Patrick Webb, Dean for Academic Affairs Friedman School of Nutrition Tufts University Boston

1. United Nations System Standing Committee on Nutrition Patrick Webb, Dean for Academic AffairsFriedman School of NutritionTufts UniversityBoston Child Malnutrition – TRENDS, SUCCESSES AND CHALLENGES Des Moines, Iowa October 13, 2005

2. United Nations Standing Committee on Nutrition (UN SCN) • “The SCN vision is a world where hunger • and malnutrition are no longer impediments • to human development.” • The mandate of SCN is to mobilize commitment • to solve nutrition problems; to refine the direction, increase the scale and strengthen the coherence and impact of actions against malnutrition worldwide.

3. The Reality • In 2005, c. 11 million children will die before age of 5—one every five seconds. • Many will die in conflicts or natural disasters • Most will die because already undernourished • But most child deaths occur outside emergencies • The main cause of death varies, but >50% will die of factors linked directly to malnutrition. 

4. Under-nutrition is responsible for half of all Child Deaths Source: Black, Morris, Bryce (2003) Lancet; 361: 2226-34

5. Trends in preschooler under-nutrition • 1990 2005 2015 • (millions, <5) • Underweight 162 136 127 • Stunted 204 162 148 • Wasted* 45 50 56 • Sources: SCN 2004; UNICEF 2005*

6. Trends • Wasting increasing in all regions of Africa • Most malnourished (<5) still in Asia, but locus of problem shifting to Africa • Obesity in some countries coexists at same level as undernutrition, and continues to grow… • But, principal challenge remains unfinished.

7. Child undernutrition increasing in SSA and still high in South Asia Millions <5 stunted Source: Based on estimates from de Onis and Blossner 2003

10. Reaching children 0-2 years

11. Factors linking under-nutrition with obesity? • In Utero nutritional ‘insults’ -- links with chronic disease, diabetes and obesity • Breastfeeding-- “increasing body of evidence shows protective effect of breastfeeding against obesity” (Labbock 2005) • Stunting-- “childhood stunting may be a risk factor in development of obesity” (Popkin et al. 2003) • Micronutrient deficiencies-- high cholesterol foods linked with declining fruit/veg., obesity in Mexico and US (Hawkes 2005)

12. Maternal obesity and low BMI BMI <18.5 >30.0 (%) Egypt 1 32 Columbia 3 10 Zimbabwe 5 7 Armenia 5 7 Ethiopia 26 0.2 Bangladesh 45 0.7 Data >2000; SCN 2004)

13. Important gains in vitamin A and iodine; but… (Discounted present value). Micronutrient Initiative (2005) Micronutrient Initiative 2005

14. Successes (…yes there are many!) • 1. Protocols and Products: Saving lives in crises • 2. Technology and Targeting: Delivering the goods • 3. Knowledge and Know-How: Nutrition as a right (legislation in India, Brazil); Entitlements; Nutrition Education • 4. Synergies not Silos: UN/SCN; MDG Hunger Task Force; joint agency programming; WFPrize

16. Protocols and Products • in Emergency Relief Despite rise in number and scale of disasters, excess mortality in crises has been falling. Reported non-violent deaths in major emergencies fell by 40% 1993 and 2003 compared with previous decade. Humanitarian agencies are doing better at saving lives through more timely responses, improved mobilization of resources, and better management of both the symptoms and causes of malnutrition.

19. 2. Technology and Targeting

21. Mobile milling and fortification unit (Nangweshi refugee camp, Zambia)

22. 3. Knowledge and Know-how • Awareness that nutrition is everyone’s responsibility (Gambia example) • Knowledge about rights, entitlements • Nutrition education (breastfeeding; riding out shocks)

24. Nutrition knowledge. “[Poorest] households with nutrition knowledge… allocate 20% more of their food budget to micronutrient-rich foods than do households lacking nutrition knowledge.” Block (2004) Maternal Nutrition Knowledge and Demand for Micronutrient-Rich Foods, JDS. Based on work by HKI, UNICEF, Gov Indonesia

25. 4. Synergies not Silos: Optimum packages for nutrition “Although increased incomes are essential, it has been shown that countries implementing direct nutrition interventions have been more successful in reducing malnutrition. Approaches that should be supported include; promotion of breastfeeding, supplementary feeding, immunization, treatment of diarrhoea, supplements such as iron, folic acid, iodised salt, food supplementation and micronutrient-rich foods.” OECD/WHO. 2003. Poverty and Health. DAC Guidelines. Paris.

