Rebecca Stoltzfus Program in International Nutrition College of Agriculture and Life Sciences

1. Division of Nutritional Sciences Water and Food Safety are Essential to Nutrition Goals for Women and Children:A Health Sector Perspective Rebecca Stoltzfus Program in International Nutrition College of Agriculture and Life Sciences Cornell University

2. Outline • Child stunting as a priority in global health and development • Timing: the 1000 days • The importance of food safety and gut health to overcoming child malnutrition • Relevance to food security initiatives • Key Interventions

3. Together with micronutrient deficiencies, responsible for 1/3 of child deaths globally

4. Stunting: Invisible Malnutrition 105 cm 125 cm 100 cm • 30% increase in risk of death from infectious disease • 10% decrease in lifetime earnings • 7 month delay in starting school • 0.7 years loss of schooling • Increased risk of NCD’s in later life 7 years 7 years 4 years

6. What is causing all this stunting and wasting?

7. Cause #1: Poor Diet • Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries • Dewey & Adu-Afarwuah, 2008 • 42 studies/programs, most published 1996-2006 • Children who received interventions gained: • 0.0 – 0.76 Z scores weight-for-age • 0.0 – 0.64 Z scores length-for-age The best studies caused a 0.7 Z score improvement. BUT: the average growth deficit of African and Asian children is -2.0 Z At best, diet solved 1/3 of the problem.

8. Cause #2: Diarrhea • Between 6-18 months of age, children in developing countries have around 9 episodes of diarrhea. • Many authors reported that diarrhea accounts for 10-80% of growth faltering • But others contend that children grow at “catch-up rates” between episodes, and thus recover these deficits The Lancet Nutrition Series (2008) concluded that by implementing sanitation and hygiene interventions with 99% coverage, child malnutrition would be reduced by only 2.4%

9. Cause #3: EEEnvironmentalEnteropathy • A subclinical condition of the small intestine, called environmental enteropathy (EE) • Characterized by: • Flattening of the villi of the gut, reducing its surface area • Thickening of the surface through which nutrients must be absorbed • Increased permeability to large molecules and cells (microbes) • Likely causes: • Too many microbes in the gut—worms may also play a role • Effects of toxins on the gut Decreased nutrient absorption + Infiltration of microbes

10. The dual contributions of food safety to child malnutrition Liver Toxicity Liver Cancer Toxins (mycotoxins) Stunting & Wasting Enteropathy Microbes & Worms (fecal-oral) Diarrhea Illness & Death

11. The dual contributions of food safety to child malnutrition Liver Toxicity Liver Cancer Toxins (mycotoxins) #1 risk factor for all child deaths (malnutrition) #2 cause of all child deaths (diarrhea) Together: about 2 million child deaths / year Stunting & Wasting Enteropathy Microbes & Worms (fecal-oral) Diarrhea Illness & Death

12. The dual contributions of food safety to child malnutrition An unknown fraction of 700,000 adult deaths/year Liver Toxicity Liver Cancer Toxins (mycotoxins) #1 risk factor for all child deaths (malnutrition) #2 cause of all child deaths (diarrhea) Together: about 2 million child deaths / year Stunting & Wasting Enteropathy Microbes & Worms (fecal-oral) Diarrhea Illness & Death

13. Safe Food and Nutritious Foodare both essential to meet child nutrition goals • Nutritious food is essential to provide nutrients needed for growth and development • Food Aid targeting • Quality of food: nutrients • Quantity • Safe food is essential to prevent diarrhea and promote healthy gastro-intestinal function (prevent enteropathy) • Quality of food: free from toxins and microbes • Household technologies and behaviors • Prioritizing those behaviors in the feeding of young children Just a reminder: (Breastmilk is the fundamental safe and nutritious food)

14. Relevance to food security initiatives

16. Foods safe from Microbes and Toxins Household Hygiene behaviors

17. Food safety interventions,focusing on microbes and soil-transmitted helminths (worms)

18. Source: World Bank, accessed 6.23.11 http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTWAT/EXTTOPSANHYG/

19. Playing in the dirt makes kids smart Letitia Rowlands From: The Daily Telegraph November 24, 2010 12:00AM Good dirty fun ... Bronte Good and Sebastian Livisianos Pic: Nic Gibson. Source: The Daily Telegraph • Maybe in Australia . . . . • But not if the dirt contains pathogens and helminth eggs! • 100% of household soil samples in rural Zimbabwe contained E. Coli • Ngure et al., unpublished 2011 • 27% of infants 5-11 months old were infected with helminths in rural coastal Tanzania. • Goodman et al., Am J Trop Hyg 2007;76(4):725-31.

20. Feeding young children in rural Zimbabwe, 2010. M Mbuya

21. If allowed, toddlers consume poultry feces Peruvian shantytown families: • Households who owned free-range poultry: • Average ingestion of poultry feces by toddlers per 12-hour observation period was 3.9 times • Marquis GM et al., Am J Public Health 1990 Rural Zimbabwe: • Not selected for poultry ownership: • 3 of 7 toddlers directly ate chicken feces during a 6-hour observation period. • Ngure F et al., unpublished observations, 2011

23. Case Study:Pilot testing of a fortified instant porridge designed for complementary feeding of infants in Tanzania • Food insecure population • High prevalence of stunting • Feeding frequency of infants too low • Micronutrient deficiencies common “This food relieves my problems. In the past the baby was crying of hunger, and I did not have any food to feed her. But nowadays, if my baby is hungry, I prepare the food and feed her and she does not demand eating other foods after eating the new baby food.” “I like its preparation very much as you do not get in the kitchen to cook it; even her father can prepare it. Also its taste has impressed me; it is like groundnuts, beans, sour taste and maize.” Instant porridge designed by Instalife, Inc. Paul KH et al., J Nutr 2008; 138:1963-8

24. Microbial contamination of infant foods in coastal Tanzania Proportion of food samples with choliform counts exceeding acceptable limit Kung’u et al., J Health Pop Nutr 2009 27:41-52

25. Food safety and hygiene interventions: Microbial • Water treatment • At source • At household • Handwashing with soap after fecal contact and before preparing/serving food • Avoid feeding leftovers, or reheat • Separate young children from poultry and household soil • Safe disposal of feces—especially of children

26. Forthcoming randomized trialin rural Zimbabwe, highly food insecure • Outcome: stunting in infants from 0-18 months Control WASH: Integrated Water, Hygiene & Sanitation Infant Feeding: Education + Nutributter WASH + Infant Feeding Principal Investigator: J Humphrey Funders: Gates, DFID, NIH, UNICEF Grantees: Zvitambo, Johns Hopkins, Cornell