Nutrition and Malnutrition


This one’s for Glenna.

There are lots of ways you can prevent or cure malnutrition. They come down to emergency feeding, supplementation, fortification, and changing food behaviors. Here’s a high-speed tour, in order of speed of impact and sexiness to donors.

Therapeutic foods come in two forms: powders that are mixed with clean water to become nutritional formulas, and ready-to-use therapeutic foods. Both are used as emergency measures, the tools of last resort to prevent death. You need to target them in a very specific way to use them well. Formulas are starting to be supplanted by the very trendy plumpy’nut, which can be used without a doctor’s attention once distributed. Some malnourished people are still so bad off that they need formula, though.

When you need therapeutic foods, something has already gone wrong. They are a patch for a broken system. A clear example of a downstream solution. Quick to get started, rapid results, no real long term impact. Very very sexy to donors, since feeding starving children is exactly the thing people think about when they picture aid work and projects get going fast.

Vitamin supplements don’t need to be heavily targeted, but you can’t just give them out to everyone. Different categories of people – children, pregnant women, and so on – need different nutritional supplements. Not a ton of supervision is needed, but some. In addition to targeting, someone has to physically give them out. Supplements need a health system, or at least a logistical system, behind them. Somewhat exciting for donors, since programs gear up fast and little children line up adorably to get their vitamins.

Food fortification doesn’t need a logistical system or medical support. If you get iron and folic acid into the flour, iodine into the salt, and vitamin E into the oil, you can improve the nutritional status of an entire population. But you end up supplementing a whole lot of people who don’t need it. It’s effective, but it’s not efficient. You also need a government capable of enforcing fortification, so it’s an upstream solution. And we’re starting to see some evidence that some kinds of fortification, like folic acid, can increase some kinds of cancer, so they are not an unqualified good. Fortification is boring for donors. They details and politics of fortification are honestly pretty boring for nutrition experts, let alone people trying to decide where to give their twenty bucks or overworked government types.

Lastly, changing food behavior involves teaching people how to eat in a way that meets their nutritional needs. The classic examples are not selling home-grown vegetables and using the money to buy processed foods, and increasing the consumption of legumes, especially in combination with leafy greens. So many things affect individual eating behavior that this is an upstream and a downstream solution. It’s about what is available to eat, and what people choose from that. Changing nutrition behaviors is very, very hard. It takes a long time and shows its impact slowly. It’s downright repulsive to donors, because it reminds everyone of all the vegetables they ought to be eating themselves.


Photo credit: mashnicaragua

Chosen for reasons I hope are obvious.

Local vs Imported Solutions, and Ashton Kutcher

I just put up three posts at the Global Health blog that Blood and Milk readers may be interested in. There is a two-part series on local and imported solutions to health problems, focused on plumpy’nut and ORS. I also posted a brief rant about Ashton Kutcher and bednets for malaria.


(photo credit: cliff1066)

Things I believe in #1 – Positive Deviance

In every village, there is at least one woman (usually a few) whose children are healthier than the rest. For whatever reason, that woman is better at navigating the complexities of village life and child nutrition. That woman has knowledge and skills which can be taught. You find her, you learn from her, you support her to teach her peers. That is positive deviance. Find the people who deviate from the norm by being more successful. Learn from them.

The original positive deviance programs were nutrition programs, with a specific structure and methodology. These are some nice examples. Positive Deviance remains one of the most powerful tools we have for improving nutrition in the developing world. You can also, however, use the ideas behind positive deviance for more than just nutrition.

Every systems has its positive deviants. People who are better at surviving within it. You don’t need a bunch of outsiders to or foreign experts to find ways to improve your system. Most of the knowledge you need is already there. It’s a profound and powerful idea. It means you improve education by learning from the teachers and principals of high-performing schools. It means you make childbirth safer by talking to maternity nurses and ob/gyns. It means you value the knowledge and experience of the people in the developing world.

When you want to make things better, look inside first. Learn from the people who know it best. After that, bring in your outside experts. See of they have anything add. But most of what you need to know is already there.

Jargon – Emergency acronyms

ECHO – ECHO is an acronym that doesn’t seem to stand for anything. It’s the European Union humanitarian aid department. ECHO actually gives grants to NGOs for humanitarian response, but everyone hates taking their money because they only provide 7% overhead.

GBV – Gender based violence, which means exactly what you think it does. Also referred to as SGBV, sex or gender based violence. A major problem in emergency situations, and may be perpetrated by the aid workers who are there to help.

HDR – Humanitarian daily ration. Produced (or purchased, anyway) by the military, each HDR will feed one person or one day. They are designed to feed large populations such as refugees or displaced people.

MUAC – Mid Upper Arm Circumference. A measure which can indicate malnutrition. Very frequently used by aid agencies to determine eligibility for feeding programs.

NEHK – New Emergency Health Kit. The old name for the Interagency Emergency Health Kit. Assembled by Mission pharma and sold to NGOs and other emergency responders, the NEHK has all the medicines necessary to care for 5000 people in an emergency situation. The drugs contained are all far from their expiration dates and the cartons are clearly marked, which makes them very efficient for emergency use. WHO often provides NEHKs to governments and NGOs during emergency situations.

OCHA – United Nations Office for the Coordination of Humanitarian Affairs. OCHA is supposed to coordinate all donors in emergency situations. Since they don’t have any enforcement power, that rarely actually happens, even though everyone agrees that donor coordination is a good thing. OCHA’s annual budget for 2007 was $159,079,639.

OFDA – Office of U.S. Foreign Disaster Assistance. An office within USAID that functions essentially autonomously. It is responsible for US government-funded emergency response overseas, including war, natural disasters, and other emergencies. Most emergency-response NGOs based in the United States receive all or some of their funding for their work from OFDA. OFDA is known for its ability to quickly identify an emergency and make funding available. OFDA support is especially valued because it has 100% line-item flexibility – organizations can make changes to their budgets as needed in rapidly changing emergency situations, as long as they stick to the correct total amount. OFDA focuses on immediate disaster response; therefore sustainability is not a priority and money comes from OFDA in a 6 or 12-month funding cycle.

Just to help this blog earn the title of eclectic, an incredibly depressing story about polar bears in zoos.Aside from being really depressing, I think this article points to a larger issue of the way that the emotional impact of a compelling narrative can overwhelm good programming. For example, in Community Therapeutic Feeding Programs — they found that inpatient care will inevitably draw resources away from more effective outpatient care, because malnourished children are so compelling that human beings will always commit their energy to the child in front of them.
That’s as it should be. None of us wants to be someone who could ignore a starving child (or starving polar bear cub). But we also need to go beyond gut instinct if we want to get the best result for our efforts.