THE STATE OFTHE WORLD’S

CHILDREN1998

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Malnutrition is largely a silent and invisible emergency, exacting a terrible tollon children and their families. The result of multiple causes, including a lackof food, common and preventable infections, inadequate care and unsafe water,it plays a role in more than half of the nearly 12 million deaths each year ofchildren under five in developing countries, a proportion unmatched since theBlack Death ravaged Europe in the 14th century. Malnutrition blunts intellectsand saps the productivity and potential of entire societies. Poverty, one of thecauses of malnutrition, is also a consequence, a tragic bequest by malnourishedparents to the next generation.

The State of the World’s Children 1998report details the scale of theloss and the steps being taken to stem it. Sentinels of progress are lighting theway: Nearly 60 per cent of the world’s salt is now iodized, and millions of chil-dren every year are spared mental retardation as a result. Vitamin A supple-mentation is helping bolster disease resistance in children and may soonbecome an important measure in helping reduce maternal deaths around theworld. Communities are working together to identify their problems, decide ontheir options and take action, with women emerging to play leadership rolesthat spark numerous other changes in people’s lives.

Children have the right, recognized in international law, to good nutri-tion. The world has the obligation to protect that right, building on both thegreat experience gained and the scientific knowledge achieved. Action is bothpossible and imperative.

OXFORD UNIVERSITY PRESS£6.95 net in UK $12.95 in USAISBN 0–19–829401-8

THE STATE OF THE WORLD’S CHILDREN1998

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Sudan, 1993, UNICEF/93-1007/Press

THE STATE OF THE WORLD’S

CHILDREN1998

Carol Bellamy, Executive Director,United Nations Children’s Fund

Published for UNICEF by

Oxford University Press

Foreword by Kofi A. Annan, Secretary-General of the United Nations

Chapter IMalnutrition: Causes, consequences and solutions

Malnutrition is rarely regarded as an emergency; the children affected are not facing famine and betray few orno obvious signs. Yet the largely invisible crisis of malnutrition is implicated in more than half of all childdeaths worldwide and violates children’s rights in profound ways, compromising their physical and mentaldevelopment and helping perpetuate poverty. More widespread than many suspect — with one out of everythree children affected — malnutrition lowers the productivity and abilities of entire societies. This chapterexamines the scale of this intractable tragedy, the approaches that are helping resolve it and the new light thatscientific research is shedding on it.

The silent emergency: In this section, the scale of malnutrition and the complex interplay of factors thatcause it, including poor health services and discrimination against women, are presented.

Approaches that work: Community involvement, food fortification, growth monitoring and promotion,supplementation programmes — these are some of the many and often overlapping approaches that arechanging, and saving, children’s lives.

Bringing science to bear: Vitamin A reduced maternal death rates by 44 per cent on average, according toa recent study. This section spotlights some of the breakthroughs that science is making in the fight for betternutrition.

Chapter IIStatistical tables

Statistics, vital indicators of the care, nurture and resources that children receive in their communities andcountries, help chart progress towards the goals set at the 1990 World Summit for Children. The eight tablesin this report have been expanded to give the broadest possible coverage of important basic indicators for nu-trition, health, education, demographics, economic indicators and the situation of women, plus rates ofprogress and regional summaries. They also include complete data, as available, on less populous countries,covering 193 countries in all, listed alphabetically. Countries are shown on page 93 in descending order oftheir estimated 1996 under-five mortality rates, which is also the first basic indicator in table 1.

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Contents

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91

Panels

1 VITAMIN A SUPPLEMENTS SAVE PREGNANT WOMEN’S LIVES 12

2 WHAT IS MALNUTRITION? 14

3 STUNTING LINKED TO IMPAIRED INTELLECTUAL DEVELOPMENT 16

4 RECOGNIZING THE RIGHT TO NUTRITION 20

5 GROWTH AND SANITATION: WHAT CAN WE LEARN FROM CHICKENS? 26

6 BREASTMILK AND TRANSMISSION OF HIV 30

7 HIGH-ENERGY BISCUITS FOR MOTHERS BOOST INFANT SURVIVAL BY 50 PER CENT 32

8 UNICEF AND THE WORLD FOOD PROGRAMME 38

9 TRIPLE A TAKES HOLD IN OMAN 40

10 CELEBRATING GAINS IN CHILDREN’S HEALTH IN BRAZIL 42

11 REWRITING ELIAS’S STORY IN MBEYA 44

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12 WOMEN IN NIGER TAKE THE LEAD AGAINST MALNUTRITION 46

13 BFHI: BREASTFEEDING BREAKTHROUGHS 50

14 TACKLING MALNUTRITION IN BANGLADESH 52

15 KIWANIS MOBILIZE TO END IODINE DEFICIENCY’S DEADLY TOLL 56

16 INDONESIA MAKES STRIDES AGAINST VITAMIN A DEFICIENCY 62

17 MAKING FOOD ENRICHMENT PROGRAMMES SUSTAINABLE 64

18 ZINC AND VITAMIN A: TAKING THE STING OUT OF MALARIA 74

19 PROTECTING NUTRITION IN CRISES 80

20 PROGRESS AGAINST WORMS FOR PENNIES 84

21 CHILD NUTRITION A PRIORITY FOR THE NEW SOUTH AFRICA 86

Spotlights

WORLD FOOD SUMMIT 39

TEN STEPS TO SUCCESSFUL BREASTFEEDING 49

VITAMIN A 76

ZINC 77

IRON 78

IODINE 79

FOLATE 83

Text figures

FIG. 1 MALNUTRITION AND CHILD MORTALITY 11

FIG. 2 TRENDS IN CHILD MALNUTRITION, BY REGION 18

FIG. 3 FROM GOOD NUTRITION TO GREATER PRODUCTIVITY AND BEYOND 19

FIG. 4 POVERTY AND MALNUTRITION IN LATIN AMERICA AND THE CARIBBEAN 21

FIG. 5 CAUSES OF CHILD MALNUTRITION 24

FIG. 6 INADEQUATE DIETARY INTAKE/DISEASE CYCLE 25

FIG. 7 INTERGENERATIONAL CYCLE OF GROWTH FAILURE 34

FIG. 8 BETTER NUTRITION THROUGH TRIPLE A 41

FIG. 9 IODINE DEFICIENCY DISORDERS AND SALT IODIZATION 55

FIG. 10 PROGRESS IN VITAMIN A SUPPLEMENTATION PROGRAMMES 59

FIG. 11 MEASLES DEATHS AND VITAMIN A SUPPLEMENTATION 72

FIG. 12 ZINC SUPPLEMENTATION AND CHILD GROWTH (ECUADOR, 1986) 73

FIG. 13 MATERNAL HEIGHT AND CAESAREAN DELIVERY (GUATEMALA, 1984-1986) 75

References 88

Index 128

Glossary 131

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6

Foreword

To look into some aspects of the future, we do not need projections by supercomputers.

Much of the next millennium can be seen in how we care for our children today.

Tomorrow’s world may be influenced by science and technology; but more than

anything, it is already taking shape in the bodies and minds of our children.

In The State of the World’s Children 1998, UNICEF — the only United Nations agency

dedicated exclusively to children — spells out a simple but most pressing truth. Sound nutrition

can change children’s lives, improve their physical and mental development, protect their health

and lay a firm foundation for future productivity.

Over 200 million children in developing countries under the age of five are malnourished.

For them, and for the world at large, this message is especially urgent. Malnutrition contributes to

more than half of the nearly 12 million under-five deaths in developing countries each year.

Malnourished children often suffer the loss of precious mental capacities. They fall ill more often.

If they survive, they may grow up with lasting mental or physical disabilities.

This human suffering and waste happen because of illness — much of it preventable; because

breastfeeding is stopped too early; because children’s nutritional needs are not sufficiently under-

stood; because long-entrenched prejudices imprison women and children in poverty.

The world knows what is needed to end malnutrition. With a strong foundation of cooperation

between local communities, non-governmental organizations, governments and international

agencies, the future — and the lives of our children — can take the shape we want and they deserve,

of healthy growth and development, greater productivity, social equity and peace.

Kofi A. AnnanSecretary-General of the United Nations

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Malnutrition: Causes,consequences and solutions

A healthy baby girl waits in a maternal and child health centre in Benin.

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Chapter I

tence has profound and frighteningimplications for children, society andthe future of humankind.

Malnutrition is not, as many think,a simple matter of whether a child cansatisfy her appetite. A child who eatsenough to satisfy immediate hungercan still be malnourished.

And malnutrition is not just a silentemergency — it is largely an invisibleone as well. Three quarters of the chil-dren who die worldwide of causesrelated to malnutrition are what nutri-tionists describe as mildly to moderatelymalnourished and betray no outwardsigns of problems to a casual observer.

Malnutrition’s global toll is alsonot mainly a consequence of famines,wars and other catastrophes, as iswidely thought; in fact, such eventsare responsible for only a tiny part ofthe worldwide malnutrition crisis. Butsuch emergencies, like the ongoingcrises in the Great Lakes region ofCentral Africa and in the DemocraticPeople’s Republic of Korea, oftenresult in the severest forms of malnu-trition. Meeting food needs in thesesituations is essential, but so is protect-ing people from illness and ensuringthat young children and other vulner-able groups receive good care.

Child malnutrition is not confinedto the developing world. In someindustrialized countries, widening in-come disparities, coupled with reduc-

9

It is implicated in more than half ofall child deaths worldwide — aproportion unmatched by any in-

fectious disease since the Black Death.Yet it is not an infectious disease.

Its ravages extend to the millionsof survivors who are left crippled,chronically vulnerable to illness —and intellectually disabled.

It imperils women, families and,ultimately, the viability of whole soci-eties. It undermines the struggle of theUnited Nations for peace, equity andjustice. It is an egregious violation ofchild rights that undermines virtuallyevery aspect of UNICEF’s work forthe survival, protection and full devel-opment of the world’s children.

Yet the worldwide crisis of malnu-trition has stirred little public alarm,despite substantial and growing scien-tific evidence of the danger. More at-tention is lavished on the gyrations ofworld stock markets than on malnutri-tion’s vast destructive potential — oron the equally powerful benefits ofsound nutrition, including mountingevidence that improved nutrition,such as an adequate intake of vitaminA and iodine, can bring profound ben-efits to entire populations.

Malnutrition is a silent emergency.But the crisis is real, and its persis-

The silent emergency

Photo: Improved nutrition brings profoundbenefits. A Bolivian girl holds a piece of bread.

More attention is lavished onthe gyrations of world stockmarkets than on malnutrition’svast destructive potential —or on the equally powerfulbenefits of sound nutrition.

