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Preventing Malnutrition: What We Can Do
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Malnutrition remains a serious issue in developing countries of the Asia and Pacific region. Ironically, as these countries develop, malnutrition has taken a new twist. Where formerly it was generally understood to mean not enough food, rising living standards have led to the emerging problem of obesity—thus malnutrition in this region has become the double burden of undernutrition and overnutrition.
Malnutrition may prevent many countries from attaining at least four of the Millennium Development Goals that they have pledged to reach by 2015. Part of the first of eight goals is to reduce the proportion of people suffering from hunger, while three other goals—reducing the under-five mortality rate, reducing maternal mortality ratio, and achieving universal primary education—can also only be reached through better nutrition.
Undernutrition causes the death of more than 1.5 million preschool children in nine low-income Asian nations each year, and has intergenerational effects. Low birth weight is strongly associated with the undernutrition of mothers—60% of women in South Asia, and 40% of women in Southeast Asia are underweight. Low birth weight is one of the main reasons why children are underweight and will have lower resistance to infection, thus making them more likely to die from childhood ailments.
Those who survive are prone to frequent illnesses that worsen their nutrition status, trapping them in recurring sickness, faltering growth, poor brain development, reduced strength and work capacity, and increased chance of chronic diseases in adulthood. Adult women with this condition will give birth to underweight babies. And so, infant malnutrition, especially for girls, plays an important role in perpetuating poverty and malnutrition across generations.
The most common form of undernourishment is lack of micronutrients—vitamins and minerals, especially iron, iodine, vitamin A, and folic acid—affecting as many as 1.5 billion Asians. For example, lack of iodine in the diet damages the brain: even moderate deficiency can lower the intelligence quotient level by 10 to 20 points. Among others things, lack of iron results in anemia that causes the deaths of thousands of Asian mothers during childbirth. Obesity caused by overnutrition in the Asia and Pacific region has grown from a minor issue 3 decades ago to a major disease. In the People’s Republic of China, for example, by 2025, more than half of all deaths are expected to be from diet-related chronic diseases.
How do individual countries in the region view the nutrition problem? The Asian Development Bank (ADB) has undertaken joint poverty assessments in 24 of its developing member countries (DMCs). Undernutrition was stated as a problem in 16 of them, although all the countries saw the need for improving nutrition as urgent. Poverty was regarded as the basic underlying cause of malnutrition, accompanied by lack of access to and poor quality of primary health care and by weak education. The most common immediate causes at the national level, however, were lack of clean water and sanitation, a gender bias resulting in poorer nutrition in women, and diet habits and/or changing diets. Obesity was seen as a problem in six countries, mainly because of dietary changes. Few countries spend enough on health and/or nutrition. Weak health services are among the major constraints to improving nutrition in the region. There is also generally not enough information on the full extent of the problem, while health and education are often not given priority. Also, dietary advice is frequently not available to those who need it.
However, ADB has found, in its annual updating of its country strategy and program reports, that many countries have a framework in place that enables nutritional progress to be made. In some, this consists of existing government activities in nutrition, water, and sanitation; an intersectoral approach to addressing the immediate causes of undernutrition; and the presence of supportive development partners. In others, there are indirect pronutrition factors, such as national poverty reduction efforts, free and compulsory education, gender and development activities, and strong networks of nongovernment organizations.
By mid-2004, ADB’s direct support to improve nutrition and food fortification in the region included four loans in Indonesia, Kyrgyz Republic, and Philippines amounting to $180 million; grants totaling $32.8 million from the Japan Fund for Poverty Reduction (JFPR) to support five regional technical assistance projects (RETAs) in 16 DMCs; $4.25 million for eight advisory technical assistance projects in six DMCs; and $600,000 for a project preparatory technical assistance. The RETA in 16 DMCs helped these countries analyze situations related to nutrition, develop national nutritional policies, promote technologies to improve nutrition, prepare governments for the nutrition transition, and enhance regional partnerships.
The Operations Evaluation Department’s 2005 special evaluation study of Selected ADB Interventions on Nutrition and Food Fortification confirms their usefulness in raising awareness of nutrition around the region. The interventions have directly helped the transfer of nutrition-related technologies, particularly food fortification. They attracted additional support for country investment plans and assistance related to health and nutrition, helped DMCs review their progress on the MDGs in nutrition, and benefited by sharing experiences.
Holistic solutions for poverty reduction that will mitigate the risks of malnutrition should include supporting complementary activities on improved nutrition and empowerment of women
For some DMCs, the regional approach was not enough. They needed countryspecific help in integrating nutrition plans into development plans and support for pilot projects, for example, to demonstrate the technology and effectiveness of micronutrient fortification. A pilot project of this nature funded by a grant from the JFPR1 in the Kyrgyz Republic encouraged the country to expand the effort and resulted in a loan by ADB to the Government for this purpose.
Although food fortification has been proven to be a cost-effective approach, it is not a panacea. Most poor people in areas with the greatest risk of micronutrient undernutrition usually do not eat fortified foods. Thus, micronutrient malnutrition prevention program has to be combined with other food security and community nutrition initiatives. Neither can the growing problem of overnutrition and its effects on productivity be ignored.
Promotional exercises on micronutrient fortification often neglect to emphasize the recurring costs of regulatory and enforcement mechanisms, testing laboratories, and training. These costs are not generally part of short-term assistance packages and need to be taken into account by governments to ensure that their efforts are sustainable.
Poverty reduction and strengthening of health care systems alone cannot solve micronutrient-deficiency problems. Consumers do not necessarily demand micronutrient-rich foods. Safety-net programs, including refugee feeding, must also respond to total nutrition needs, not only calorie needs.
Based on the experience of ADB, its development partners, and the countries involved, future nutrition efforts should consider several issues.
First, geographic and socioeconomic baseline data on malnutrition risks are essential to develop the appropriate mix of nutrition interventions.
Second, periodic assessments of and updates on the nutrition situation are important, such as regularly updating information on childhood population nutrition, obesity, and micronutrient status.
Third, in association with this, monitoring and risk management capacities of participating countries may need improving to enable increased coverage and sharper focus on delivery of fortified foods consumed by the poor.
Fourth, technologies have to be transferred to governments, nongovernment organizations, the food industry, and consumer groups to ensure successful and sustainable fortification projects.
Fifth, technical assistance should include a small investment component to improve effectiveness and sustainability through demonstration. Stakeholders should have ownership in nutrition interventions by tailoring them to local social conditions through involvement of development partners, civil society, and private sector representatives throughout the phases of these interventions.
Finally, holistic solutions for poverty reduction that will mitigate risks of malnutrition by supporting complementary activities on improved nutrition and empowerment of women are essential. ADB should continue being a catalyst in the region’s nutrition development efforts.
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