This week, the World Food Programme (WFP) and their partners convened for the 2014 World Economic Forum in Davos, Switzerland, united in their common goal to improve the nutritional status of children everywhere.
It was announced that a new project to establish best practices for tackling stunting has been launched in Malawi. Recurrent food insecurity, poor dietary diversity and repeated illness are among the root causes of stunting (low growth for age) among nearly 1 million Malawian children under five.
This project targets children up to two years of age, and their mothers, over a three-and-a-half year period, and is designed to reduce stunting by 5-10 percent, as well as build evidence for the best ways of tackling the problem. Later in the year, the project will be introduced to Mozambique. By helping children to first survive, and then thrive and grow into adults, this programme should ultimately contribute to national development through greater productivity and higher lifetime earnings.
Funded by the Children’s Investment Fund Foundation (CIFF) at a cost of US$10 million, the stunting prevention project is supported by the Government of Malawi, WFP and other members of the Scaling Up Nutrition (SUN) initiative. World Vision (WV) has been selected by WFP as the lead NGO partner for project.
This ‘innovative’ project claims to be founded on the latest evidence about the most effective nutrition and hygiene interventions. ‘This project will deliver the right foods at the right time and aims to improve education about feeding practices as well as access to proper nutrition.’ A stunting-focused communications campaign has been initiated to increase awareness about the best infant and child feeding practices, hygiene, and the use of a lipid-based nutrient supplement, Nutributter, which will be provided to all registered children aged 6 to 23 months.
No one disputes the evidence showing the potential to make the greatest difference in the lives of children lies in the crucial 1,000 days between conception and two years of age, but WFP’s and WV’s record of delivering ‘the right food at the right time’ is highly questionable. When WFP Representative, Coco Ushiyama, states, “Through strong partnerships, multi-sector engagement, a strong evidence-based approach and IT solutions, we want to show the world that we can and must address stunting,” I too feel excited, but let us look at the evidence.
One of the main reasons that people are undernourished in the first place is the ubiquitous consumption of refined cereal and sugar. Monoculture and NPK farming has already ensured that our cereal crops contain only a fraction of the nutrients they used to contain. We then compound the felony by refining them. This process removes most of the important micronutrients. What is left is best described as ‘empty calories’.
It would make sense to stop refining cereals, but that is not on anyone’s agenda. Instead, we attempt to fortify these empty calories with chemicals, courtesy of the pharmaceutical industry. This is on everyone’s agenda, despite the plethora of evidence that phytic acid in cereal grains forms insoluble and non-absorbable complexes with these added chemicals, and the overwhelming evidence from South Africa that the fortification of maize and wheat flour over several years has achieved little, if anything.
Despite this, the distribution of corn soya blend (CSB) – a refined and fortified cereal blend – continues to be promoted by WFP and WV.
Another approach, for which there is little evidence of benefit, is the use of Sprinkles. The idea here is that one can sprinkle the micronutrients that are missing from the diet directly onto the food. The Soofi study in Pakistan was a large and authoritative RCT within the SUN 1000 Days initiative. It used Sprinkles to get micronutrients to the study group. Intervention was for an extended period. But the results were appalling. Haemoglobin improved in the treated groups but they all remained anaemic. The improved growth in the one group was paltry. Serum zinc and retinol showed little change. One wonders what happened with the Vitamin C, Vitamin D and Folic Acid because, although they were in the intervention, they never got another mention. Side effects were serious and militated against any benefit. These included diarrhoea, even though zinc is believed to be important in controlling infant diarrhoea. This is not an intervention that anyone would wish to recommend and it comes as no surprise to those who understand the importance of nutrient form. The Nepal UNHCR research also showed no benefit.
Despite this, the use of Sprinkles enjoys widespread support.
But the big gun in our armoury is apparently Plumpy’Nut. In the Malawi project, a specialised, ready-to-use product, Nutributter, will be provided to all registered children aged 6 to 23 months. For Nutributter, read Plumpy’Nut.
Plumpy’Nut is promoted and marketed across Africa as a major breakthrough in the fight against malnutrition. Manufactured by the French company, Nutriset, it was designed by Dr André Briend to be used for a maximum of two to three weeks in cases of severe acute malnutrition. This may well be appropriate, but it is not the reality on the ground, where Plumpy’Nut is hailed as a miracle food and as the solution to malnutrition, particularly in Africa. This is complete nonsense, but it goes unchallenged as a claim.
Plumpy’Nut is a combination of powdered milk (30%), sugar (28%), peanut butter (25%), cotton-seed oil (15%) and vitamins and minerals, as chemical isolates. It has the consistency of a paste. The dangers of high levels of refined sugar and fat for young children are now so well understood that the British Government recently banned all advertising to young children of such products. This ban would include Plumpy’Nut. Furthermore, high levels of protein in malnourished children can cause diarrhoea.
The only scientific evidence that I can find anywhere is that Plumpy’Nut increases body mass index (BMI) and mid upper arm circumference (MUAC). As I have stated, this may be useful to rescue someone who is dying, but increases in BMI or MUAC in the moderately malnourished tell us nothing about nutritional status, unless we believe that fatter kids are healthier kids. I have not seen any evidence that it makes children nutrient replete, or that it improves nutritional status. As far as the vitamins and minerals are concerned, Plumpy’Nut uses a micronutrient mix of chemical isolates that will have little impact addressing the nutritional needs of the malnourished.
The project protocol, entitled ‘Formative research to develop culturally-appropriate, supplementary feeding programs for children 6‐23 months in rural Mozambique and Malawi’, states, inter alia, that it will identify potential barriers and facilitating factors to appropriate complementary feeding, and that these findings will be used to develop culturally-appropriate message and communication strategies based on local food concepts and behaviour to successfully promote age‐appropriate, energy‐dense foods, including but not limited to Nutributter, which will yield appropriate and sustained usage among children 6‐23 months.
It frankly horrifies me that ‘developing culturally-appropriate, supplementary feeding programs for children’ is a euphemism for weaning them onto daily high fat, high sugar ‘treats’. In Davos 2013, Marc Van Ameringen, Executive Director of the Global Alliance for Improved Nutrition (GAIN), highlighted the links between under-nutrition and over-nutrition – or obesity – and how many emerging countries suffer from what is referred to as a double-burden of malnutrition.
So, wake up and get real. We should not be intervening in the diets of children unless we have solid evidence that our interventions improve their nutritional status. We need to measure the deficiencies and show that our interventions have corrected them. None of the interventions mentioned above are evidence-based, and none of them will produce nutrient-replete children. Nor will this so-called research add anything useful to our body of scientific knowledge, but then I suspect it was never meant to. The children will continue to suffer, and we will have failed them yet again.
Geoff Douglas, CEO HETN