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tions in social protection, are havingworrying effects on the nutritionalwell-being of children.

Whatever the misconceptions, thedimensions of the malnutrition crisisare clear. It is a crisis, first and fore-most, about death and disability of chil-dren on a vast scale, about women whobecome maternal mortality statisticspartly because of nutritional deficien-cies and about social and economiccosts that strangle development andsnuff out hope.

Malnutrition has long been recog-nized as a consequence of poverty. Itis increasingly clear that it is also a cause.

In some parts of the world, notablyLatin America and East Asia, therehave been dramatic gains in reducingchild malnutrition. But overall, theabsolute number of malnourished chil-dren worldwide has grown.

Half of South Asia’s children are mal-nourished. In Africa, one of every threechildren is underweight, and in sev-eral countries of the continent, the nu-tritional status of children is worsening.

Malnourished children are muchmore likely to die as a result of a com-mon childhood disease than thosewho are adequately nourished. Andresearch indicates a link between mal-nutrition in early life — including theperiod of foetal growth — and the de-velopment later in life of chronic con-ditions like coronary heart disease,diabetes and high blood pressure, giv-ing the countries in which malnutri-tion is already a major problem newcause for concern.

The most critically vulnerablegroups are developing foetuses, chil-dren up to the age of three and womenbefore and during pregnancy andwhile they are breastfeeding. Amongchildren, malnutrition is especiallyprone to strike those who lack nutri-tionally adequate diets, are not pro-tected from frequent illness and donot receive adequate care.

Illness is frequently a consequenceof malnutrition — and malnutrition isalso commonly the result of illness.Malaria, a major cause of child deathsin large parts of the world, also takesa major toll on child growth and de-velopment. In parts of Africa wheremalaria is common, about one third ofchild malnutrition is caused by malaria.The disease also has dangerous nutri-tional consequences for pregnantwomen. In addition, pregnant womenare more susceptible to malaria, andchildren born to mothers with malariarun a greater chance of being bornunderweight and anaemic.

There is no one kind of malnutri-tion. It can take a variety of forms thatoften appear in combination and con-tribute to each other, such as protein-energy malnutrition, iodine deficiencydisorders and deficiencies of iron andvitamin A, to name just a few.

Many involve deficiencies of ‘mi-cronutrients’ — substances like vita-min A and iodine that the human bodycannot make itself but that are needed,often in only tiny amounts, to orches-trate a whole range of essential physi-ological functions.

Each type of malnutrition is the re-sult of a complex interplay of factorsinvolving such diverse elements ashousehold access to food, child andmaternal care, safe water and sanitationand access to basic health services.

And each wreaks its own particu-lar kind of havoc on the human body.

Iodine deficiency can damage in-tellectual capacity; anaemia is a factorin the pregnancy and childbirth com-plications that kill 585,000 womenannually; folate deficiency in expec-tant mothers can cause birth defects ininfants, such as spina bifida; and vita-min D deficiency can lead to poorbone formation, including rickets.

Vitamin A deficiency, which af-fects about 100 million young chil-dren worldwide, was long known to

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Reducing malnutrition should be an urgentglobal priority; inaction is a scandalousaffront to the human right to survival.A malnourished child with his motherin Afghanistan.

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Perinatalcauses

18%Diarrhoea

19%

Measles7%Malaria

5%Other32%

Acute respiratoryinfections (ARI)

19%

Source: WHO, based on C.J.L. Murray and A.D. Lopez, The Global Burden of Disease, Harvard University Press, Cambridge (USA), 1996; and D.L. Pelletier, E.A. Frongillo and J.P. Habicht, ‘Epidemiological evidence for a potentiating effect of malnutrition on child mortality’, in American Journal of Public Health, 1993:83.

Fig. 1 Malnutrition and child mortality

If a child is even mildly underweight, the mortality risk is increased. WHO estimates that malnutrition was associated with over half of all child deaths that occurred in developing countries in 1995.

Malnutrition 55%

cause blindness. But it has become in-creasingly clear that even mild vita-min A deficiency also impairs theimmune system, reducing children’sresistance to diarrhoea, which kills2.2 million children a year, andmeasles, which kills nearly 1 millionannually. And new findings stronglysuggest that vitamin A deficiency is acause of maternal mortality as well,especially among women in impover-ished regions (Panel 1).

At its most basic level, malnutri-tion is a consequence of disease andinadequate dietary intake, which usu-ally occur in a debilitating and oftenlethal combination. But many moreelements — social, political, economic,cultural — are involved beyond thephysiological.

Discrimination and violence againstwomen are major causes of malnutrition.

Women are the principal providersof nourishment during the most cru-cial periods of children’s develop-ment, but the caring practices vital tochildren’s nutritional well-being in-variably suffer when the division oflabour and resources in families andcommunities favours men, and whenwomen and girls face discriminationin education and employment.

A lack of access to good educationand correct information is also a causeof malnutrition. Without informationstrategies and better and more acces-sible education programmes, the aware-ness, skills and behaviours neededto combat malnutrition cannot bedeveloped.

There is, in short, nothing simpleabout malnutrition — except perhapsthe fact of how vast a toll it is taking.

Of the nearly 12 million childrenunder five who die each year in de-veloping countries mainly from pre-ventable causes, the deaths of over6 million, or 55 per cent, are eitherdirectly or indirectly attributable tomalnutrition (Fig. 1).

Some 2.2 million children die fromdiarrhoeal dehydration as a result ofpersistent diarrhoea that is often ag-gravated by malnutrition.

And anaemia has been identifiedas a contributing factor, if not a prin-cipal cause, in 20 per cent to 23 percent of all post-partum maternaldeaths in Africa and Asia,1 an estimatemany experts regard as conservative.

If there were no other conse-quences of malnutrition, these horrificstatistics would be more than enoughto make its reduction an urgent globalpriority — and inaction a scandalousaffront to the human right to survival.

But the issue goes beyond childsurvival and maternal mortality andmorbidity. Malnourished children,unlike their well-nourished peers, notonly have lifetime disabilities andweakened immune systems, but theyalso lack the capacity for learning thattheir well-nourished peers have.

In young children, malnutritiondulls motivation and curiosity and re-duces play and exploratory activities.These effects, in turn, impair mentaland cognitive development by reduc-ing the amount of interaction childrenhave both with their environment, andwith those who provide care.

Malnutrition in an expectant mother,especially iodine deficiency, can pro-duce varying degrees of mental retar-dation in her infant.

In infancy and early childhood,iron deficiency anaemia can delaypsychomotor development and impaircognitive development, lowering IQby about 9 points.

Anaemic pre-schoolers have beenfound to have difficulty in maintainingattention and discriminating betweenvisual stimuli. Poor school achieve-ment among primary school and ado-lescent children has also been linkedto iron deficiency.2

Low-birthweight babies have IQsthat average 5 points below those of

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Panel 1

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Each year, nearly 600,000 womendie worldwide from pregnancy-related causes. Prenatal vitamin

A supplements will help reduce thismassive toll, according to prelimi-nary results from a major new study.By measuring the impact of lowweekly doses of the vitamin on thehealth and survival of pregnantwomen in southern Nepal, the studyfound that deaths among women re-ceiving either low-dose vitamin A orbeta-carotene supplements droppeddramatically, by an average 44 per cent.

Like many parts of the developingworld, Nepal has a notoriously highmaternal mortality rate — 125 timesthat of the United States — and vita-min A deficiency is common, par-ticularly among pregnant women.Night-blindness, long ignored by themedical establishment and viewedby women as a routine consequenceof pregnancy, but in reality a worry-ing sign of vitamin A deficiency, de-

velops in 10 to 20 per cent of preg-nant women.

Researchers from Johns HopkinsUniversity in the United States andthe National Society for Eye Healthand Blindness Prevention in Nepal,supported by the United StatesAgency for International Develop-ment (USAID) and Task Force Sightand Life, based in Switzerland, con-ducted the study to see whethermaternal, foetal or infant mortalitycould be lowered by providing wo-men of childbearing age one low-dose vitamin A capsule each week.Night-blindness and anaemia in wo-men in the study and birth defectsin their infants were also carefullyinvestigated.

Approximately 44,000 young mar-ried women, nearly half of whom be-came pregnant during the study,were given either vitamin A supple-mentsa or placebos. The supplementswere in the form of either pure vita-

min A or beta-carotene, the vitaminA-active ingredient found in fruitsand vegetables that the body con-verts to vitamin A.

Among the women receiving purevitamin A there were 38 per centfewer deaths and among those re-ceiving beta-carotene there were 50per cent fewer deaths, during preg-nancy and the three months follow-ing childbirth, than among womenreceiving no supplements.b Anaemia,which is usually associated with irondeficiency and which is known to bea contributing cause of maternaldeaths, was a surprising 45 per centlower in the women receiving sup-plements who were not infected withhookworm.

Women suffering from night-blindness (an inability to see at duskor in dim light) were found to bemore likely to get infections, to beanaemic and underweight and tobe at greater risk of death. Night-blindness was reduced by 38 percent and 16 per cent, respectively, inthe vitamin A and beta-carotenegroups, leaving questions about themost appropriate mix of nutrients,and the amounts needed, to preventthe condition. No reduction in foetalor infant mortality through sixmonths of age was apparent in chil-dren born to women in the study.

The scientists have not yet com-pleted analysing the effects of sup-plements on the different causes ofmaternal deaths. However, deathsfrom infection are one importantcause of high maternal mortalityrates, and vitamin A is known to beessential for the effective functioningof the immune system that reducesthe severity of infection.

The results of this study indicatethat where vitamin A deficiency iscommon, the regular and adequate

Vitamin A supplements savepregnant women’s lives

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healthy children. And children whowere not breastfed have IQs that are 8points lower than breastfed children.

The depletion of human intelli-gence on such a scale — for reasonsthat are almost entirely preventable —is a profligate, even criminal, waste.

Robbed of their mental as well asphysical potential, malnourished chil-dren who live past childhood facediminished futures. They will becomeadults with lower physical and intel-lectual abilities, lower levels of pro-ductivity and higher levels of chronicillness and disability, often in soci-eties with little economic capacity foreven minimal therapeutic and rehabil-itative measures.

At the family level, the increasedcosts and pressures that malnutrition-linked disability and illness place onthose who care for them can be devas-tating to poor families — especially tomothers, who receive little or no helpfrom strained social services in devel-oping countries.

And when the losses that occur inthe microcosm of the family are re-peated millions of times at the societallevel, the drain on global developmentis staggering.

