The State of the World's Children 1998: Focus on Nutrition
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The Silent Emergency

It is implicated in more than half of all child deaths worldwide -- a proportion unmatched by any infectious disease since the Black Death. Yet it is not an infectious disease.

Its ravages extend to the millions of survivors who are left crippled, chronically vulnerable to illness -- and intellectually disabled.

It imperils women, families and, ultimately, the viability of whole societies. It undermines the struggle of the United Nations for peace, equity and justice. It is an egregious violation of child rights that undermines virtually every aspect of UNICEF's work for the survival, protection and full development of the world's children.

Yet the worldwide crisis of malnutrition has stirred little public alarm, despite substantial and growing scientific evidence of the danger. More attention is lavished on the gyrations of world stock markets than on malnutrition's vast destructive potential -- or on the equally powerful benefits of sound nutrition, including mounting evidence that improved nutrition, such as an adequate intake of vitamin A and iodine, can bring profound benefits to entire populations.

Malnutrition is a silent emergency. But the crisis is real, and its persistence has profound and frightening implications for children, society and the future of humankind.

Malnutrition is not, as many think, a simple matter of whether a child can satisfy her appetite. A child who eats enough to satisfy immediate hunger can still be malnourished.

And malnutrition is not just a silent emergency -- it is largely an invisible one as well. Three quarters of the children who die worldwide of causes related to malnutrition are what nutritionists describe as mildly to moderately malnourished and betray no out ward signs of problems to a casual observer.

Malnutrition's global toll is also not mainly a consequence of famines, wars and other catastrophes, as is widely thought; in fact, such events are responsible for only a tiny part of the worldwide malnutrition crisis. But such emergencies, like the ongoing crises in the Great Lakes region of Central Africa and in the Democratic People's Republic of Korea, often result in the severest forms of malnutrition. Meeting food needs in these situations is essential, but so is protecting people from illness and ensuring that young children and other vulnerable groups receive good care.

Child malnutrition is not confined to the developing world. In some industrialized countries, widening income disparities, coupled with reductions in social protection, are having worrying effects on the nutritional well-being of children.

Whatever the misconceptions, the dimensions of the malnutrition crisis are clear. It is a crisis, first and foremost, about death and disability of children on a vast scale, about women who become maternal mortality statistics partly because of nutritional deficiencies and about social and economic costs that strangle development and snuff out hope.

Malnutrition has long been recognized as a consequence of poverty. It is increasingly clear that it is also a cause. In some parts of the world, notably Latin America and East Asia, there have been dramatic gains in reducing child malnutrition. But overall, the absolute number of malnourished children worldwide has grown.

Half of South Asia's children are malnourished. In Africa, one of every three children is underweight, and in several countries of the continent, the nutritional status of children is worsening.

Malnourished children are much more likely to die as a result of a common childhood disease than those who are adequately nourished. And research indicates a link between malnutrition in early life -- including the period of foetal growth -- and the development later in life of chronic conditions like coronary heart disease, diabetes and high blood pressure, giving the countries in which malnutrition is already a major problem new cause for concern.

The most critically vulnerable groups are developing foetuses, children up to the age of three and women before and during pregnancy and while they are breastfeeding. Among children, malnutrition is especially prone to strike those who lack nutritionally adequate diets, are not protected from frequent illness and do not receive adequate care.

Illness is frequently a consequence of malnutrition and malnutrition is also commonly the result of illness. Malaria, a major cause of child deaths in large parts of the world, also takes a major toll on child growth and development. In parts of Africa where malaria is common, about one third of child malnutrition is caused by malaria. The disease also has dangerous nutritional consequences for pregnant women. In addition, pregnant women are more susceptible to malaria, and children born to mothers with malaria run a greater chance of being born under weight and anaemic.

There is no one kind of malnutrition. It can take a variety of forms that often appear in combination and contribute to each other, such as protein-energy malnutrition, iodine deficiency disorders and deficiencies of iron and vitamin A, to name just a few.

Many involve deficiencies of 'micronutrients' -- substances like vitamin A and iodine that the human body cannot make itself but that are needed, often in only tiny amounts, to orchestrate a whole range of essential physiological functions.

Each type of malnutrition is the result of a complex interplay of factors involving such diverse elements as household access to food, child and ma ternal care, safe water and sanitation and access to basic health services.UNICEF/5510/Isaac

And each wreaks its own particular kind of havoc on the human body.

