Category Archives: Nutrition

Malnutrition’s multiple pathways, including malaria

The Sahel of West and Central Africa with its successive droughts is an area of nearly constant food insecurity and malnutrition.  Development partners, in trying to find more accurate ways to predict malnutrition and food insecurity have come to realize that the relationship between crop production on one hand and malnutrition on the other is complicated.

IRIN quotes USAID as saying “… the links between cereal production and malnutrition have been exaggerated, the complexities of regional market conditions inadequately conveyed, and the need for long-term structural solutions under-emphasized.” Furthermore, “While harvest outputs and malnutrition rates are linked, they are not inextricable.”  Ironically, food aid may not solve food problems.

dscn9123sm.jpgIRIN commented on the structural factors of the chronic malnutrition problem by saying that, “This is because much of the malnutrition in the region is caused by other factors: poor water quality, low-quality health care, poor sanitation and poor feeding practices.”

According to IRIN the magnitude of the problem is huge. “A third of the population of Chad is chronically undernourished, regardless of the rains or size of the harvest. More than 50 percent of the population in Niger suffers from food insecurity, with 22 percent extremely food insecure, according to the World Bank in 2009.”

IRIN suggests that the solution to the problem requires addressing “the multi-dimensional aspects of malnutrition, including livelihoods, food production, social protection, health, water and disaster risk reduction; and on responses that focus on strengthening the incomes of poor households.”

Although malaria prevalence is low and seasonal in the Sahel, it is one of the health risks that contribute to chronic malnutrition in the Sahel. Bechir and colleagues researching the problem in Chad found …

“Thirty-four percent (CI 27-40) of nonpregnant women, 53% (CI 34-72) of pregnant women, and 27% (CI 23-32) of children were anemic. In subjects infected with Plasmodium, all women and 54% (CI 22-85) of children were anemic. Malnutrition was significantly associated with anemia in mothers and with selected intestinal parasites, anemia and age in their children.”

As an intervention, Tine et al. found in Senegal that “Combining IPTc and HMM can provide significant additional benefit in preventing clinical episodes of malaria as well as anaemia among children in Senegal.”

We must not forget the interrelatedness of health and development issues and their interventions. More inter-sectoral thinking and planning is needed.

urban hunger –> urban agriculture –> urban malaria

The growing problem of urban hunger and urban food insecurity was featured in the Wall Street Journal today. In Monrovia, Liberia, “The cost of a cup of rice has risen to nearly 50 cents from 20 cents, a huge leap for many families who live on less than $1 per day.” The result: “Escalating hunger in African cities is forcing aid agencies accustomed to tackling food shortages in rural areas to scramble for strategies to address the more complex hunger problems in sprawling slums.”

One of these strategies, according to IDRC is urban agriculture:

Urban agriculture (UA) is wrongly considered an oxymoron. Despite its critical role in producing food for city dwellers around the world, urban food production has largely been ignored by scholars and agricultural planners; government officials and policymakers at best dismiss the activity as peripheral and at worst burn crops and evict farmers, claiming that urban farms are not only unsightly but also promote pollution and illness. Contradicting this image, recent studies document the commercial value of food produced in the urban area while underscoring the importance of urban farming as a survival strategy among the urban poor, especially women heads of households.

Urban farming requires water. The International Water Management Institute reports that, “Manual water fetching with watering cans is most common.” They often get water from “polluted streams or they do farming along storm water drains and gutters.” This sometimes leads to “wastewater irrigation.”

Of course malaria vectors need water. In urban Accra, Ghana, Klinkenberg and collaegues found that Anopheles and Culex “outdoor biting rates were respectively three and four times higher in areas around agricultural sites (UA) than in areas far from agriculture.”

The solution to the problem of urban malaria is not to stop urban agriculture, but to intensify integrated vector management interventions.  We certainly don’t want to protect people from malaria and then have then suffer from food insecurity.

When people can’t afford food – what of malaria treatment?

crs-food-crisis-urban-poor.jpgCatholic Relief Services describes the life of Rasmané, a day laborer in Burkina Faso, who works at “a plastic chair factory, where he makes about $37 a month. This won’t go far for Rasmané, his four kids, his mother and wife. That’s why they eat baobab leaves and cheap millet (see photo by Lane Hartill/CRS). A sack of rice that would last a few weeks costs about $55.”  According to CRS, “Some 75 percent of people living in or near Burkina’s major cities don’t have enough food to eat.”

Staple food prices have more than doubled. “Rasmané says he has never seen food prices jump like this. A portion of corn last year was 50 cents. Now, it’s $1.15. A portion of millet was 55 cents. Now it’s $1.25. For someone who doesn’t know from one day to the next if he will work, these price swings sting.” CRS notes the contrast: “Residents of Burkina Faso spend about 76 percent of their monthly income on food. Americans, on the other hand, spend only about 10 percent of their income on food a year, according to the USDA.”

The question arises, what if one of those 4 children get malaria?  Kouéta and colleagues found in Burkina that poor nutritional status was one of the key factors associated with increased risk of death in children with malaria.

Burkina had a short-lived Global Fund Malaria Grant in Round 2 and recently started on its Round 7 grant in June 2008. The first objective of the new grant is to “ensure proper treatment of simple malaria cases diagnosed in health facilities.” Public, private and community health workers are to be trained in proper case management. The GFATM expressed concern in the first progress report that there be proper coordination between principle and sub-recipients for full implementation. The need to closely monitor ACT estimations and actual consumption was stressed.

A reading of the Round 7 proposal implies that ACTs may be subject to the overall national strategy of cost recovery.  One wonders if people like Rasmané can really pay for proper malaria treatment for their children?