In 1990 alone, the worldwide lossof social productivity caused by fouroverlapping types of malnutrition — nu-tritional stunting and wasting, iodinedeficiency disorders and deficienciesof iron and vitamin A — amounted toalmost 46 million years of productive,disability-free life, according to onereckoning.3

Vitamin and mineral deficienciesare estimated to cost some countriesthe equivalent of more than 5 per centof their gross national product in lostlives, disability and productivity. Bythis calculation, Bangladesh and Indiaforfeited a total of $18 billion in 1995.4

Malnourished children’s low resis-tance to illness diminishes the effec-tiveness of the considerable resources

intake of vitamin Ac or beta-carotene by women during theirreproductive years can markedlyreduce their risk of pregnancy-related mortality. Adequate intakeof vitamin A may also dramaticallyreduce anaemia in pregnant wo-men if combined with deworming.

This study helps highlight theurgent need to improve the nutri-tion of girls and women as part ofa multi-pronged approach to re-duce the tragedy of maternal mor-tality in the developing world andopens the way to new preventionstrategies that can be widely im-plemented in the near future.

NOTES

a. The low-dose supplements contained7,000 µg of retinol equivalents (RE)(23,300 IU) of vitamin A, or a similaramount of beta-carotene, which isapproximately equivalent to a woman’sweekly requirement.

b. Deaths were reduced from 713 per100,000 pregnancies in the group ofwomen not receiving supplements to 443and 354 deaths per 100,000 respectivelyin women receiving the weekly vitaminA and beta-carotene supplements.

c. Although found in many foods,vitamin A has powerful biological effectsand care is essential to prevent themisuse of supplements, especially bypregnant women. High-dose (200,000 IU)vitamin A supplements of the typeroutinely provided at four to six monthlyintervals to young children in developingcountries should never be taken bywomen of childbearing age because ofthe risk of possible harm to a developingfoetus. High-dose supplements may,however, be safely given to womenwithin eight weeks following childbirth.Low-dose weekly vitamin A supple-ments, like those given in this study,and even lower-dose daily supplementscan be taken by women during theirreproductive years with little risk tomother or foetus and with considerablebenefit wherever deficiency is likely.

Photo: A mother and child in Nepal, wherea recent study showed that weekly vitaminA supplements given to pregnant womensubstantially reduced maternal deaths.

Vitamin and mineraldeficiencies are estimatedto cost some countries theequivalent of more than5 per cent of their grossnational product in lost lives,disability and productivity.

Panel 2

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Malnutrition is usually the re-sult of a combination of in-adequate dietary intake and

infection (Fig. 6). In children, malnu-trition is synonymous with growthfailure — malnourished children areshorter and lighter than they shouldbe for their age. To get a measure ofmalnutrition in a population, youngchildren can be weighed and mea-sured and the results compared tothose of a ‘reference population’known to have grown well. Meas-uring weight and height is the mostcommon way of assessing malnutri-tion in populations.

Although many people still referto growth failure as ‘protein-energymalnutrition,’ or PEM, it is now rec-ognized that poor growth in childrenresults not only from a deficiency ofprotein and energy but also from aninadequate intake of vital minerals(such as iron, zinc and iodine) and vi-tamins (such as vitamin A), and oftenessential fatty acids as well. Theseminerals are needed in tiny quantities,on the order of a few thousandths ofa gram or less each day. They are con-

sequently called micronutrients. Mi-cronutrients are needed for the pro-duction of enzymes, hormones andother substances that are required toregulate biological processes leadingto growth, activity, development andthe functioning of the immune andreproductive systems.

All of the minerals that the bodyneeds — calcium, phosphorous, iron,zinc, iodine, sodium, potassium andmagnesium, for example — have tocome either from the food we eat orfrom supplements. While the bodymanufactures many of the complexorganic molecules it needs from sim-pler building blocks, the vitamins —A, the B complex, C and so on — arenot synthesized. Vitamin D is excep-tional in that it can be made in theskin, providing a person has sufficientexposure to direct sunlight.

While micronutrients are neededat all ages, the effects of inadequateintake are particularly serious duringperiods of rapid growth, pregnancy,early childhood and lactation. We arelearning more every day about theimportance of micronutrients for the

physical and the cognitive develop-ment of children.

While widespread moderate mal-nutrition may not be obvious unlesschildren are weighed and measured,some severely malnourished chil-dren develop clinical signs that areeasily observed — severe wasting (ormarasmus) and the syndrome knownas kwashiorkor, with skin and hairchanges and swelling of arms andlegs. Despite years of research, thereasons why some children developkwashiorkor and why others developmarasmus remains a mystery. Whatis clear is that left untreated, childrenwith either condition are at high riskof dying from severe malnutrition,and that both kwashiorkor and maras-mus can be prevented by ensuringan adequate intake of nutritious foodand freedom from repeated infec-tions. Less severe forms of malnutri-tion also cause death, mostly becausethey weaken children’s resistance toillness (Fig. 1).

The 1990 World Summit forChildren singled out deficiencies ofthree micronutrients — iron, iodine,and vitamin A — as being particularlycommon and of special concern forchildren and women in developingcountries. Recently, knowledge of theprevalence and importance of zinc forchild growth and development hasplaced it in that league as well. VitaminD deficiency is now recognized as amajor problem of children in countriessuch as Mongolia, the northern partsof China and some of the countries ofthe Commonwealth of IndependentStates that have long winters.

Throughout this report, the termmalnutrition is used to refer to the con-sequences of the combination of aninadequate intake of protein energy,micronutrients and frequent infections.

What is malnutrition?

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Photo: Three sisters at a health centre in Haiti.

that are spent to ensure that familieshave access to basic health servicesand sanitation. And investments inbasic education by governments andtheir partners are compromised bymalnutrition’s pernicious effects onbrain development and intellectualperformance.

Iodine deficiency and iron defi-ciency anemia, which threaten mil-lions of children, are especially worri-some factors as countries strive toimprove their educational systems.

Iron-deficient children under theage of two years show problems withcoordination and balance and appearmore withdrawn and hesitant. Suchfactors can hinder a child’s ability tointeract with and learn from the envi-ronment and may lead to lower intel-lectual abilities.5

Severe iodine deficiency in uterocan cause the profound mental retar-dation of cretinism. But milder defi-ciencies also take an intellectual toll.In the republic of Georgia, for in-stance, a widespread iodine defi-ciency, recently detected, is estimatedto have robbed the country of 500,000IQ points in the 50,000 babies born in1996 alone.6

Many children suffer from multi-ple types of malnutrition, so numberstend to overlap. But it is reliably esti-mated that globally 226 million chil-dren are stunted — shorter than theyshould be for their age, and shorterthan could be accounted for by anygenetic variation (Panel 2). Stuntingis particularly dangerous for women,as stunted women are more likely toexperience obstructed labour and arethus at greater risk of dying while giv-ing birth. Stunting is associated with along-term reduction in dietary intake,most often closely related to repeatedepisodes of illness and poor-quality diets.

A study in Guatemala found thatseverely stunted men had an averageof 1.8 fewer years of schooling than

those who were non-stunted, whileseverely stunted women had, on aver-age, one year less. The differences areimportant since every additional yearof schooling translated into 6 per centmore in wages7 (Panel 3).

Some 67 million children are esti-mated to be wasted, which meansthey are below the weight they shouldbe for their height — the result of re-duced dietary intake, illness, or both.

About 183 million children weighless than they should for their age. Inone study, children who were severelyunderweight8 were found to be two toeight times more likely to die withinthe following year as children of nor-mal weight for their age.9

More than 2 billion people — prin-cipally women and children — areiron deficient,10 and the World HealthOrganization (WHO) has estimatedthat 51 per cent of children under theage of four in developing countriesare anaemic.11

In most regions of the developingworld, malnutrition rates have beenfalling over the last two decades, butat markedly different paces (Fig. 2).The exception is sub-Saharan Africa,where malnutrition rates began in-creasing in most countries during theearly 1990s, following the regionaleconomic decline that began in thelate 1980s. As government budgetsshrank, basic social services andhealth services were hit particularlyhard. Per capita incomes also de-clined, affecting people’s ability topurchase food.

In the United States, researchersestimate that over 13 million children —more than one in every four under theage of 12 — have a difficult time get-ting all the food they need, a problemthat is often at its worst during the lastweek of the month when families’social benefits or wages run out.12

Over 20 per cent of children in theUnited States live in poverty, more

Iron-deficient children underthe age of two years showproblems with coordinationand balance and appear morewithdrawn and hesitant. Suchfactors can hinder a child’sability to interact with andlearn from the environmentand may lead to lowerintellectual abilities.

15

Panel 3

16

Malnutrition early in life islinked to deficits in children’sintellectual development that

persist in spite of schooling and im-pair their learning ability, accordingto a recent study in the Philippines.The study analysed stunting —which is low height for age and abasic indicator of malnutrition —among more than 2,000 children liv-ing in metropolitan Cebu, the Phil-ippines’ second largest city. Nearlytwo thirds of the children studiedwere stunted. Those stunted earliestin life, before six months of age, werethe most severely stunted by agetwo, the study found. The same chil-dren scored significantly lower on in-telligence tests at 8 and 11 years of agethan children who were not stunted.

The study holds profound impli-cations on a global level: 226 millionchildren under age five in developingcountries, nearly 40 per cent of thisage group, suffer from moderate orsevere stunting. “High levels of stunt-ing among children suggest that therewill also be long-term deficits in men-

tal and physical development thatcan leave children ill-prepared to takemaximum advantage of learning op-portunities in school. This can alsohave consequences for children’s suc-cess later in life,” says Linda S. Adair,Ph.D., Associate Professor of Nu-trition at the University of NorthCarolina, in Chapel Hill (US), one ofthe researchers.

“Stunting does not directly causepoor intellectual development in chil-dren,” emphasizes Professor Adair.“Rather, the same underlying factorsthat cause stunting are also likely toimpair children’s intellectual growth.”Among children in Cebu, the causesinclude low birthweight, insufficientbreastfeeding, nutritionally inade-quate food given to complement orreplace breastmilk, and frequent di-arrhoea and respiratory infections.Stunted children tend to enter schoollater and miss more days of schoolthan well-nourished children, thestudy also found.

The study, part of a collaborativeresearch programme of the Office ofPopulation Studies at the Universityof San Carlos in Cebu and the Uni-versity of North Carolina, found that28 per cent of the children surveyedwere severely stunted. At age two,these children were nearly 11 cen-timeters (5 inches) shorter than chil-dren who were not stunted. The IQscores of the severely stunted chil-dren at eight years of age were 11points lower than those of the chil-dren who were not stunted.

