11 September 2013

Africa: Hidden Hunger in the Spotlight

Can a scarcely reported health condition unite the global community against what many medical professionals say is the leading cause of death worldwide?

Next week an estimated 5,000 delegates from over 100 countries will meet in the Spanish city of Granada for the 20th International Congress of Nutrition, promoted every four years by the International Union of Nutrition Science. This year's theme, 'Joining Cultures Through Nutrition', aims to spotlight undernutrition as a cause of chronic disease and mortality in both rich and poor nations and present research designed to better understand and address it.

Among the participants will be Dr. Klaus Kraemer, director of Sight and Life - a nonprofit nutrition think tank launched by the Dutch company DSM. Kraemer is an author of the research article "The Global Hidden Hunger Indices and Maps: An Advocacy Tool for Action," published in June, which shows hot spots for micronutrient deficiencies that are the cause of hidden hunger, a problem that robs people of healthy development. Children who get inadequate nutrients in their first 1,000 days of life are permanently 'stunted' and never reach their full intellectual or physical potential.

The index, for the first time, maps the combined prevalence in preschool children of multiple micronutrient deficiencies: vitamin A, zinc and iron, as well as iodine. Scientists, academics and decision-makers from a range of global institutions - including UN agencies, U.S. government agencies, universities and international NGOs - helped develop the tool.

Kraemer spoke with AllAfrica about the index and what it means for helping to improve nutrition in Africa. Excerpts:

Tell me a little about Sight and Light in the context of global malnutrition.

Sight and Life is a humanitarian nutrition think tank dedicated to improve micronutrient deficiencies and malnutrition in developing countries. We have a significant partnership with the United Nations World Food Programme, and our work in this partnership is to improve the quality of the food that it is distributing and to learn lessons from programs where these products are being distributed. We have been partnering with the Scaling Up Nutrition movement and are an important stakeholder in bringing the nutrition agenda forward.

To what extent is the Hidden Hunger Index a useful tool for helping improve nutrition in Africa, and the rest of the developing world?

With the Hidden Hunger Index we want to raise awareness about the importance of micronutrients in development. We correlated this new index with the Human Development Index, and we showed that the quality of the diet is more important than the quantity. So dietary quality is required in order to develop human capital.

We tried to develop a new and useful tool in addition to other indices that exist. We had to rely on available data. Our data clearly shows that we need more indicators, more surveys, that will elaborate deficiency in different kinds of micronutrients and other deficiencies.

This is important because we need a baseline or benchmark in order to improve. More specifically, it is important to have an essential baseline on nutritional data for the post-2015 agenda [following the 15-year period of the UN Millennium Development Goals, a global campaign to end severe poverty].

I always use the term 'what gets measured gets done'. If you have an index or indicator that has been established and can be repeatedly measured, then you can monitor progress. If you don't have it you are starting somewhere where you don't know how well you really performed.

The index shows undernutrition 'hot spots'. So, in the places where there is better nutrition what is being done that is most effective?

Micronutrient deficiency can be most effectively diffused by dietary improvements. Ideally, everyone should have widened access to a nutritious diet. For a child, that would be exclusive breast feeding for the first six months and then quality complimentary food containing fruit, vegetables, meat and eggs and dairy products to give the child optimal conditions for growth. A quality diet should also be available for girls and mothers - before they become pregnant, during pregnancy and while breastfeeding. This is the ideal situation; it is not reality because many people are just too poor to buy a balanced diet or they don't have the knowledge.

In many countries we have successful programs with food fortification.

For example, in the United States, they have developed fortification with folic acids and other vitamins and iron. Now we have more and more countries that also fortify flour or oil with vitamin A and vitamin D; very critical nutrients like iron and zinc.

But when we talk about this kind of fortification, they are only reaching those who have access to industrially produced goods, and they are usually located in cities and urban areas. Those who are producing their own foods in villages need a different kind of approach.

This was just proven in the new Lancet series on maternal and child nutrition, showing that multiple micronutrient supplements are producing good outcomes. The series highlights 10 proven interventions and provides evidence that we can really reduce in the high-burden countries the number of children dying under the age of five by almost one million, and we can reduce stunting by more than 20 percent.