World food crisis and malaria

The Washington Post reports today that “More than 100 million people are being driven deeper into poverty by a “silent tsunami” of sharply rising food prices, which have sparked riots around the world and threaten UN-backed feeding programs for 20 million children,” according to the director of the World Food Program (WFP). The article reports that the WFP is running out of funds and may cut back on school feeding programs.

The WFP Director explained that because of rapidly rising food prices, “Those living on less than $1 a day were giving up meat and vegetables, and those living on less than 50 cents were facing increasingly desperate hunger.” WFP food rations are depicted in the WFP ‘red cup’ photo seen below.

wfp154505sm.jpgWhat are the implications for malaria?

In Mozambique, Bassat et al. (2008) found that. “For children aged eight months to four years, the risk factors [for dying from with malaria] were malnutrition, hypoglycaemia, chest indrawing, inability to sit and a history of vomiting.” In Tanzania Sunguya et al. (Tanzania Health Research Bulletin, 2006) found that, “coinfections [such as malaria] complicate the management of severe malnutrition and are associated with higher death rate.”

A review by Schaible and Kaufmann (2007) linked malnutrition with impaired immunity. They state that, “Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, measles, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity.”

Whether the current food crises results from the international economic meltdown, global warming or diversion of food crops to make biofuels, the potential impact on mortality from malaria is serious. There has never been a greater need to link nutrition, agriculture policy and food aid with malaria programming. Vertical funding will not solve the problem.

A to Z of reducing malaria morbidity

Nutrition Journal has just published a study that shows micronutrient supplements – Vitamin A and Zinc – can produce a ‘major reduction’ in malaria morbidity in Burkina Faso. Previous work has been pointing to a positive role for Vitamin A on malaria, and zinc has shown positive effects on other health problems such as diarrhoeal diseases. The authors hypothesized a positive effect of the two micronutrients, and were not disappointed. There was a 30% reduction in malaria cases and a 22% reduction in fever episodes in the supplemented group compared to the placebo group.

The study covered a 6-month period, and the regimen consisted of Vitamin A once and zinc supplementation daily, 6 days a week for the 6 months. The authors acknowledge that comparison arms with zinc only and Vitamin A only would have been instructive in determining whether the results were additive or synergistic. We assume others will take up this challenge, but assuming that we want now to add this A-Z regimen to the toolkit of malaria prevention, what are the implications for a safe and feasible delivery mechanism?

Concerning safety, the BBC quoted Dr Ron Behrens, an expert in tropical diseases at the London School of Hygiene and Tropical Medicine. He addressed the issue of seasonality of micronutrient deficiencies as well as the need for caution to avoid excess dosing of these supplements. “Neither of these micro-nutrients is totally safe. They should be used like pharmaceuticals, and not seen as cure alls,” he said.

Vitamin A has already been incorporated into immunization campaigns. The authors think that, “Ultimately, the more affordable and sustainable solution would be the incorporation of vitamin A and zinc in food fortification for children.” Campaigns may not offer a long term or sustainable delivery mechanism, and food supplementation in resource poor settings, especially more remote rural areas is not likely feasible in the foreseeable future.

the-tdr-program-has-shown-that-vitamin-a.jpgEnabling the community to take charge of delivery of malaria interventions has been advocated here. This works for Vitamin A supplementation as seen in the graph to the left and continues to be the preferred approach to ensure people participate in their own health care. Hopefully the Global Fund and other donors will be willing to pay for this addition to the malaria prevention toolkit.

Finally, Bhutta et al. in the Lancet this month offer another ‘ultimate’ or long term solution by recommending that nutritional “interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women’s empowerment.”

Better Nutritional Status through Malaria Prevention

Researchers in Senegal studied the effect of intermittent preventive treatment (IPT) of malaria for children during the malaria transmission season in that country and found that, “The prevention of malaria would improve child nutritional status in areas with seasonal transmission.” In particular mean weight gain was significantly better for those receiving IPT.

These researchers also note that similar positive results have been observed in other malaria prevention research efforts in the Gambia and Tanzania. The Tanzania work included ITNs in addition to IPT.

A basic child health monitoring tool, the Road to Health Chart, comes to mind. The guidance with the charts was usually to suspect illness, such as diarrhoeal diseases and TB should a child’s weight remain static or decrease between clinic visits. It is encouraging to know that we can also improve overall child nutritional status through malaria prevention. More work is needed to document these effects of preventive interventions in areas with year-round malaria transmission. Such results also add to the economic benefits arguments for malaria control as children with better nutritional status will hopefully grow into more productive adults.

Hunger and Malaria

On Thursday a demonstration protesting hunger in Nigeria was broken up because of littering, a trivial excuse for trying to block attention to a crucial development and health issue.  Action Aid, organizers of the Abuja march said, “Despite the country’s massive oil wealth, one in three of Nigeria’s 140 million people goes to bed hungry.” Hunger and the related issue of malnutrition is especially important to control infectious diseases like malaria.
sscn1268.JPGThere has been controversy about the exact relationship between malnutrition and malaria, but greater death rates from all causes is associated with malnutrition. A recent PLoS review summarized the issue as follows: “Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, measles, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity.” The review clarified that Chronic PEM was associated with malaria.

The association between malaria and the nutritional problem of anemia is not in doubt, and not long ago we shared findings about diet and Artemisinin-Lumenfantrine (AL), the most commonly recommended ACT. Studies found the need for adequate fat consumption to enhance AL absorption, a major challenge for hungry children who have poor diets with low energy intake.

Regardless of associations, the two issues, ending hunger and ending malaria, come together in the Millennium Development Goals. Both should receive the undivided attention of child health advocates and government policy makers