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Consequences of Undernutrition-Reduced Future Productivity of Children


Saud Bin Ahsen |

Nutrition is a maker and a marker of a country’s sustainable development. The World including Pakistan is confronting a huge challenge in the form of malnutrition especially stunting. Malnutrition is generally defined, lacking enough energy or nutrients to live a physically active life that allows for optimal health. According to WHO, malnutrition generally refers to the deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. It encompasses both overnutrition (obesity) and undernutrition, has direct & indirect negative consequences in terms of disease, disability, brain development, educational attainment & income potential for individuals and communities.

WHO considers poor nutrition to be the single most important threat to the world’s health. The early childhood stunting and the number of people living in absolute poverty are closely associated with poor cognitive and educational performance in children and over 200 million children aged less than 5 years are not fulfilling their developmental potential thus contributing to the intergenerational transmission of poverty. Most of these children live in South Asia and sub-Saharan Africa. It is estimated that stunting, severe wasting, and intrauterine growth restriction together were responsible for 2.2 million deaths and 21% of Disability Adjusted Life Years (DALY) for children younger than 5 years.

Malnutrition is generally defined, lacking enough energy or nutrients to live a physically active life that allows for optimal health.

Pakistan’s population is also suffering from malnutrition including under-nutrition, micronutrient deficiencies and overnutrition. The preliminary findings of PDHS 2017-18 indicate that the nutritional status of children has improved a little over the last 5 years however there is a lot need to do to reverse the situation completely. Lancet series, the most credible and leading journals series on public health,  indicate that severe deficits occur during pregnancy and up to 02 years of age for malnutrition which weakens immune systems and increases susceptibility to infections and related illnesses.

The stagnating prevalence of these worsening conditions have contributed to a pile-up of stunted generations over the decades. The consequences of stunting on education are also dramatic. Various studies show that child stunting is likely to impact brain development and impair motor skills. According to UNICEF, stunting in early life is linked to 0.7-grade loss in schooling, a 7-month delay in starting school and between 22 and 45 % reduction in lifetime earnings. Stunted children become less educated adults, thus making malnutrition a long-term and inter-generational problem.

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Malnutrition also slows economic growth and perpetuates poverty. Mortality and morbidity associated with malnutrition represent a direct loss in human capital and productivity for the economy. At a microeconomic level, it is calculated that one (01) percent loss in adult height as a result of childhood stunting equals to a 1.4 percent loss in productivity of the individual. A study “The Economic Consequences of Under-nutrition in Pakistan” was conducted to estimate economic losses due to malnutrition, revealed that Pakistan is losing US$ 7.6 billion annually which is almost three percent (03 %) of GDP.

This study provided evidence to nutrition partners to carry out advocacy for securing additional budgetary allocations for nutrition specific and nutrition sensitive interventions. Computer modelling undertaken for the 15 indicators of undernutrition indicates the economic consequences emerging from the current prevalence and risk factors for poor nutritional status, as documented by the NNS- 2011 and PDHS 2012-13. The above mentioned report measures the economic losses via four pathways:

(1) Maternal nutrition and breastfeeding behaviour, along with child underweight, wasting and micronutrient deficiencies, are linked to approximately 177,000 deaths annually in Pakistan, which corresponds to more than one-third of all child mortality. The lost future workforce is valued at US$ 2.24 billion per year.  (2) Projections indicate that anaemia among adult men and women who are engaged in agriculture, industry and other manual labour will lower their economic output by US$ 657 million per year. (3) The cost of utilization of health care services due to zinc deficiencies, suboptimal breastfeeding and low birth weight is estimated at approximately US$ 1 billion annually. (4) Cognitive deficits derived from childhood stunting, anaemia and iodine deficiency disorders will result in reduced future adult productivity, which is valued at a Net Present Value (NPV) of US$ 3.7 billion per year. Neuromotor and cognitive impairments are the most important consequences of Iodine Deficiency Disorders (IDD). An Iodine deficient population has their intelligence reduced by 13.5 IQ points. Pakistan has shown notable progress from 17% (NNS2001) to 69 %  Households utilizing iodized salt.

The early childhood stunting and the number of people living in absolute poverty are closely associated with poor cognitive and educational performance in children.

In Pakistan, the prevalence of malnutrition especially stunting has been stagnant over the past decades. The national surveys including NNS-2011 and PDHS 2012-13, found widespread undernutrition throughout Pakistan. A summary of fifteen (15) indicators measured through these surveys reveal that there are more than 110 million individual cases of undernutrition in Pakistan, including more than half of adult women and possibly 97 % of children. Indicator by indicator, each case of undernutrition brings concrete and quantifiable values for risks and deficits.

The “coefficients of risk” are then applied to national prevalence, along with demographic, health, economic and labour statistics, to project the magnitude of reduction of the national economic activity that is associated with the undernutrition status quo. Almost half of women and two-thirds of children suffer from micronutrient deficiencies. Widespread vitamin A, vitamin D, zinc, folic acid and iron deficiency anemia among children represents a severe public health problem with significant impacts on morbidity and mortality, including more than 50 thousand deaths of children less than five (05) years of age.

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The immediate causes of malnutrition are due to inadequate food intake (in terms of quantity or quality) and diseases. However, malnutrition is influenced by a host of underlying factors related to poverty, including food insecurity, poor water & sanitation and inadequate health care services, lack of adequate infant and young child feeding practices, which have strong links from conflict situations to climate-related issues; from scarcity of non-renewable resources and lack of new technologies to variant food prices; from low governance mechanisms to demographic growth. Moreover, all these issues are widely spread in rural communities as compared to urban.

