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Bringing science to bear

The successes stemming from breakthroughs in science and technology have stirred new hope for healthier, more productive lives for both children and adults. Following are some of these advances that are helping to reduce malnutrition — or that may do so.

Nutritionally acquired immune deficiency

The immune systems of some 23 million people worldwide have been damaged by HIV, the virus that causes AIDS. It is less well known that malnutrition impairs the immune systems of at least 100 million young children and several million pregnant women — none of them infected by HIV. But unlike AIDS, the cure' for immune deficiency due to malnutrition has been known for centuries: It is achieved by ensuring an adequate dietary intake containing all essential nutrients. Today, more is being learned about the specific role of individual nutrients in the functioning of the immune system.

The results of a dozen field studies, conducted in Brazil, Ghana, India, Indonesia, Nepal and elsewhere, indicate that supplementing the diets of children who are at risk of vitamin A deficiency can reduce deaths from diarrhoea by 35-50 per cent, and the vitamin can almost halve the number of deaths due to measles.

Zinc is essential for the growth and development of cells and for the functioning of the immune system. Trials have already shown reductions of about one third in the duration and severity of diarrhoea in children receiving zinc supplements — and a median 12 per cent decline in the incidence of pneumonia. In these investigations, zinc supplements did the most good for the children who started out the most malnourished. And new research indicates that even the effects of malaria, a deadly enemy of both children and adults, may be lessened by zinc and vitamin A.

Nutrition and AIDS

The role of nutrition in preventing infection is now being investigated as one possible way to help reduce the transmission of AIDS. Vitamin A may form part of the arsenal needed to combat HIV, which is expected to infect between 4 million and 5 million children by early in the next century.

A 1994 study of HIV-infected women in Malawi found that 32 per cent of those who were vitamin A deficient during pregnancy had passed HIV on to their infants. In contrast, only 7 per cent of HIV-infected women with sufficient levels of vitamin A did so. A 1995 study from Kenya reported that the concentration of HIV in breastmilk is higher in vitamin A-deficient mothers than in those with good vitamin A status. Based on the findings of the first studies — and to demonstrate whether the connection between vitamin A and HIV transmission is causal — four clinical trials were begun recently to examine HIV transmission rates in women who have received vitamin A supplements during the second or third trimester of pregnancy.

Using nutrition to reduce maternal deaths

Maternal mortality is a tragedy in social, economic and public health terms, since the vast majority of the 585,000 yearly maternal deaths around the world are preventable. Obstructed labour is more likely to occur among women who were stunted in childhood. It is estimated that anaemia may be responsible for 20 per cent of maternal mortality. Programmes already exist to reduce anaemia in pregnant women, but more work is needed to make iron/folate supplementation programmes more effective and to improve the treatment and prevention of malaria and hookworm, which contribute to maternal anaemia.

Other connections between nutrition and maternal mortality suggested below are not yet definitively demonstrated but hold great promise for the future.

• New findings have shown that improving the vitamin A status of pregnant women whose intake of the vitamin is low dramatically reduces maternal mortality.

• Zinc deficiency, increasingly recognized as widespread among women in developing countries, is associated with long labour, which increases the risk of death. Severe zinc deficiency is also believed to impair foetal development in several ways. A number of studies have found that zinc supplementation reduces the complications of pregnancy.

• It has long been known that iodine deficiency in women increases the risk of stillbirths and miscarriages. And there is some evidence that in highly iodine-deficient areas, another result of this deficiency may be increased maternal mortality through severe hypothyroidism.

• One recent study showed that calcium supplementation did not reduce the risk of hypertension in pregnancy that could result in death, but a number of experts have suggested that supplementation might reduce this risk in areas where women are especially calcium deficient.

• Folate deficiency, now well known to induce neural-tube birth defects if it is present during the first month of pregnancy, may also represent a risk for maternal morbidity and mortality, as well as increase the risk of low birthweight.

Breastfeeding: Good for mothers' health, too

A number of studies have shown that initiating breastfeeding immediately after birth, as most women do in baby-friendly hospitals, stimulates the contraction of the uterus and reduces blood loss. Also, a recent study in the United States demonstrated that women who breastfed their children had a lower risk of breast cancer in the pre-menopausal period, and that the longer they breastfed, the lower the risk.

Prevention of chronic diseases

Chronic degenerative diseases, such as heart disease, are largely regarded as diseases of affluence. Arguments are being made, however, that these diseases may in large measure also be diseases of poverty — particularly poverty early in life and during foetal development. The hypothesis is particularly intriguing in light of the fact that ischaemic heart disease is projected to be the world's leading cause of death and disability in the year 2020.