Iodine deficiency can damage intellectual capacity; anaemia is a factor in the pregnancy and childbirth complications that kill 585,000 women annually; folate deficiency in expectant mothers can cause birth defects in infants, such as spina bifida; and vitamin D deficiency can lead to poor bone formation, including rickets.

Photo: Reducing malnutrition should be an urgent global priority; inaction is a scandalous affront to the human right to survival. A malnourished child with his mother in Afghanistan.

Vitamin A deficiency, which affects about 100 million young children worldwide, was long known to cause blindness. But it has become increasingly clear that even mild vitamin A deficiency also impairs the immune system, reducing children's resistance to diarrhoea, which kills 2.2 million children a year, and measles, which kills nearly 1 million annually. And new findings strongly suggest that vitamin A deficiency is a cause of maternal mortality as well, especially among women in impoverished regions (Panel 1).

At its most basic level, malnutrition is a consequence of disease and inadequate dietary intake, which usually occur in a debilitating and often lethal combination. But many more elements -- social, political, economic, cultural -- are involved beyond the physiological.

Discrimination and violence against women are major causes of malnutrition.

Women are the principal providers of nourishment during the most crucial periods of children's development, but the caring practices vital to children's nutritional well-being invariably suffer when the division of labour and resources in families and communities favours men, and when women and girls face discrimination in education and employment.

A lack of access to good education and correct information is also a cause of malnutrition. Without information strategies and better and more accessible education programmes, the aware ness, skills and behaviours needed to combat malnutrition cannot be developed.

There is, in short, nothing simple about malnutrition -- except perhaps the fact of how vast a toll it is taking.

Of the nearly 12 million children under five who die each year in developing countries mainly from preventable causes, the deaths of over 6 million, or 55 per cent, are either directly or indirectly attributable to malnutrition (Figure 1).

Some 2.2 million children die from diarrhoeal dehydration as a result of persistent diarrhoea that is often aggravated by malnutrition.

And anaemia has been identified as a contributing factor, if not a principal cause, in 20 per cent to 23 per cent of all post-partum maternal deaths in Africa and Asia,1 an estimate many experts regard as conservative.

If there were no other consequences of malnutrition, these horrific statistics would be more than enough to make its reduction an urgent global priority -- and inaction a scandalous affront to the human right to survival.

But the issue goes beyond child survival and maternal mortality and morbidity. Malnourished children, unlike their well-nourished peers, not only have lifetime disabilities and weakened immune systems, but they also lack the capacity for learning that their well-nourished peers have.

In young children, malnutrition dulls motivation and curiosity and reduces play and exploratory activities. These effects, in turn, impair mental and cognitive development by reducing the amount of interaction children have both with their environment, and with those who provide care.

Malnutrition in an expectant mother, especially iodine deficiency, can produce varying degrees of mental retardation in her infant.

In infancy and early childhood, iron deficiency anaemia can delay psychomotor development and impair cognitive development, lowering IQ by about 9 points.

Anaemic pre-schoolers have been found to have difficulty in maintaining attention and discriminating between visual stimuli. Poor school achievement among primary school and adolescent children has also been linked to iron deficiency.2

Low-birthweight babies have IQs that average 5 points below those of healthy children. And children who were not breastfed have IQs that are 8 points lower than breastfed children.

The depletion of human intelligence on such a scale -- for reasons that are almost entirely preventable -- is a profligate, even criminal, waste.

Robbed of their mental as well as physical potential, malnourished children who live past childhood face diminished futures. They will become adults with lower physical and intellectual abilities, lower levels of productivity and higher levels of chronic illness and disability, often in societies with little economic capacity for even minimal therapeutic and rehabilitative measures.

At the family level, the increased costs and pressures that malnutrition-linked disability and illness place on those who care for them can be devastating to poor families -- especially to mothers, who receive little or no help from strained social services in developing countries.

And when the losses that occur in the microcosm of the family are repeated millions of times at the societal level, the drain on global development is staggering.

