Category: Nutrition

A contribution from Jessica Fanzo of Bioversity International. Many thanks, Jess!

As of 2010, one billion people are hungry, and 129 and 195 million children under five years of age are underweight and stunted respectively, with 90% of these children living in just 36 countries. Vitamin A and zinc deficiency alone contribute to over half a million child deaths annually. How could things have gone so wrong? Why is hunger and poor nutrition increasing or at least stagnating in much of the developing world?

Much of this falls on the nutrition and development community themselves. Although the prevention and treatment interventions highly endorsed in the 2008 Lancet series on maternal and child undernutrition provided some consensus among the global nutrition community, not all are comfortable with the current interventions being put forth to scale, which are predominantly health- and clinic-based interventions. To add more complications, the “how” to implement interventions from country to country in the developing world remains elusive. But then the international nutrition community has always been contentious.

The latest debate is coming from Michael Latham’s recent paper in World Nutrition, which is rebuking an often regarded “life saving” and cost effective intervention of giving children ages 6 to 59 months of age two high doses of vitamin A. Pioneering work by colleagues such as Professors Alfred Sommer and Keith West demonstrated very effectively that vitamin A can save children’s lives and prevent vitamin A caused blindness. And it certainly does, particularly in places where vitamin A deficiency has wreaked havoc on the lives of children. And we know that there are pockets where vitamin A deficiency still does.

Latham reported that what was thought of as a stop gap or short-term approach in preventing vitamin A deficiency, became THE only recommended approach to treat such deficiencies. He contests the evidence that the supplements reduce child morbidity: they not only have little effect on mortality, but can have adverse effects on respiratory infections, he says. Latham argued that the International Vitamin A Consultative Group and UNICEF pushed for the “magic bullet” capsule approach, in collaboration with industry, with little regard for other approaches, including plant-based foods.

So the debate continues. What PREVENTATIVE approaches should be undertaken? Prevention and treatment-based interventions, such as vitamin A supplementation, form a necessary and important dimension of addressing immediate needs and undernutrition. But more durable reductions in hunger must be accompanied by strategies that enhance food and livelihood security, including food production-based approaches aimed to enhance food availability and diet quality through local production and agricultural biodiversity.

There are food-focused interventions that can be integrated into the agriculture investments (largely staple crop food production) that could improve diet diversity and quality of diets rich in vitamin A sources, directly impacting the nutritional status of children. Promotion and usage of diverse homegardens and intercropping of plant foods rich in carotene, such as leafy greens and fruits such as mango, papaya, bananas, and pumpkin, along with plant oils, can provide rich sources of vitamin A for family diets, especially for complementary foods for young children. Livestock and small animal rearing can provide rich sources of vitamin A even if consumed a few times during the week. Introduction of nutrient-rich foods such as orange-fleshed sweet potato have been shown to increase vitamin A intake and serum retinol concentrations in young children in east Africa.

However, there is more than one way to skin a mango. The food-focused interventions are as essential as the vitamin A supplements as stop gaps in areas with documented vitamin A deficiency. But we need to go further. Recent calls for greater attention to hunger and undernutrition highlight the importance of integrating technical, well-coordinated interventions with broader strategies that address underlying causes of food insecurity – incorporating perspectives from agriculture, health, water and sanitation, infrastructure, gender and education. We need to think beyond “interventions” and more about systems approaches – in particular, food systems. How can food be better grown to improve the quantity and quality of the diet and of livelihoods. Food systems involve not only the land itself, but also water, natural resources, the ecosystem as a whole, and of course food, but all tethered to together with gender equity, better education, and legal reform and land tenure. Long-term investments in ensuring food systems are protected, conserved, rebuilt or promoted will be critically important to making real progress in preventing vitamin A deficiency, undernutrition and hunger, and ultimately the big culprit of them all, poverty.

Reading The great Vitamin A fiasco, ((Michael Latham (2010). The great Vitamin A fiasco World Nutrition, 1 (1), 12-45)) by Professor Michael Latham of Cornell University, I had to force myself not to punch the air and shout “Yes!”. More than once. Mainly because he provides the backstory and the supporting evidence that makes sense of a deep-seated feeling I’ve long had, that food has been sidelined as a response to malnutrition.

No, I’m not exaggerating. Richer countries emphasize eating more and more diverse fruit and vegetables for better health. No matter that few people pay any attention. The advice is sound. Developing countries? Fuggedabout it. High-tech, simplistic solutions are the order of the day, often purveyed as medical cures for specific diseases. Latham’s critique is pretty devastating. He shows, first off, that massive doses of vitamin A — the overwhelmingly dominant solution to vitamin A deficiency — have had little impact on child mortality. Where deaths are falling, and they are, there is no evidence that this is caused by vitamin A supplements. Indeed, in some well-conducted studies vitamin A is associated with more deaths.

Latham points out the many ways in which the medical establishment has captured micronutrient malnutrition and how to deal with it, in the process blocking other approaches that often have multiple benefits. Not only are vitamin A interventions ineffective, he says:

They use up precious human and material resources. Most of all, they impede other approaches to the prevention of vitamin A deficiency, best initiated at national and local level, which need much more support. These include breastfeeding, and the protection and development of healthy, affordable and appropriate food systems and supplies. Such approaches also protect against other diseases, are sustainable, enhance well-being, and have social, cultural, economic and environmental benefits.

Food-based approaches were the primary recommendations adopted when micronutrient deficiencies began to be recognized and tackled in the early 1990s, but they were comprehensively eclipsed by the merchants of silver-bullets, who offered simplicity and, say it softly, profits and power. ((The big pharmaceutical companies who make and market vitamins have been fined hundreds of millions of dollars in the US and Europe for creating price-fixing cartels.)) Latham carefully documents the shift from food to pharmaceuticals and shows how it was not sustainable, ignored and suppressed evidence, blocked other approaches, thus denying developing countries their multiple benefits, and might actually have done more harm than good, especially where megadoses of vitamin A were given to children regardless of need. ((For an alternative view — at least I think it is but the document is so dull it is hard to be sure, see Vitamin and mineral deficiencies technical situation analysis: a report for the Ten Year Strategy for the Reduction of Vitamin and Mineral Deficiencies.)) But he is also hopeful, warning that, in the absence of evidence, donor fatigue may at last be setting in. Will developing countries continue these efforts when they have to pay for them themselves?

When explicitly asked if China would take over funding for this if the donor ended its support, officials in the Chinese ministry of health consulted among themselves and replied: ‘Anyone who wants to come to China to do something beneficial for our children is welcome’. (Greiner T, personal communication). Asian elegance in delivering difficult messages is always impressive.

Maybe countries will then be willing to adopt food-based approaches, and we won’t have to keep bleating about agricultural biodiversity’s potential contributions being ignored. Now that really would be something to punch the air for.