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 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.