In 1990 alone, the worldwide loss of social productivity caused by four over lapping types of malnutrition -- nutritional stunting and wasting, iodine deficiency disorders and de ficiencies of iron and vitamin A -- amounted to almost 46 million years of productive, disability-free life, according to one reckoning.3

Vitamin and mineral deficiencies are estimated to cost some countries the equivalent of more than 5 per cent of their gross national product in lost lives, disability and productivity. By this calculation, Bangladesh and India forfeited a total of $18 billion in 1995.4

Malnourished children's low resistance to illness diminishes the effectiveness of the considerable resources that are spent to ensure that families have access to basic health services and sanitation. And investments in basic education by governments and their partners are compromised by malnutrition's pernicious effects on brain development and intellectual performance.

Iodine deficiency and iron deficiency anemia, which threaten millions of children, are especially worrisome factors as countries strive to improve their educational systems.

Iron-deficient children under the age of two years show problems with coordination and balance and appear more withdrawn and hesitant. Such factors can hinder a child's ability to interact with and learn from the environment and may lead to lower intellectual abilities.5

Severe iodine deficiency in utero can cause the profound mental retardation of cretinism. But milder deficiencies also take an intellectual toll. In the republic of Georgia, for instance, a widespread iodine deficiency, recently detected, is estimated to have robbed the country of 500,000 IQ points in the 50,000 babies born in 1996 alone.6

Many children suffer from multiple types of malnutrition, so numbers tend to overlap. But it is reliably estimated that globally 226 million children are stunted -- shorter than they should be for their age, and shorter than could be accounted for by any genetic variation (Panel 2). Stunting is particularly dangerous for women, as stunted women are more likely to experience obstructed labour and are thus at greater risk of dying while giving birth. Stunting is associated with a long-term reduction in dietary intake, most often closely related to repeated episodes of illness and poor-quality diets.

A study in Guatemala found that severely stunted men had an average of 1.8 fewer years of schooling than those who were non-stunted, while severely stunted women had, on average, one year less. The differences are important since every additional year of schooling translated into 6 per cent more in wages 7 (Panel 3).

Some 67 million children are estimated to be wasted, which means they are below the weight they should be for their height -- the result of reduced dietary intake, illness, or both.

About 183 million children weigh less than they should for their age. In one study, children who were severely underweight were found to be two to eight times more likely to die within the following year as children of normal weight for their age.9

More than 2 billion people -- principally women and children -- are iron deficient,10 and the World Health Organization (WHO) has estimated that 51 per cent of children under the age of four in developing countries are anaemic.11

In most regions of the developing world, malnutrition rates have been falling over the last two decades, but at markedly different paces (Figure 2). The exception is sub-Saharan Africa, where malnutrition rates began increasing in most countries during the early 1990s, following the regional economic decline that began in the late 1980s. As government budgets shrank, basic social services and health services were hit particularly hard. Per capita incomes also declined, affecting people's ability to purchase food.

In the United States, researchers estimate that over 13 million children -- more than one in every four under the age of 12 -- have a difficult time getting all the food they need, a problem that is often at its worst during the last week of the month when families' social benefits or wages run out.12 Over 20 per cent of children in the United States live in poverty, more than double the rate of most other industrialized countries.13

In the United Kingdom, children and adults in poor families face health risks linked to diet, according to a recent study that cited high rates of anaemia in children and adults, and of premature and low-weight births, dental diseases, diabetes, obesity and hypertension.14

In Central and Eastern Europe, economic dislocations accompanying the transition to market economies and major cutbacks in state-run social programmes are having a more profound effect on the most vulnerable.

In the Russian Federation, the prevalence of stunting among children under two years of age increased from 9 per cent in 1992 to 15 per cent in 1994.15 And in the Central Asian republics and Kazakstan, 60 per cent of pregnant women and young children are now anaemic.

The effects of malnutrition also cross generations. The infants of women who are themselves malnourished and underweight are likely to be small at birth.

Overall, 60 per cent of women of childbearing age in South Asia -- where half of all children are underweight -- are themselves underweight. In South-East Asia, the proportion of underweight women is 45 per cent; it is 20 per cent in sub-Saharan Africa.

Figure 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 and child mortality

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

Figure 2. Trends in child malnutrition, by region

The chart show trends in malnutrition in 41 countries, in 4 regions covering one half of children under five years old in the developing world. Countries with under five population below one million are not included, even where trend data were available.

Sub-Saharan Africa
Sub-Saharan Africa

Middle East and North Africa
Middle East and North Africa

Asia and Pacific
Asia and Pacific

Latin America and
the Caribbean
Latin America and the Caribbean

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.

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