Over 30 studies around the world, for example, have indicated that low-birthweight babies who were not born prematurely have a higher incidence of hypertension later in life than those with a normal birthweight. Low birthweight, as well as thinness at birth, has also been correlated with glucose intolerance in childhood and non-insulin dependent diabetes in later life.

In central India, an ambitious study involving over 800 women is exploring the impact that a mother's nutrition may have on the development of diabetes, high blood pressure and heart disease in her offspring when they reach adulthood. An interesting early finding suggests that birthweights are most strongly associated with the size of the mother — not only her weight gain during pregnancy but also her weight, height, percentage of body fat and head circumference before conception. These early findings lend support to the premise that building a sturdy baby depends on a life of good nutrition for the expectant mother.

New ways to reduce malnutrition deaths in emergencies

In the last few years, a new protocol is improving the treatment of severe malnutrition. This protocol recommends milk for the early stages of therapeutic feeding, enhanced by the addition of both oil and a vitamin and mineral mix, which addresses the special micronutrient imbalance that accompanies severe malnutrition. The new recommendations call for modification of the standard oral rehydration salts (ORS) to reduce the risk of heart failure in severely malnourished children. Known as ReSoMal (rehydration solution for malnutrition), it contains more potassium and different concentrations of elements from those in standard ORS.

The new protocol also emphasizes the need for rapid attention to clinical factors, such as low body temperature (hypothermia) and low body sugar (hypoglycaemia), as well as to less strictly medical factors such as meeting malnourished children's great needs for emotional support, intellectual stimulation and play.

New ways to measure malnutrition

Here are some of the promising new tools for assessment and analysis.

• A simplified way to look for vitamin A: A new technique that promises to be easier, cheaper and less invasive than blood retinol analysis is 'dark adaptometry'. This method takes advantage of the fact that in very early stages of vitamin A deficiency, the ability of the pupil of the eye to constrict under illumination is impaired. By flashing a simple hand-held light at one pupil and covering the other, the degree of impairment of the pupillary reflex can be estimated.

• 'Dipsticks' for iodine deficiency: Since iodine excreted in the urine is a good indicator of iodine consumed, iodine deficiency disorders can be reliably detected by analysing urine samples. A reagent-treated testing strip, or dipstick', may soon be available that allows iodine content of urine to be analysed and read directly on the spot without transporting samples to a laboratory, saving time and money.

• Improved test kits for iodized salt: Simple iodized salt test kits have helped make salt-testing a community affair, but the kits have a limited shelf life and do not distinguish very sensitively among levels of salt iodization. Work is now under way to improve the test kit in both these respects and make it an even more useful assessment tool.

• Computerizing anaemia surveys: Portable electronic haemoglobinometers now enable blood to be drawn easily from a finger into a small cuvette that is then inserted directly into a machine. In a few seconds there is a digital read-out of the precise haemoglobin level. These machines can help to raise awareness of the enormous magnitude of the anaemia problem.

New ways to enrich diets

Agricultural research is trying to develop staple food crops that contain higher quantities of essential micronutrients — or lower amounts of phytates, substances that impede the bio-availability' of some important minerals.

The Consultative Group on International Agricultural Research, made up of 17 internationally funded research centres, is coordinating a global effort to increase the micronutrient content of five major staple food crops: rice, wheat, maize, beans and cassava. In developed countries, such crops have already been produced: High-zinc wheat, for example, is being grown in Australia. It will probably take 6 to 10 years to breed comparable new plants in developing countries.

More effective action for nutrition improvement

The technical advances described in this report, whether new research on nutrition and illness or better ways to detect problems, are not magic bullets. They will contribute to sustainable improvement in nutrition only if they sharpen the ability of people, including poor people, to assess and analyse the causes of malnutrition around them — and to plan and carry out appropriate responses.

None of the preventive and supportive actions to promote child growth and development described in this report requires a doctor or nurse or a trained educator. Communities can be helped to organize themselves to provide or administer these services, and in most communities, groups that can take on these responsibilities already exist.

It has often been said that meeting this challenge is a matter of political will. In a $28 trillion global economy, the problem is surely not a lack of resources. But it may be more useful to see the challenge as a matter of political choice. Governments in poor and rich countries alike may choose to allow children to be intellectually disabled, physically stunted and vulnerable to illness in childhood and later life. This is the price of doing little or nothing to ensure good nutrition.

But governments could instead resolve to move to consolidate lessons already learned about reducing malnutrition. They could do everything possible to mount massive actions that can clearly succeed and that can be implemented by communities themselves. And they could encourage research on, and implementation of, new and better actions.

For the well-being and protection of children and the human development of the world, the course of action is clear.

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