26. Synergies not Silos Micronutrient Initiative 2005

27. Institutional Synergies, not Silos • SCN is forum for identifying gaps in knowledge (science and practice), promote harmonized policies and approaches, share information, advocate. • Joint programming among agencies

28. Persistent Challenges • Reaching early pregnancy and 0-2 years • Exclusive Breastfeeding • Iron deficiency anemia • Preventing obesity • Interventions at scale • Resolving the worst cases—where capacity is weakest and funding negligible • Mutually reinforced actions needed

29. Prioritizing Assistance Nepal MDG1 Ranking (versus 84 other countries)

30. Progress to meeting MDG 1: Mauritania and Peru

31. Conclusions • Target the process, not just the problem: Mainstreaming in development, PRSPs • Challenge the ‘invisibility of malnutrition: ‘forgotten emergencies’, ‘hidden hunger’, • Address all aspects (lifecycle) of malnutrition: Wasting, stunting, micronutrients, obesity • Protect investments against shocks: Multiple inputs, links with all MDGs • Legislated empowerment (rights): Meeting demand requires funds for nutrition

32. http://www.unsystem.org/scn/ Thank-you

33. Synergies not Silos:Child Malnutrition and GNP Per Capita Percent of children under 5 underweight 40 1970's 1980's 30 1990's 20 10 0 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 GNP per capita (PPP) Alderman, H. (2004) World Bank

34. Returns on investments in food fortification In Kenya, Mexico and Indonesia: • fortification increased workforce productivity by 7 to 42 times the cost of the programs In The Philippines: • rise in productivity 6 to 21 times cost of program Micronutrient Initiative (2005)

35. Infant and Maternal Under-Nutrition is Leading Cause of Disease % Burden of Global Disease from Ezzati et. al. 2002

36. Trends in underweight <5s

37. North Korea: Repeat National Surveys • 1998 2002 2004 • Stunting 62% 42% 38% • Wasting 16% 9% 7% Source: UNICEF/WFP/DPRK (children 6-72m)

38. Progress to date in reaching MDG1 targets On track Reversing Mauritania Tunisia Chile Azerbaijan Malaysia Kenya China Thailand Brazil Madagascar Lesotho Zambia El Salvador Uzbekistan Laos Bolivia Niger Mongolia

39. MDG1 Goal: Eradicate Extreme Poverty and Hunger • MDG1 Targets: By 2015 (vz 1990) • Halve % people with income <US$1/day • Halve % people suffering from Hunger

40. “Reducing malnutrition is central to reducing poverty. As long as malnutrition persists, development goals for the coming decade will not be reached.” World Bank (2003) Combating Malnutrition: Time to Act

41. Bangladesh 2005

42. Thank-you

43. Aceh, January 2005

46. Severe Wasting (<-2 S.D. wfh) • India 3, 500,000 • Pakistan 706,000 • *Ethiopia140,000? • Cambodia 84,500 • *Niger76,500? • Mali 51,600 • Nepal 36,900 • Ghana 29,800 • Laos 26,000 UNICEF (2005; 2005b)

47. Wasting is a concern beyond emergencies • 10 years to 2005 saw every sub-region of Africa increase number of wasted under-5s. • Largest number of wasted children not in Africa: 78% of world’s 6 million wasted children live in India, Pakistan and Bangladesh. • Thus, wasting is not simple bi-product of conflict or famine—it reflects failure of long-term processes, not theirsudden and dramatic collapse.

48. What is a calorie? “The quantity of thermal energy required to raise one gram of water by 1°C (i.e. 15°C to 16°C ), at sea level.“ In other words….food is fuel.

49. Child malnutrition and death Manifestation Inadequate Dietary Intake Childhood Sickness, Growth Impairment Immediate Causes Household Food Insecurity Inadequate Child and Maternal Care Lack Health Care, Sanitation, Underlying Causes Social, Economic, Environmental Constraints Adapted from UNICEF