sub-Saharan Africa. Many of the malnourished children die before reaching school or even before they become toddlers, he said, but it's the survivors who have to go through worse. In the short-run, they are more vulnerable to infectious illnesses like diarrhea or pneumonia, take longer for their wounds to heal or to recover from illness, have weaker muscles and may become depressed. And when they grow up to be adults, they also have reduced work productivity, said Dr Tahmeed Ahmed, who serves as the Director of Centre for Nutrition and Food Security at ICDDR,B.

“The most alarming of the effects of malnutrition is the stunted capability of brain. We can never expect a nation with sound intellectual development, if the rate of malnourished children is not reduced," he said. The country made long strides in reducing the rates of childhood malnutrition in 1990s, he said, sharply reducing the proportion of underweight children from 70 percent to 40 percent by the end of 2000. However, the rate of decline in malnutrition stagnated from there, and now, 41 out of every hundred children remain underweight.

Underweight, along with wasting and stunting, are major indicators of malnutrition, all of which remain high in the country showing little signs of improvements, said Dr Tahmeed. It is important to prevent children from becoming malnourished. This can be done by improving the health of the mother who is carrying the child in her womb, breastfeeding the new born exclusively for the first six months of life, giving appropriate complementary food after six months when breast milk alone is not sufficient to promote growth, preventing and treating infections, promoting appropriate sanitation and hygiene, for example, hand washing. Daily supplementation with essential vitamins and minerals that cannot be provided through food is also important.

Children with the more deadly form of malnutrition, known as severe acute malnutrition, are at increased risk of death. There is treatment for this condition, according to Dr Tahmeed, but it is expensive and not widely available across the country. ICDDR,B has come up with a low-cost method to treat malnutrition, and even reverse its ill effects. The method has been shown to reduce deaths by 50% among children suffering from severe acute malnutrition. After recovering from the acute illnesses that accompany severe acute malnutrition, the children under treatment in ICDDR,B hospital are provided with a nutritious diet based on local foods for increasing body weight that the children have already lost. Their family members are also given training about what kind of diets the children should be provided at home, said Dr Tahmeed.

Most children suffering from severe acute malnutrition, however, cannot afford to come to a hospital. They need to be identified in the community and those who are not critically ill should be treated at home. A solution for severe malnourishment is to make Ready-to-Use Therapeutic Foods (RUTF) more readily available. This is a special diet that is like medicine for the child with severe acute malnutrition. It does not require any cooking or preparation and can stored for a long period of time. The RUTF currently available in the market are exported from other countries and are therefore too expensive for many, said Dr Tahmeed.

“We should introduce locally produced therapeutic foods to reduce their costs and make them more available across the country,” he said. These therapeutic foods should be made of locally available food ingredients like rice, soybean oil, milk powder, sugar and micronutrients.

However, therapeutic food or better treatments would do little to control malnutrition if other basic conditions are not improved. These include improving livelihood of people, reducing poverty and increasing female literacy. One in every three women in the country is undernourished, who can give birth to a malnourished child, who in turn would go on to grow up as malnourished adults, he said. “This is the vicious cycle of malnutrition,” said Dr Tahmeed, adding that it cannot be stopped unless the maternal malnutrition situation is not improved.

The next issue of Promoting Child Rights will be published on November 23, 2011. Readers are welcome to send their
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