These direct nutrition interventions with proven evidence need to be supported by other interventions: giving cash to poor families so that they can buy more and better food, or improving agriculture and giving farmers better seeds that contain more nutrients, or guidance to what kind of crops should they grow that are more nutritious.

For example, sweet potatoes. In most African countries, sweet potatoes are either white or light yellow with little vitamin A. Now there are many activities that are trying to replace those with orange sweet potatoes, which provide a significant amount of the daily needs of vitamin A.

These approaches need to be taken to scale, and they need to fit into the local environment. If there is no water, then you can't grow sweet potatoes, so you have to find other approaches to deliver a quality diet.

It was a surprise to see that Kenya was number two on the Hidden Hunger Index, behind Niger, and before Benin.

I was also surprised about that. It's mainly linked to the quality of the provided data that is available. Not all of the surveys are from the same year. We need to revisit this index on a regular basis. Nutrition and health surveys are taken regularly and countries need to do more about these kinds of assessments. I cannot tell you off the top of my head when Kenya did the last survey. It may be many years ago.

I know that Kenya is doing a lot about improving nutrition. There has been national fortification that was mandated last year for flour and maize meal fortification, oil fortification, which will certainly make a significant impact over time. For children under the age of two years, particularly from six months to two years, the micronutrient powder is a very effective product to deliver the right kind of micronutrients that are often lacking in a diet based on cereals and pulses [legumes].

I was in Kenya at a Millennium Village in January. We support a project in this village with micronutrient powders. The women that are eligible, with children under the age of two, receive it free of charge. They were extremely delighted. Their kids were more active, more healthy and even naughty to the mothers when they received the powder!

This observation is not really based on solid science, but we have many, many surveys now that prove that anemia and iron deficiency can be reduced with micronutrient powders. The World Health Organization (WHO) published a guideline in 2011 recommending the use of micronutrient powders to reduce anemia and iron deficiency for this age group. Iron is particularly important to a child's development, for its brain and future cognitive performance.

But taking micronutrient interventions to scale really requires different approaches. It requires distribution to the poorest - or the poorest receiving vouchers so that they can get it from somewhere. It also requires that the product is in local markets, because you shouldn't try to bring a new product into a country without experiences by the population. They need to know it, and also if there is some kind of [food] emergency, then it's much more appropriate that these kinds of products are locally available and locally produced.

Is there anything else you'd like to add?

Once again, I would like to emphasize that we need data. We need data in order to move the global nutrition agenda, because what gets measured really gets done. I think that is a very important message that we now have to work toward for the post-2015 agenda. We need an excellent baseline where we really can monitor progress.

An approach with the Hidden Hunger Index could be very helpful. We have to revisit this index on a regular basis but this can only be every few years because surveys in the countries don't take place every year. And we need to include more indicators for nutrition and health so that we have much better basis to monitor progress.

Is there anyone in particular focusing on the data aspect?

There are a number of organizations working on data. One is the Centers for Disease Control and Prevention in the United States. They develop a number of monitoring and evaluation approaches. And I know that GAIN is also very interested in data monitoring. And of course WHO is collecting data.

But for other micronutrients like folic acid, vitamin B12, vitamin D, zinc and others we need better indicators. We can't just use anemia as an indicator, because with anemia we have prevalence of low hemoglobin levels, but low hemoglobin levels are not just affected by iron deficiencies. They are also affected by vitamin A deficiency, and also by infection, or inflammation where the body cannot utilize the iron that may be available to make the red blood cells.

So we need indicators that give us an idea whether there is inflammation. There is quite an interest now to refine that. The NIH in the United States has an initiative that is called Bond - biomarkers on nutrition for development - where they collect the most recent information on biomarkers. What we need now is to use it in an appropriate way. And we need to raise further funds so these measurements can be done.

How about places where there are high rates of malaria - how might that affect measurement?

Malaria is an important contributor to anemia. If malaria is treated, anemia is reduced. And we know there is a loss of iron with malaria infection, but there is also inflammation that blocks further building of red blood cells. You have to have a very comprehensive program, and you have to consider if there is a disease like malaria or if there are worms in the intestine or an HIV/Aids infection leading to anemia. You need to know the origins.

It's very important if you have anemia due to malaria that the malaria is treated and you don't just supplement iron to treat the anemia because it wouldn't be used by the body.

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