Pakistan is off track to meet the global stunting targets, i.e. World Health Assembly (WHA) targets, to reduce the number of children less than 5 years who suffer from stunting by 40% up to 2025. In Pakistan 52% males and 53% females die of Non-Communicable Diseases (NCDs) under the age of 70 as per research conducted by WHO in 2014. The expenditure on the management of disease through specialized medical care including health, education, essential medicines, access to a health system along with family care, and organizational care/support (insurance) can be increased with the increase of incidence of stunting.

The national surveys including NNS-2011 and PDHS 2012-13, found widespread undernutrition throughout Pakistan.

Pakistan has allocated $1.8 per capita and 0.69% of GGE for nutrition-sensitive programs, which is less than the estimated average budget allocation by 30 countries – $4.4 per capita and 1.7% of GGE. Pakistan budgeted allocation for nutrition-sensitive programs is less than Bangladesh – $3.16 per capita and 2.1% of GGE – and even Nepal – $4.02 per capita and 3.1% of GGE.  In 2015, Pakistan government and foreign donors spent a total of $49.3 million on the WHA nutrition targets, $12.1 million came from the government and $37.2 million came from development partners (foreign donors). The foreign funding supported interventions for anaemia, exclusive breastfeeding, stunting and wasting.

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Nutrition objectives have been included in Pakistan’s Vision 2025, the eleventh (11th) Five Year Plan (2013–2018)  and now in twelfth (12th) Five Year Plan (2018-23) to ensure national food security, reduce rural poverty, increased literacy, support the overall growth of the country and improved the nutritional status of women and children of Pakistan. The following documents have the weightage at the national policy level for nutrition:

Agriculture and Food Security Policy (2018) – to reduce malnutrition and bringing food insecurity down to zero by 2030, the Ministry of Food Security and Research (MNFSR); Breastfeeding laws have been approved at the national level and ratified by all the provincial assemblies; The Protection of breastfeeding and child nutrition Act was passed in 2002; later on all provinces have endorsed it while Gilgit Baltistan (GB) is working on it.; The Pakistan Young Child and Feeding Strategy 2018 identifies the comprehensive actions to improve legislation, policies and standards to protect optimum infant and young child feeding practices, and to strengthen the capacity of health services and communities to promote and support the nutritional needs of infants and young children; The Universal Salt Iodization Act has been enacted by Sindh while other provinces have endorsed the law but it is not approved by relevant legislative assemblies; The Child Marriage Act has been enacted by Sindh and Punjab Assembly, however in other provinces legislation against child marriage is still pending; The Vitamin A Supplementation (VAS) Guidelines have been developed by MNHSRC in 2018 for successful scale-up of VAS. The VAS program is linked to the EPI and is provided twice a year with NIDs for polio eradication since 1999.

The expenditure on the management of disease through specialized medical care including health, education, essential medicines, access to a health system along with family care.

Pakistan Multi-sectorial Nutrition Strategy and National Action Plan (2018-25): Nutrition Section/SUN Secretariat, MPDR in collaboration with other ministries & partners at the national level has developed and launched. This strategy has provided over-arching guidelines to improve nutritional status through cohesive and coordinated efforts in the country by implementing respective nutrition inter-sectorial strategies; The Pakistan National Food Fortification Strategy 2017 has provided an overarching framework to develop a strategic plan and comprehensive fortification programs for staple food fortification with key micronutrients necessary for adequate health & nourishment; The Fortification Assessment Coverage Toolkit (FACT) survey in Pakistan 2018 has revealed that there is need to sustain the fortification of salt, wheat /flour and oil/ghee; The IYCF Communication Strategy 2015: Provided guidelines to improve IYCF practices through behavior change communication in Pakistan; Adolescent Nutrition: The focus on adolescent girl’s nutrition in Pakistan is also attaining attention being directly linked to improving the maternal nutrition and child health.

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It was highlighted by the Prime Minister in his victory speech (26 July, 2018) and then inaugural address (19 August, 2018), showed strong commitment and desired to reduce child stunting and improve maternal health. The following recommendations are put forth to the concerned quarters in this regard. Malnutrition is a complex issue having various dimensions which needs to be addressed through multi-sectoral approaches with the provision of adequate capacities. The governments may enhance investment for nutrition interventions on sustainable basis with an and equate progress tracking mechanism.

The nutrition information systems is essential for adequate policy, planning and programming. Nutritional awareness among masses and behaviour change to healthy dietary practices needs to be created. Strong coordination among all stakeholders needs to be enhanced to create synergies. The national/international laws, rules, regulations and best practices need to adhere. Existing poverty alleviation programs such as social safety nets like Bait-ul-Mall, Zakat and BISP have huge potentials to be linked with food and nutrition security. And there is dire need of high-quality research-based with innovative solutions.

Saud Bin Ahsen is associated with a Public Policy Think Tank Institute and has done MPA (Master of Public Administration) from Institute of Administrative Sciences Punjab University, Lahore. He is interested in Comparative Public Administration, Post-Colonial Literature, and South Asian Politics. He can be reached at saudzafar5@ gmail.com. The views expressed in this article are author’s own and do not necessarily reflect the editoral policy of Global Village Space. 

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