When the children in the studywere tested again at age 11, thosewho had been most severely stuntedat age 2 still scored lower on the in-telligence test than children who hadnot been stunted, although the gapwas narrower at about 5 IQ points.Children who were severely stunted

also had significantly lower scores onlanguage and math achievement tests.

Most of the children in the studywere from poor families, and theirdiets, and those of their mothers, werebelow the nutritional levels recom-mended by the Philippine Govern-ment. They came from densely pop-ulated, poor urban communities, fromnewly settled areas on the outskirts ofthe city and from rural communities.

This study underscores the impor-tance and lasting impact of nutritionin the crucial months of infancy andbeginning before birth with soundmaternal nutrition. Infants denied astrong start in life face problems inmaking up the lost ground, and theimpact on their own developmentand that of their societies can be alasting one.

Stunting linked to impaired intellectual development

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Nearly 40 per cent of all children under five inthe world are stunted due to malnutrition. Manyof them will also face challenges in school asa result. Here, a contrast in stature is apparentbetween two girls the same age in Bangladesh.

The effects of stuntingIn a non-verbal intelligence test given to eight-year-olds in the Philippines, scores stronglycorrelated with children’s level of stunting atage two. Children severely stunted at age twohad the lowest test scores, while non-stuntedchildren had scores on average 11 points higher.

than double the rate of most other in-dustrialized countries.13

In the United Kingdom, childrenand adults in poor families face healthrisks linked to diet, according to a re-cent study that cited high rates ofanaemia in children and adults, andof premature and low-weight births,dental diseases, diabetes, obesity andhypertension.14

In Central and Eastern Europe,economic dislocations accompanyingthe transition to market economiesand major cutbacks in state-run socialprogrammes are having a more pro-found effect on the most vulnerable.

In the Russian Federation, theprevalence of stunting among chil-dren under two years of age increasedfrom 9 per cent in 1992 to 15 per centin 1994.15 And in the Central Asian re-publics and Kazakstan, 60 per cent ofpregnant women and young childrenare now anaemic.

The effects of malnutrition alsocross generations. The infants ofwomen who are themselves malnour-ished and underweight are likely to besmall at birth.

Overall, 60 per cent of women ofchildbearing age in South Asia —where half of all children are under-weight — are themselves underweight.In South-East Asia, the proportion ofunderweight women is 45 per cent; itis 20 per cent in sub-Saharan Africa.

The power of goodnutrition

The devastation of malnutrition ishard to overstate, but so is the coun-tervailing power of nutrition. Not onlyis good nutrition the key to the healthydevelopment of individuals, familiesand societies, but there is also grow-ing reason to believe that improvingthe nutrition of women and childrenwill contribute to overcoming some ofthe greatest health challenges facing

the world, including the burden ofchronic and degenerative disease, ma-ternal mortality, malaria and AIDS.

The most obvious proof of thepower of good nutrition can be seen inthe taller, stronger, healthier childrenof many countries, separated by onlya generation from their shorter, lessrobust parents, and by the better dietsand more healthful, nurturing envi-ronments they enjoy.

Stronger children grow intostronger, more productive adults. Well-nourished girls grow into women whoface fewer risks during pregnancy andchildbearing, and whose children setout on firmer developmental paths,physically and mentally. And historyshows that societies that meet women’sand children’s nutritional needs alsolift their capacities for greater socialand economic progress (Fig. 3).

Approximately half of the eco-nomic growth achieved by the UnitedKingdom and a number of WesternEuropean countries between 1790 and1980, for example, has been attributedto better nutrition and improved healthand sanitation conditions, social in-vestments made as much as a centuryearlier.16

Even in countries or regions wherepoverty is entrenched, the health anddevelopment of children and womencan be greatly protected or improved(Fig 4). In parts of Brazil, for example,the percentage of underweight childrenplummeted from 17 per cent in 1973 tojust under 6 per cent in 1996, at a timewhen poverty rates almost doubled.

Much has already been achieved.For example, 12 million children everyyear are being spared irreversiblemental impairment from iodine defi-ciency because of iodized salt. Andmore than 60 per cent of young chil-dren around the world are receivingvitamin A supplements.

Some effects of even severe malnu-trition on a child’s mental development

Approximately half of theeconomic growth achieved bythe United Kingdom and anumber of Western Europeancountries between 1790 and1980, for example, has beenattributed to better nutritionand improved health andsanitation conditions, socialinvestments made as muchas a century earlier.

17

18

Note: Malnutrition is measured as the percentage of under-five children below -2 standard deviations of the median value for the National Center for Health Statistics (NCHS) reference population for weight-for-age. Rates have been adjusted for age; data for some countries reflect rates for the under-three population.

Source: UNICEF, 1997.

Fig. 2 Trends in child malnutrition, by region

The chart shows trends in malnutrition in 41 countries, in four regions, covering over half of children under five years old in the developing world. Countries with under-five populations below 1 million are not included, even where trend data were available.

Middle East and North Africa

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Syria

Yemen

TurkeyTunisia

Sudan

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Egypt

Morocco

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Colombia

Haiti

Guatemala

Honduras

Peru

Chile

BoliviaDominican Rep.

Brazil

Latin America and the Caribbean

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Burundi

Cameroon

Mali

Madagascar

Niger

SenegalTanzania

Uganda

Congo Dem. Rep.

Zambia

Zimbabwe

Malawi

Kenya

Ghana

Côte d'lvoire

Sub-Saharan Africa

Sri Lanka

Nepal

Myanmar

Viet Nam

Indonesia

China

Bangladesh

Pakistan

Philippines

Asia and Pacific

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Nepal

Myanmar

Viet Nam

Indonesia

China

Bangladesh

Pakistan

Philippines

Asia and Pacific

can be at least partially reversed. Theintelligence of severely malnourishedchildren was found to improvemarkedly, for example, when healthcare, adequate food and stimulationwere provided continually.17

And there is increasing evidencethat good nutrition helps the body re-sist infection; that when infection oc-curs, nutrition relieves its severity andseriousness; and that it speeds recovery.

Thirty years ago, most peoplecould readily accept the notion that a‘good diet’ was beneficial to overallhealth. But the idea that specific nutri-ents could help fend off — or, evenmore outlandishly, help treat — specificdiseases smacked of ‘fringe science’.

Today, through clinical trials andstudies, the fringe is edging closer tothe mainstream, as nutrition scientists aswell as immunologists, paediatriciansand gerontologists test the implica-tions for public policy of large-scaleinterventions to improve nutrition andits effects on an array of critical phys-iological processes.

Malnutrition, reflected in the poorgrowth of children and adolescents andthe high prevalence of low-birthweightbabies, already has well-known ef-fects on a child’s capacity to resist ill-ness. It is thus reasonable to arguethat in the global fight to reduce child-hood death and illness, initiatives toimprove nutrition may be as powerfuland important as, for example, immu-nization programmes.

There are now numerous scientificstudies that suggest, but do not yetprove, that vitamin A deficiency in amother infected with the human im-munodeficiency virus (HIV) may in-crease her risk of transmitting thevirus to her infant.

Early in the next millennium, it isthought that between 4 million and 5million children will be infected withHIV. The majority, mostly in sub-Saharan Africa, will acquire the infec-

tion directly from their mothers.Although it will take another year ortwo to be absolutely sure, improvingthe vitamin A status of populationswhere both HIV infection and vitaminA deficiency are common may makesome contribution to reducing thetransmission of the virus.

The right to goodnutrition

However far-reaching the benefits ofnutrition may be, ensuring good nutri-tion is a matter of international law,articulated in variously specific lan-guage in international declarationsand human rights instruments datingback to the adoption of the Declara-

19

Fig. 3 From good nutrition to greater productivity and beyond

Good early nutrition is most likely to result where there is economic growth, especially equitable growth; when social services become affordable and accessible; and when adequate investment is made in human resources, including the empowerment of women. Good nutrition, in turn, contributes to greater productivity and thus to economic growth.

Source: Adapted from Stuart Gillespie, John Mason and Reynaldo Martorell, How Nutrition Improves, ACC/SCN, Geneva, 1996.

Economic growth

Social-sector investments

Enhanced human capital

Poverty reduction

Improved child nutritionIncreased productivity

Panel 4

20

Nutrition has been expressed asa right in international humanrights instruments since 1924.

Among these are declarations, whichare non-binding, and conventionsand covenants, which are treatiescarrying the force of law.

Some of these human rights mile-stones are noted below.

1924: Declaration of the Rights of

the Child (also known as the

Declaration of Geneva). Adoptedafter World War I by the League ofNations through the efforts of Britishchild rights pioneer Eglantyne Jebb,the Declaration marks the beginningof the international child rightsmovement and is also the first inter-national affirmation of the right tonutrition. The Declaration affirmsthat “the child must be given themeans needed for its normal devel-opment, both materially and spiritu-ally” and states that “the hungrychild should be fed.”

1948: Universal Declaration of

Human Rights. This human rightslandmark, adopted by the UnitedNations General Assembly, proclaimsin article 25 that “everyone has theright to a standard of living adequatefor the health and well-being of him-self and of his family, including food,clothing, housing and medical careand necessary social services . . . .”This article also affirms that “mother-hood and childhood are entitled tospecial care and assistance.”

1959: Declaration of the Rights of

the Child. Adopted unanimously bythe United Nations General Assem-bly, the Declaration states in principle4 that children “shall be entitled togrow and develop in health” and thatchildren “shall have the right to ade-

quate nutrition, housing, recreationand medical services.”

1966: International Covenant on

Economic, Social and Cultural Rights.

Adopted by the United Nations andratified by 137 States as of mid-September 1997, this Covenant wasthe first to spell out States’ obliga-tions to respect people’s economic,social and cultural rights. Article 11affirms the right of everyone to anadequate standard of living, includingadequate food, and the “fundamen-tal right of everyone to be free fromhunger.” The Covenant also man-dates States parties to take steps torealize this right, including measures“to improve methods of production,conservation and distribution of food.”

1986: Declaration on the Right to

Development. Article 1 of the Dec-laration, which was adopted by theUnited Nations General Assembly,proclaims that the right to devel-opment “is an inalienable humanright,” with all people entitled to par-ticipate in and enjoy economic, so-cial, cultural and political develop-ment “in which all human rights andfundamental freedoms can be fullyrealized.” Article 8 calls for all Statesto ensure equal opportunity for all inaccess to health services and food.

1989: Convention on the Rights of

the Child. The most widely ratifiedhuman rights treaty, the Conventionestablishes as international law allrights to ensure children’s survival,development and protection. Article24 mandates States parties to recog-nize children’s right to the “highestattainable standard of health” and totake measures to implement thisright. Among key steps, States aremandated to provide medical assis-

tance and health care to all children,with an emphasis on primary healthcare; combat disease and malnutri-tion, within the framework of pri-mary health care, through the pro-vision of adequate nutritious foods,and safe drinking water and ade-quate sanitation; and provide fami-lies with information about the ad-vantages of breastfeeding.

Ratifications: 191 States as of mid-September 1997, with only two coun-tries — Somalia and the UnitedStates — yet to ratify.

1990: World Declaration and Plan

of Action on the Survival, Protection

and Development of Children. Theunprecedented numbers of worldleaders attending the World Summitfor Children committed themselvesto “give high priority to the rights ofchildren” in the Summit’s WorldDeclaration. The Summit’s Plan ofAction set out the steps in 7 majorand 20 supporting goals for imple-menting the Declaration. Reducingsevere and moderate malnutrition byhalf of 1990 levels among under-fivechildren by the end of the century isthe main nutrition goal.

The 7 supporting nutrition goalsare: reduction of low-weight births toless than 10 per cent of all births;reduction of iron deficiency anaemiain women by one third of 1990 levels;virtual elimination of iodine defici-ency disorders; virtual elimination ofvitamin A deficiency; empowermentof all women to exclusively breast-feed their children for about the firstsix months; institutionalization ofgrowth monitoring and promotion;and dissemination of knowledge andsupporting services to increase foodproduction to ensure household foodsecurity.

Recognizing the right to nutrition

tion of the Rights of the Child in 1924(Panel 4).

Under the 1979 Convention on theElimination of All Forms of Dis-crimination against Women, for ex-ample, States parties must ensure thatwomen receive full and equal accessto health care, including adequate nu-trition during pregnancy and lactation.And the 1990 World Summit forChildren, with a Plan of Action thatrecognized the devastating effects ofmalnutrition on women and their chil-dren, set specific nutritional goals forchildren and women, including accessto adequate food during pregnancyand lactation; the promotion, protec-tion and support of breastfeeding andcomplementary feeding practices; growthmonitoring with appropriate follow-upactions; and nutritional surveillance.

But the right to nutrition receivesits fullest and most ringing expressionin the 1989 Convention on the Rightsof the Child, whose 191 ratificationsas of late 1997 make it the mostuniversally embraced human rightsinstrument in history.

Under the Convention, whichcommits States parties to realize thefull spectrum of children’s political,civil, social, economic and culturalrights, virtually every government inthe world recognizes the right of allchildren to the highest attainable stan-dard of health, to facilities for thetreatment of illness and for the reha-bilitation of health — specifically in-cluding the right to good nutrition andits three vital components: food, healthand care.

Under the Convention’s pre-eminentguiding principle, good child nutritionis a right because it is in the “best in-terests of the child.”

Article 24 of the Convention spec-ifies that States parties must take “ap-propriate measures” to reduce infantand child mortality, and to combatdisease and malnutrition through the

use of readily available technologyand through the provision of adequate,nutritious foods and safe drinking water.

The world is obligated to easechild malnutrition on the basis of in-ternational law, scientific knowledge,practical experience and basic morality.

The ravages caused by malnutri-tion on individuals, families and soci-eties are preventable. The measuresneeded to reduce and end it are be-coming increasingly well understood.And the gains for humanity fromdoing so — in greater creativity, energy,productivity, well-being and happi-ness — are immeasurable.

Why time is ofthe essence

A child’s organs and tissues, blood,brain and bones are formed, and intel-lectual and physical potential isshaped, during the period from concep-tion through age three.

Since human development pro-ceeds particularly rapidly for the first18 months of life, the nutritional statusof pregnant and lactating mothers andyoung children is of paramount im-portance for a child’s later physical,mental and social development. It is notan exaggeration to say that the evolu-tion of society as a whole hinges onthe nutrition of mothers and childrenduring this crucial period of their lives.

The healthy newborn who devel-ops from a single cell — roughly thesize of the period at the end of thissentence — will have some 2 billioncells and weigh an average of 3,250grams.18 Under optimal conditions,the infant will double its birthweightin the first four months of life; by itsthird birthday, a healthy child will befour and a half times as heavy.

Brain cells proliferate at the rate of250,000 a minute, beginning in thethird week of gestation.19 By the timeof birth, a child will have 100 billion

21

Fig. 4 Poverty and malnutrition in Latin America and the Caribbean

Malnutrition in Latin America decreased from an estimated 21% in 1970 to 7.2% in 1997, while the rate of poverty, measured by income level, fluctuated only slightly over the last three decades, dropping from 45% in 1970 to 44% in 1997. These trends show that the reduction of malnutrition is not solely dependent on increases in income. In Latin America, the gains in reducing malnutrition are attributed at the underlying level to good care practices and access to basic health services, including family planning, and water/sanitation services; and at the basic level to women's empowerment in terms of their education and the cash resources they control.

Source: Aaron Lechtig, 'Child Undernutrition in Latin America and the Caribbean: Trends, reasons and lessons', presented to the Workshop on the Changing Conditions of the Child in Latin America and the Caribbean, University of Notre Dame, South Bend (USA), 26 September 1997, based on ACC/SCN, 'Update of the Nutrition Situation 1996', Summary of results for the Third Report on the World Nutrition Situation, ACC/SCN, Geneva, 1996,and ECLAC, Social Panorama of Latin America 1996, Santiago (Chile), 1996.

1970 1975 1980 1985 1990 1995 2000

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Per cent of underweightchildren

neurons, linked by synapses, the com-plex nerve junctions that begin form-ing in the 13th week of gestation.20

Proliferating most rapidly afterbirth, in large part because of thestimulation and care a child receives,millions upon millions of these junc-tions will be forged by the time ahealthy child reaches the age of twoand a half. Physical, mental andcognitive development depend onthese communication links betweenneurons. Without them, messageswould dead-end, muscles would notflex, and the complex processes ofthought and learning would not bepossible.

Growth during the foetal stage de-pends on how well nourished awoman was before pregnancy, as wellas how much weight she gains whileshe is pregnant. Gains in weight areessential for the development of newmaternal and foetal tissues, and formaternal body maintenance and energy.

Since the foetus relies entirely onthe mother for nutrients, pregnantwomen not only need to gain weightbut also must maintain an optimal in-take of essential nutrients such as ironand iodine.

But fulfilling these interlockingfood, health and care needs can be astruggle for many women in the de-veloping world, where economic,social and cultural factors may be abarrier to good nutrition.

Currently about 24 million low-birthweight babies are born everyyear, which is about 17 per cent of alllive births. Most are born in develop-ing countries, where the main causeof low birthweight is not prematurebirth, as it is in the industrializedworld, but poor foetal growth.

Low-birthweight babies, definedas weighing less than 2.5 kilograms,are at greater risk of dying than infantsof average weight. If they survive,they will have more episodes of ill-

ness, their cognitive development maybe impaired, and they are also morelikely to become malnourished. Evi-dence is also mounting that low birth-weight predisposes children to a highrisk of diabetes, heart disease andother chronic conditions later in life.

The measures that are essentialfor an expectant mother — care andrest, a reduced workload and a well-balanced diet that affords ample en-ergy, protein, vitamins, minerals andessential fatty acids — are equally im-portant when a woman is breastfeed-ing her child.

Breastfeeding perfectly combinesthe three fundamentals of sound nutri-tion — food, health and care — and isthe next critical window of nutritionalopportunity after pregnancy. Whilenot all children are breastfed, it re-mains an important protection forchildren (see also page 47).

Because breastmilk contains allthe nutrients, antibodies, hormonesand antioxidants an infant needs tothrive, it plays a pivotal role in pro-moting the mental and physical devel-opment of children.

Breastfed infants not only showbetter immune responses to immuni-zations, but their intake of breastmilkalso protects the mucous membranesthat line their gastrointestinal and res-piratory tracts, thus shielding themagainst diarrhoea and upper respira-tory tract infections.21

In countries where infant mortalityrates are high or moderately high,a bottle-fed baby in a poor communityis 14 times more likely to die fromdiarrhoeal diseases and 4 times morelikely to die from pneumonia than ababy that is exclusively breastfed.22

Breastfeeding also has cognitivebenefits. In one study, breastfed sub-jects generally had IQs that wereabout 8 points higher than childrenwho had been bottle-fed, and higherachievement scores as well.23 Nutri-

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Women need rest and protection fromoverwork during pregnancy. As long as theunequal division of labour so common aroundthe world persists, the caring practices vital tothe nutritional well-being of children willsuffer. In Niger, a pregnant woman carriesseveral large bowls of sorghum.

tionists theorize that the effect may bethe result of the growth-promotinglong-chain fatty acids of breastmilk.It may also be related to the fact thatbreastfed infants have fewer infectionsand, as healthier infants, they take agreater interest in their environmentand thus learn more than ill infants.

However, for mothers infectedwith HIV, breastfeeding’s enormousvalue as a bulwark against malnutri-tion, illness and death must be weighedagainst the 14 per cent risk that theymay transmit the virus to their infantsthrough breastmilk — and the vastlygreater risk, especially in poor com-munities with inadequate water andsanitation, that feeding their childrenartificially will lead to infant deathsfrom diarrhoeal dehydration and res-piratory infections.

During the second half of a child’sfirst year, synaptic growth in the pre-frontal cortex of the brain, the seat offorethought and logic, consumes twicethe amount of energy required by anadult brain. Much of this synapticgrowth is believed to result from thecaring stimulation that an infant andyoung child receives — the nurturing,feeding and learning play in whichparents engage their children.

After about six months, for opti-mal growth and development, a childneeds to be fed frequently with energy-rich, nutrient-dense foods. The failureto make such investments at the righttime can never be remedied later. Anadequate intake of micronutrients,especially iodine, iron, vitamin A andzinc, remains crucial.

Spotlighting the causesAn understanding of the complex andsubtle causes of malnutrition is im-portant to appreciate the scale anddepth of the problem, the progressachieved to date and the possibilitiesfor further progress that exist.

Malnutrition, clearly, is not a simpleproblem with a single, simple solu-tion. Multiple and interrelated deter-minants are involved in why malnutri-tion develops, and a similarly intricateseries of approaches, multifaceted andmultisectoral, are needed to deal withit (Fig. 5).

Immediate causesThe interplay between the two mostsignificant immediate causes of mal-nutrition — inadequate dietary in-take and illness — tends to create avicious circle: A malnourished child,whose resistance to illness is com-promised, falls ill, and malnourish-ment worsens. Children who enterthis malnutrition-infection cycle canquickly fall into a potentially fatalspiral as one condition feeds off theother (Fig. 6).

Malnutrition lowers the body’sability to resist infection by under-mining the functioning of the mainimmune-response mechanisms. Thisleads to longer, more severe and morefrequent episodes of illness.

Infections cause loss of appetite,malabsorption and metabolic and be-havioural changes. These, in turn, in-crease the body’s requirements fornutrients, which further affects youngchildren’s eating patterns and howthey are cared for (see also page 27).

Underlying causesThree clusters of underlying causeslead to inadequate dietary intake andinfectious disease: inadequate accessto food in a household; insufficienthealth services and an unhealthful en-vironment; and inadequate care forchildren and women.

❑ Household food securityThis is defined as sustainable accessto safe food of sufficient quality andquantity — including energy, proteinand micronutrients — to ensure ade-

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A complex interplay of factors such ashousehold access to food, women’s status,caring practices, disease and access to safewater, sanitation and basic health servicesaffect a child’s nutrition. A girl stands in thedoorway of her home in Lebanon.

24

Fig. 5 Causes of child malnutrition

This conceptual framework on the causes of malnutrition was developed in 1990 as part of the UNICEF Nutrition Strategy. The framework shows that causes of malnutrition are multisectoral, embracing food, health and caring practices. They are also classified as immediate (individual level), underlying (household or family level) and basic (societal level), whereby factors at one level influence other levels. The framework is used, at national, district and local levels, to help plan effective actions to improve nutrition. It serves as a guide in assessing and analysing the causes of the nutrition problem and helps in identifying the most appropriate mixture of actions.

Source: UNICEF, 1997.

Child malnutrition, death and disability

Inadequate dietary intake

Disease

Insufficient access to food

Inadequate maternal and child-care practices

Poor water/ sanitation and inadequate health services

Quantity and quality of actual resources — human, economic and organizational — and the way they are controlled

Potential resources: environment, technology, people

Political, cultural, religious,

economic and social systems,

including women’s status, limit

the utilization of potential

resources

Outcomes

Immediate causes

Basic causes at societal level

Underlying causes at household/family level

Inadequate and/or

inappropriate knowledge and

discriminatory attitudes limit

household access to actual

resources

household food security to translateinto good nutrition, this often over-whelming burden of work must beredistributed or reduced so that otherneeds of children, also related to nu-trition, can be met.

❑ Health services, safe waterand sanitation

An essential element of good health isaccess to curative and preventivehealth services that are affordable andof good quality.

Families should have a health cen-tre within a reasonable distance, andthe centre’s staff should be qualifiedand equipped to give the advice andcare needed. According to the UnitedNations Development Programme(UNDP), access varies widely, but inas many as 35 of the poorest countries30 to 50 per cent of the population mayhave no access to health services at all.24

In Africa, the programme knownas the Bamako Initiative was launched

25

quate intake and a healthy life for allmembers of the family.

In rural areas, household foodsecurity may depend on access toland and other agricultural resourcesto guarantee sufficient domesticproduction.

In urban areas, where food islargely bought on the market, a rangeof foods must be available at accessi-ble prices to ensure food security.Other potential sources of food areby exchange, gifts from friends orfamily and in extreme circumstancesfood aid provided by humanitarianagencies.

Household food security dependson access to food — financial, physi-cal and social — as distinct from itsavailability. For instance, there maybe abundant food available on themarket, but poor families that cannotafford it are not food secure.

For the poor, therefore, householdfood security is often extremely pre-carious. Agricultural production varieswith the season and longer-term envi-ronmental conditions. Families sell-ing crops may find themselves paidfluctuating prices depending on a va-riety of factors beyond their control,while those who need to buy foodmay encounter exorbitant prices.

Families living on the edge of sur-vival have few opportunities to buildup sufficient stocks of food, or to de-velop alternatives that would cushionthem in times of hardship. So whilepoor families may have adequate ac-cess to food for one month, what is es-sential is access that is consistent andsustainable.

Women have a special role to playin maintaining household food secu-rity. In most societies, they are solelyresponsible for preparing, cooking,preserving and storing the family’sfood — and in many societies theyhave the primary responsibility ofproducing and purchasing it. For

Inadequate dietary intake

Weight lossGrowth falteringImmunity lowered

Mucosal damage

Disease: - incidence - severity - duration

Appetite lossNutrient lossMalabsorptionAltered metabolism

Source: Andrew Tomkins and Fiona Watson, Malnutrition and Infection, ACC/SCN, Geneva, 1989.

Fig. 6 Inadequate dietary intake/disease cycle

Inadequate dietary intake and infection operate in a vicious cycle that accounts for much of the high morbidity and mortality seen in developing countries. When children don't eat enough or well enough, their immune system defences are lowered, resulting in greater incidence, severity and duration of disease. Disease speeds nutrient loss and suppresses appetite — so sick children tend not to eat as they should — and the cycle continues.

Panel 5

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Poultry farmers have known forsome time that a chicken livingin a dirty environment is a

chicken that grows poorly. Even if itis not overtly sick all the time, it gainslittle weight.

Is there a message here about thegrowth of children? Because growth,like other nutrition outcomes, is deter-mined most immediately by diet andillness status, the answer, at least inpart, may be yes. Infectious illness —which spreads more easily in unsani-tary conditions — leads to poorer di-etary intake and poor use of thenutrients ingested. This, in turn,leads to lower resistance to infection,and so on, in a vicious diet-infectioncycle (Fig. 6).

Now studies suggest that an un-sanitary environment may have ef-fects beyond those associated withparticular bouts of illness. Research-ers believe that children living insuch conditions may suffer from afairly constant, low-level challenge totheir immune systems that impairs

their growth, as has been shown indomestic fowl. Dr. Noel Solomons ofthe Centre for Studies of SensoryImpairment, Aging and Metabolismand colleagues suggest that alongwith classifying children as healthy(having no clinical illness) andacutely infected (with signs of illnessreadily detectable), there is also acategory of “inapparently infected.”Children who are inapparently in-fected have no signs of clinical illnessbut do have abnormal levels of someimmunological indicators. Such in-apparent infections and the chroniclow-level stimulation of the immunesystem associated with life in unsan-itary conditions may mean thatnutrients go to support the body’s im-mune response rather than growth.

Poverty occurs in both South Asiaand sub-Saharan Africa, but rates ofmalnutrition, especially stunting, aremuch higher in South Asia. A num-ber of hypotheses have been ad-vanced to explain this difference, andone is that it is due to poorer sanita-

tion and hygiene practices, the muchgreater population density and de-gree of overcrowding in South Asia.

Certainly, the dangers posed bypoor access to potable water are wellknown. A recent review of data col-lected by the Demographic and HealthSurveys, a USAID-supported project,indicates that health and nutritionbenefits from improved sanitation,especially improved excreta dis-posal, may be even greater thanthose associated with better accessto safe water alone.

A group led by Dr. ReynaldoMartorell of Emory University (US)has designed a study to shed light onthe relationship between sanitationand growth stunting. This studywould follow 800 children in two lo-cations in South Asia and 800 morein two locations in sub-SaharanAfrica from the time their mothersbecome pregnant to when they aretwo years old and would collect awide range of information on sanita-tion, hygiene practices and other as-pects of the household environment.The children’s growth would be meas-ured frequently along with indicatorsof feeding practices, diet quality, ill-ness and many other factors. UNICEFis helping to secure funds for thisstudy.

Establishing a link between sani-tation conditions and child growth ina cause-and-effect way will go a longway to clarifying priorities for actionin this area. Such a link will alsoreveal just how useful the ‘dirtychicken’ model is for understandingstunted growth among children.

Growth and sanitation:What can we learn from chickens?

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Photo: Unsanitary living conditions causeillnesses that threaten children’s health andgrowth. New research now suggests that growthis harmed in unhygienic surroundings evenbefore acute infection occurs. In Egypt, a girlamid mounds of garbage and animal waste.

in 1987 to address the crisis in healthcare that came on the heels of budgetcuts and economic decline in the1980s. It is a strategy for improvinghealth services by moving their con-trol, management and even some oftheir financing out of central jurisdic-tion and into communities.

Now in place in a number of coun-tries in Africa, the Initiative’s princi-ples are being adopted and adapted inother regions as well. The results arepromising: The supply of basic drugsin health centres is more consistent,and management committees, com-posed of village residents, help ensurethat people pay reasonable fees forbasic services and that the funds gen-erated are well used.

Nevertheless, the fact remains thatmany people do not have access tohealth care and may be further de-terred from seeking timely and appro-priate care by user fees for health careservices.

The additional challenge of creat-ing a climate where preventive healthand nutritional care components arealso integrated into the Bamako modelis harder to realize. Because they areless tangible to communities, preven-tive health and nutrition services arealso often less in demand than cura-tive care. Prevention, nonetheless, isvital and cost-effective.

In terms of environmental health,the lack of ready access to a safewater supply and proper sanitationand the unhygienic handling of foodas well as the unhygienic conditionsin and around homes, which causemost childhood diarrhoea, have sig-nificant implications for the spread ofinfectious diseases.

Moreover, when food is handledunder unhygienic conditions and theenvironment is unhealthful, litteredwith animal and human wastes, youngchildren are also more prone to infec-tion by intestinal parasites, another

cause of poor growth and malnutrition(Panels 5 and 20).

Also, women and children are usu-ally responsible for fetching the waterneeded for domestic use, a task thatdrains considerable time and energy.Depending on how much the distanceto the water source is shortened, it hasbeen estimated that women couldconserve large reserves of energy, asmany as 300 to 600 calories a day.25

Progress has been made in improv-ing access to safe water. But morethan 1.1 billion people lack this funda-mental requirement of good nutrition.26

As for sanitary waste disposal, theworld is actually losing ground, withthe rate of coverage falling in bothurban and rural areas. Only 18 per centof rural dwellers had access to adequatesanitation services at the end of 1994,27

and overall some 2.9 billion peoplelack access to adequate sanitation.28

❑ Caring practicesExperience has taught that even whenthere is adequate food in the houseand a family lives in a safe and health-ful environment and has access tohealth services, children can still be-come malnourished.

Inadequate care for children andwomen, the third element of malnutri-tion’s underlying causes, has onlyrecently been recognized and under-stood in all its harmful ramifications.

Care is manifested in the ways achild is fed, nurtured, taught andguided. It is the expression by individ-uals and families of the domestic andcultural values that guide them.

Nutritionally, care encompasses allmeasures and behaviours that trans-late available food and health re-sources into good child growth anddevelopment. This complex of caringbehaviours is often mistakenly as-sumed to be the exclusive domain ofmothers. It is, in fact, the responsibil-ity and domain of the entire family

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Experience has taught thateven when there is adequatefood in the house and afamily lives in a safe andhealthful environment andhas access to health services,children can still becomemalnourished.

and the community, and both mothersand children require the care of theirfamilies and communities.

In communities where mothers aresupported and cared for, they are, inturn, better able to care for youngchildren.

Among the range of caring behav-iours that affects child nutrition andhealth, the following are most critical:

t Feeding: As we have seen, exclu-sive breastfeeding for about sixmonths, and then continued breast-feeding with the addition of safe,high-quality complementary foodsinto the second year of life, providesthe best nourishment and protectschildren from infection.

The introduction of complemen-tary foods is a critical stage. A childwill be put at increased risk of mal-nutrition and illness if these foodsare introduced much before the ageof six months, or if the preparationand storage of food in the home isnot hygienic.

On the other hand, a child musthave complementary foods at the six-month point, since breastmilk nolonger meets all nutritional needs.Delaying the switch-over much be-yond six months of age can cause achild’s growth to falter.

From about 6 months to 18 monthsof age, the period of complementaryfeeding, a child needs frequent feed-ing — at least four times daily, de-pending on the number of times achild is breastfed and other factors —and requires meals that are both densein energy and nutrients and easy todigest.

The foods a family normally eatswill have to be adapted to the needs ofsmall children, and time must bemade available for preparing themeals and feeding children.

Good caring practices need to begrounded in good information and

knowledge and free of cultural biasesand misperceptions. In many cultures,for instance, food and liquids arewithheld during episodes of diar-rhoea in the mistaken belief that doingso will end the diarrhoea. The practiceis dangerous because it denies thechild the nutrients and water vital forrecovery.

Other behaviours that affect nutri-tion include whether children are fedfirst or last among family members,and whether boys are fed preferen-tially over girls. In a number of cul-tures and countries, men, adult guestsand male children eat before womenand girls.

The level of knowledge about hy-giene and disease transmission is an-other important element of care. Itinvolves food preparation and storage,and whether both those who preparethe food and those who eat it washtheir hands properly before handling it.

Ideas concerning appropriate childbehaviour are also important. If, forinstance, it is considered disrespectfulfor a child to ask for food, feedingproblems can occur.

t Protecting children’s health: Sim-ilarly rooted in good knowledge andinformation is the caring act of seeingthat children receive essential healthcare at the right time. Early treatmentcan prevent a disease from becomingsevere.

Immunizations, for example, haveto be carried out according to a spe-cific schedule. Sound health informa-tion needs to be available to commu-nities, and families and those caringfor children need to be supported inseeking appropriate and timely healthcare.

Therapeutic treatment for a se-verely malnourished child in thehospital is far more expensive thanpreventive care. According to a 1990US Department of Agriculture study,

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The introduction ofcomplementary foods is acritical stage. A child willbe put at increased risk ofmalnutrition and illness ifthese foods are introducedmuch before the age of sixmonths, or if the preparationand storage of food in thehome is not hygienic.

nutrition investments for pregnantwomen were very cost-effective:Every $1 spent on prenatal nutritioncare yielded an average savings ofabout $3 in reduced medical costs forthe children during the first twomonths after birth.29

A study in Ghana has also foundsavings in health care costs: Childrenreceiving vitamin A supplementsmade fewer clinic visits and had lowerhospital admission rates than childrennot receiving the supplement.

t Support and cognitive stimulationfor children: For optimal develop-ment, children require emotional sup-port and cognitive stimulation, andparents and other caregivers have acrucial role in recognizing and re-sponding to the actions and needs ofinfants.

The link between caring stimula-tion and malnourished children is alsoimportant: Several studies have foundthat malnourished children who weregiven verbal and cognitive stimulationhad higher growth rates than thosewho were not.30

Breastfeeding affords the bestearly occasion to provide support andstimulation. It enables mothers andtheir infants to develop a close emo-tional bond that benefits both. Allchildren need — and delight in — thekind of play and stimulation that is es-sential for their cognitive, motor andsocial development.

Verbal stimulation by caregivers isparticularly important for a child’slinguistic development. Ill or mal-nourished children who are in painand have lost their appetite need spe-cial attention to encourage them tofeed and take a renewed interest intheir surroundings during recovery.

In addition to improved nutrientintake, optimal cognitive developmentalso requires stimulation of, and regu-lar interaction with, young children.

The quality of these actions can be en-hanced through education of parentsand other caregivers. Child-to-childprogrammes, for example, can pro-vide simple resources to older chil-dren to improve the care, develop-ment and nutritional well-being oftheir younger siblings.

Policy makers need to recognizethe significance of such measures andactions and take them into accountwhen devising policy and programmes.

But the timing must be carefullyplanned: Many early child develop-ment activities concentrate on chil-dren who are age three and olderwhen the focus should be on childrenup to the age of three and should linkcare, good feeding and psychosocialactivities.

t Care and support for mothers: Aslong as the unequal division of labourand resources in families and commu-nities continues to favour men, and aslong as girls and women face discrim-ination in education and employment,the caring practices vital to the nutri-tional well-being of children will suffer.

Women, on average, put nearlytwice the hours of men into familyand household maintenance. InBangladesh, India and Nepal, for ex-ample, girls and women spend threeto five hours more a week than boysand men in tasks such as carrying fueland growing and processing food.31

They then spend an additional 20to 30 hours a week performing otherunpaid household work. If the bur-dens they carry are not better andmore equitably distributed, both theyand their caring role will suffer.

The elements of care most critical forwomen during pregnancy and lactationinclude extra quantities of good-qualityfood, release from onerous labour, ad-equate time for rest, and skilled andsensitive pre- and post-natal healthcare from trained practitioners.

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Exclusive breastfeeding for the first six monthsof a child’s life not only provides the bestnourishment and protection from infection,but also enables mothers and their infants todevelop close emotional bonds. A womanbreastfeeds her three-month-old baby inthe Federal Republic of Yugoslavia.

Panel 6

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Breastfeeding confers enormousbenefits, preventing malnutri-tion and illness, saving lives

and money. It is also, however, oneway an HIV-positive mother couldtransmit the virus to her infant. Achild stands the greatest risk —believed to be 20 per cent — of verti-cal or mother-to-child transmissionduring the time of late pregnancyand childbirth. There is an additional14 per cent risk that an infant will be-come infected through breastmilk.

This risk of infection throughbreastfeeding needs to be weighedagainst the great dangers posed byartificial feeding: In communitieswhere sanitation is inadequate andfamilies are poor, death from diar-rhoea is 14 times higher in artificiallyfed infants than in those who arebreastfed. If HIV-positive women andthose who fear HIV (without actuallybeing infected) were to abandonbreastfeeding in large numbers, with-out safe and reliable alternatives forfeeding their children, the ensuinginfant deaths from diarrhoea and res-piratory infections could vastly out-number those from HIV.

The dilemma facing an HIV-positivewoman who does not have easy ac-cess to safe water, who does nothave enough fuel to sterilize feedingbottles and prepare alternatives tobreastmilk, or who cannot afford tobuy sufficient formula to ensure herchild’s nutrition is a wrenching onethat no mother can solve on her own.Support for women facing this dilem-ma is imperative, as the Joint UnitedNations Programme on HIV/AIDS(UNAIDS) made clear in 1996. Thefollowing measures are importantstarting points:

• Pregnant women should have ac-cess to voluntary and confidential

counselling and testing to deter-mine their health status. If theyare HIV positive, they should re-ceive appropriate treatment toreduce the risk of vertical trans-mission. If they are HIV negative,health education is vital to helpthem and their partners remainthat way.

• HIV-positive mothers should beinformed of the risks of both verti-cal transmission through breast-feeding and infections associatedwith artificial feeding in their localenvironment. Each woman shouldbe assisted by HIV counsellors orhealth professionals to under-stand these risks and then makeher own decision.

• If an HIV-positive mother has ac-cess to adequate breastmilk sub-stitutes that she can preparesafely, then she should considerartificial feeding. Other alterna-tives include wet-nursing by anHIV-negative woman, which maybe acceptable in some cultures.Heat treatment of expressed breast-milk (62.5°C for 30 minutes) de-stroys the virus, which may be agood choice for some women.

• When mothers who test positivefor HIV choose not to breastfeedbut are unable to or cannot affordfeeding alternatives, help will beneeded from a range of parties, in-cluding governmental and partneragencies. Attention must be paidto the needs of the most disad-vantaged women, which includeimproved water and sanitationand attentive family health care.

These measures should be part ofan integrated strategy to reduce ver-

tical transmission since breastfeed-ing is only a small part of the prob-lem. Access to voluntary, confidentialtesting and counselling is key to anystrategy to reduce vertical transmis-sion. Access to a range of prenataland obstetric care measures associ-ated with reduced transmission riskis also essential.

Studies now in progress will soongive a better understanding of themechanisms, timing and risks of ver-tical transmission. It may be possiblein a few years to offer all women low-cost, easily delivered services thatwill minimize or even eliminate therisk of vertical transmission. For now,access to the testing, counselling, in-formation and other services notedabove should be high priorities.

Breastmilk and transmission of HIV

The AIDS pandemic has intro-duced new and volatile considerationsand aspects of care into already sensi-tive areas of human behaviour and in-teraction. High priority should begiven to improving access to servicesthat help minimize the risk of HIVtransmission to women before, duringand after pregnancy, as well as to theirpartners (Panel 6).

Cultural norms and misconcep-tions affect the care women receiveduring pregnancy. In some culturallyconservative communities in parts ofAsia, for example, fish, meat, eggsand fat are not part of the diets ofpregnant women because it is fearedthey will make a baby too large anddifficult to deliver. Research shows,however, that better maternal diet canimprove the birthweight of children inmany cases without causing signifi-cantly increased head circumferenceof the newborn, which is the factormost likely to put small women at risk(Panel 7).

The adjustment of workload is an-other aspect of the care accordedwomen during pregnancy — and onewith powerful ramifications.

A survey in one village in theGambia, for example, found that evenduring periods of relatively low sea-sonal agricultural activity, womengained on average just 5.5 kilogramsduring pregnancy — only about halfof the recommended weight gain thatwomen need to sustain their develop-ing foetus.32

Reductions in a woman’s workloadduring pregnancy, combined with morefood of good quality, improve the nu-tritional status of a woman and herunborn child and reduce the risk thatthe child will have a low birthweight.

In Viet Nam, when men assumedsome of their pregnant wives’ respon-sibilities during the third trimester ofpregnancy, women rested more, and

their infants weighed more at birth.In Indonesia, infants born to womenwho received a food supplement did notweigh more at birth, but they developedbetter during the first year of life.

The fact that women are usuallythe primary caregivers does notmean that men, families and commu-nities are exempt from care-givingresponsibilities.

The often oppressive and demand-ing patriarchal environment in whichmillions of women live must give wayto an equal partnership in whichwomen enjoy autonomy and the senseof accomplishment that comes frombuilding skills and capacities.

At the same time, girls need to befree from pressures to marry early. Astudy in West Africa, for example,found that nearly 20 per cent of girlsin rural areas of the Gambia andSenegal and 45 per cent of girls inNiger marry before the age of 15.

Figures such as these underscorethe great need for girls and women tobe involved in major personal deci-sions, including not only their marry-ing age but also how closely the birthsof their children will be spaced.

Adolescent pregnancy is a majorrisk factor for both mother and infant,as the girl may not have finishedgrowing before her first pregnancy,making childbirth dangerous.

The infant of a very young mothermay have a low birthweight (Fig. 7).Higher risks of toxaemia, haemor-rhage, anaemia, infection, obstructedlabour and perinatal mortality areall associated with childbearing inadolescence.

A number of measures are essen-tial, therefore, to enable women andgirls to develop their skills and abilities.These include ensuring their access tofamily and community resources,such as credit, and to education andinformation.

31

The often oppressive anddemanding patriarchalenvironment in whichmillions of women livemust give way to anequal partnership.

Panel 7

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In the Gambia, well-targeted inter-ventions to improve the nutrition ofpregnant women are making a dif-

ference in the birthweight of their ba-bies, and at the same time sharplyreducing the risk of babies dying dur-ing, or shortly after, birth.

A large, controlled study in thecountry’s rural West Kiang region hasdetermined that the number of low-birthweight babies fell by nearly 40per cent and that stillbirth and peri-natal mortality rates in infants werealmost 50 per cent lower when preg-nant women received a daily rationof locally prepared, energy-rich bis-cuits. These remarkable resultsstrengthen the argument for provid-ing food supplements to pregnantwomen to reduce low birthweight.

“The study clearly demonstratesthat improved maternal nutrition, de-liverable through a primary healthcare system, can have highly benefi-cial effects when efficiently targeted

at women in genuine need,” saysone of the study’s authors, Dr. SanaCeesay, of the Dunn Nutrition Centreaffiliated with the University of Cam-bridge, which has been working inpartnership with the Gambian HealthDepartment. The findings were pub-lished in the British Medical Journalin September 1997.

UNICEF estimates that each yearover 24 million babies are bornbelow the low-birthweight thresholdof 2.5 kg, and that 95 per cent ofthese births occur in the developingworld. Low birthweight puts infantsat a greatly increased risk of neonataldeath and is an important cause ofpoor growth and development inlater childhood. It can be due to anumber of factors, including awoman’s small size, uterine infec-tions, smoking, low oxygen levels inthe blood (due to excessive work orhigh altitude) and malarial infection.However, when all these factors are

equal, the incidence of low birth-weight is higher in economically de-prived mothers than in affluent ones.

The most likely explanation forthe difference is that inadequatematernal nutrition suppresses foetalgrowth. It has often been difficult,nevertheless, to show real benefits toinfants from improvements to amother’s diet during pregnancy. Thestudy in the Gambia provides suchevidence.

In this part of West Africa, previ-ous studies had indicated that preg-nant women — challenged as manywomen are by the high energy de-mands of water and fuel collection,agricultural work and child-care ac-tivities but also by the energy andother nutrient needs of pregnancy —did not eat enough or well enough tomeet all these needs. The growth oftheir babies was thus threatened.

The five-year, prenatal supple-mentation trial covered 28 villages inone region of the Gambia. In the in-tervention villages, pregnant moth-ers received daily high-energygroundnut-based biscuits, providing1,000 kcal/day on average after 20weeks of pregnancy. The biscuitswere made from local ingredientsand were baked by two village bak-ers in traditional clay ovens. Womenin control villages received anti-malarials, iron/folate supplementsand antenatal care as did women inthe intervention villages, but they didnot receive the biscuits during preg-nancy. Field workers weighed all thewomen in the study at regular inter-vals, and weighed and measured allinfants at delivery.

The biscuit supplement caused ahighly significant increase in birth-weight, reducing the numbers of in-fants classified as low birthweight by39 per cent. Particularly noteworthy

High-energy biscuits for mothers boostinfant survival by 50 per cent

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Basic causesIt is often said that poverty at the fam-ily level is the principal cause of childmalnutrition. While it is true that alack of resources and malnutritionoften go hand in hand, this statementtells only part of the story.

Many poor families do in fact re-ceive adequate nutrition, and malnutri-tion is found in many better-off families.

The broader explanation lies with-in a fuller understanding of the differ-ent types of resources necessary forgood nutrition, and of the factors thataffect families’ ability to access andcontrol these resources.

The three components of nutri-tion — food, health and care — inter-act closely in their influence onfamily life. Often efforts to fulfil oneprecondition for good nutrition com-pete for the same resources requiredto fulfil another condition.

For example, if a woman has tospend excessive time in producingfood to achieve household food secu-rity, her ability to provide adequatechild care can be compromised. The re-sult may be malnutrition in her youngchild.

Political, legal and cultural factors atthe national and regional levels maydefeat the best efforts of householdsto attain good nutrition for all members.

These include the degree to whichthe rights of women and girls areprotected by law and custom; the po-litical and economic system thatdetermines how income and assets aredistributed; and the ideologies and poli-cies that govern the social sectors.

For example, where it is known andappreciated by everyone in society —men and boys, women and girls,teachers and religious leaders, doctorsand nurses — that women in the latestages of pregnancy need rest and pro-tection from overwork, families aremore apt to receive the social supportthey need to ensure this protection.

Photo: A healthy newborn sleepspeacefully in the Gambia.

was the reduction in low birth-weight occurring in births duringthe annual ‘hungry season’, whenbirthweights normally are lowerthan in the harvest season, as aresult of poor maternal nutritioncombined with hard seasonalagricultural work. (It is unlikelythat food supplements wouldhave the same impact on preg-nant women who are not chroni-cally energy-deficient.)

In addition to these remarkablebenefits, this study refutes theidea prevailing in some circlesthat improving the diet of preg-nant women will cause them tosuffer higher rates of obstetricalcomplications because of thelarger size of their newborns.Birthweight was indeed higher inthe children of women who re-ceived the biscuits, but head cir-cumference, which is the factormore closely related to pelvic dis-proportion in birth, was onlyslightly greater. The rate of obstet-ric complications of this kind wasnot higher in the supplementedwomen.

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How women are valued and treated in society,including their level of education, affects theirability to feed and care for their children.A first-grader in Colombia takes lunchbefore class begins.

In places where there is a traditionof non-discrimination against womenin law and custom, women are morelikely to have good access to re-

sources, including credit, and to thedecision-making power that can en-able them to make the best use of ser-vices for themselves and their children.

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Source: ACC/SCN, Second Report on the World Nutrition Situation: Vol. I: Global and Regional Results, ACC/SCN, Geneva, 1992.

Fig. 7 Intergenerational cycle of growth failure

The cycle of poor nutrition perpetuates itself across generations. Young girls who grow poorly become stunted women and are more likely to give birth to low-birthweight infants. If those infants are girls, they are likely to continue the cycle by being stunted in adulthood, and so on, if something isn't done to break the cycle. Adolescent pregnancy heightens the risk of low birthweight and the difficulty of breaking the cycle. Support is needed for good nutrition at all these stages — infancy, childhood, adolescence and adulthood — especially for girls and women.

Child growth failure

Low weight and height in teenagers

Small adult woman

Low-birthweight baby

Early pregnancy

There is no doubt that whileeconomic poverty is not theonly kind of poverty that

eventually affects nutrition, it is stillan important factor.

Overcoming entrenched povertyand underdevelopment requires re-sources and inputs that few develop-ing countries, particularly the poorest,can muster, either on their own, throughexisting levels of private external in-vestment and loans, or through cur-

rent patterns of official assistance andloans.

In 1996, for example, aggregate re-source flows to the developing worldfrom all sources totalled $232 billion,$59 billion of which was official de-velopment loans and grants and therest, $156 billion, was private. Middle-income countries were the biggest re-cipients of the private investments andloans: Two thirds went to them andone third to low-income countries.

* * * *

The two regions of the world with thehighest rates of childhood malnutri-tion — sub-Saharan Africa and SouthAsia — received only $1.6 billion and$5.2 billion respectively.

And although bright spots exist interms of investment and trade in sub-Saharan Africa, the problems of thecontinent’s economies remain stark,including relatively low levels of in-ternal demand and the import quotasindustrialized countries impose onAfrican manufactured goods.

At the same time, developingcountries overall owed more than$2 trillion in external debt in 1995.Sub-Saharan Africa, for example,paid $13.6 billion in debt servicing in1995 — nearly double what it spenton health services. And developingcountries bear by far the greatest pro-portion of the global burden of dis-ease, which drains their human andeconomic resources.

One potentially optimistic note inthis dismal picture of declining aidflows and increasing debt is the new‘Heavily Indebted Poor Countries(HIPC) Debt Initiative’ launched bythe World Bank and the InternationalMonetary Fund in 1996. This initia-tive is designed to assist poor coun-

tries to achieve sustainable levels ofdebt based on an established trackrecord of implementing social andeconomic reform and on the conditionadditional resources are channelled tobasic social services. Bolivia, BurkinaFaso and Uganda will benefit fromthe initiative only in April 1998 orlater. More generous and timelydebt-relief would enable these coun-ties and others that will hopefullysoon qualify to release resources toreduce malnutrition.

If the basic causes of malnutritionare to be addressed, greater and bettertargeted resources and improved col-laboration, participation and dialogueare needed. Awareness and informa-tion must be generated: between sec-tions of national governments; betweengovernments; with all developmentpartners, donors, UN agencies, non-governmental organizations (NGOs)and investors; and above all with thosewhose circumstances are rarely under-stood or noticed, the poor themselves.

Action against malnutrition is bothimperative and possible. The world,as the next part of this report explains,has already accumulated a wealth ofexperience and insights on whichprogress can be built.

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Increased awareness and education about thecauses of malnutrition are essential if theproblem is to be successfully addressed.A health card in her hand, a woman holdsher baby at a UNICEF-assisted healthcentre in Syria.