The cost of malnutrition

It’s noon. Mildred Achitsa, a Grade Two pupil in Kakamega County, is quite elated to hear the bell ring.

“I have not had anything to eat since yesterday. Grandmother prepares sukuma wiki and traditional vegetables when she can afford, but I am tired of eating vegetables every day,” the girl who was orphaned at birth discloses.

At her school, the situation is no better; they are fed on githeri (maize and beans mixture) from Monday to Friday. She gets some respite when she buys mandazi with the few coins she gets thanks to the generosity of friends, or Ms Masitsa, a teacher of English and her favourite. Mildred says Ms Masitsa is motherly and has taken interest in her.

Ms Merab Lugonzo, an early childhood development (ECD) nursery teacher in Lirhembe, which is located in Ikolomani Constituency, says all her school can afford is a cup of maize meal porridge for the little ones.

“We add some sugar to it and serve once a day because that’s all we can afford.  I interact with these children on a daily basis as I live around here and I can assure you that for many, that porridge is the only meal they end up having since there’s nothing to eat in their homes,” she discloses.

The situation is no different In Bungoma County.

Anne Mashetti, 50, the Principal at Maliki Mixed Secondary School told Healthy Nation that from Monday to Friday, her students feed on githeri, apart from Wednesdays when they have rice with beans.

“Since we are a day school, we have a lunch agreement between parents and teachers who fund it. I have, however, been around long enough to know that most of the children we have come from very impoverished backgrounds and their families cannot afford a balanced diet at home, so most depend on the food provided in school,” says.

“We have many malnutrition cases because most people do not have land to produce food since they have sold it. Despite the fact that the Western region counties have for a long time been regarded as food basket counties, our children do not get a proper, healthy balanced diet,” the education expert who is currently pursuing a masters in family psychology says.

The principal further observes that the land in the settlement scheme where her school is located is also not good for farming.

“Some areas here are not arable since the land is composed of rocks, making it impossible to grow food. Our county government, however, provides lunch bursaries to some of our students who cannot afford that one plate of githeri at lunch and the break time cup of tea.

A while back, the Ministry of Education used to run a programme called Pockets of poverty through which some district education officers tried to help those children who couldn’t afford meals, but I am not sure it is still in existence.

"My colleagues in Busia County are grappling with providing a balanced diet for students as well, especially because the land there is frequently flooded, making it difficult to grow crops,” Ms Mashetti explained.

Sylvanus Wekesa, a father to three school-going children in Busia County agrees.

“There is no parent who would wish for their children to go hungry, but as much as I have tried farming, with the poor soil conditions here, it is increasingly proving impossible,” he says.

Critical needs

Ms Maryanne Mwanza, a consultant dietician based in Nairobi, explains that school-aged children grow significantly while being very physically active, meaning their nutritional needs are high and critical.

“Genetic background, gender, body size and shape are all important determinants of nutrient requirements. A recent review of research on the effects of deficiencies in zinc, iodine, iron and folate on the cognitive development of school-aged children showed that nutrition has an impact on children’s ability to think.

For example, deficiencies in iron and zinc have been associated with impairment of neuropsychological function, retardation of growth and development, reduced immunity and increased vulnerability to infectious diseases,” the nutrition expert tells Healthy Nation .

The brain needs energy to function properly and so the supply of glucose, which is found in carbohydrates and fats is important for children.

Cognitively demanding tasks such as schoolwork require regular supplies of glucose to the brain in order to enhance cognitive functioning and improve memory.

“For children, protein builds, maintains and repairs body tissue. It’s important that parents encourage children to eat two to three servings of protein daily.  Good sources of protein for children include meat, fish, pork, poultry, milk and other dairy products,” says Ms Mwanza.

The dietician further discloses that lack of what she refers to as essential fatty acids could lead to dyslexia and dyspraxia, which are associated with difficulties in spelling, handwriting and written expression.

“Deficiency of unsaturated fatty acids may have a negative impact on school performance,” she says.

She adds: “Osteoporosis, a weakened bone disease, affects a significant proportion of adults. This begins in childhood if diets are not providing adequate calcium-rich foods.  Milk and dairy products and some dark-green, leafy vegetables are good sources of calcium.”

Experts encourage parents to ensure their children eat breakfast every day to help maintain concentration in class. A good breakfast should be able to provide a third of the total daily energy requirements and includes a cereal (for example rice, bread and oats), protein-rich food such as eggs, a glass of milk and vitamin C rich fruit like oranges.

A recent study found that an overnight and morning fast among school children had detrimental effects on memory and attention while research on the effects of breakfast on cognition shows that, particularly for younger children, skipping breakfast can have adverse effects on both general energy levels and cognition.

Parents, according to Ms Mwanza, must not let their children make poor snack choices that result in too many high-energy, low-nutrient foods.

Salty snacks such as potato crisps are of little value as they provide few nutrients.

“Frequent snacking may as well result in loss of appetite during the main meal. A healthy snack should be less in size or quantity to the amount of a regular meal and should be taken at least two hours before a regular meal,” she advises.

Highest prevalence

Child undernutrition is one of the major challenges the world is currently grappling with as Africa records highest prevalence.

Undernutrition refers to lack of proper nutrition caused by not having enough food or not eating enough food containing nutrients necessary for growth and health.

As per the Cost of Hunger policy brief by the National Treasury and Planning Ministry , it  is manifested through stunting (low height for age), wasting (low weight for height) and/or being underweight (low weight for age).

 “Undernutrition, and in particular stunting in children, has a negative impact on the affected children’s productivity at later stages in life. Without proper care, underweight and wasting in children results in high risk of mortality,” it notes.

Even though the number of undernourished people has fallen globally by 13.2 per cent from one billion to 868 million in the last 20 years, Africa’s share in the world’s undernourished population remained high at 23.5 per cent in 2014, representing an increase in the absolute number of underweight children from 32.4 million to 36.9 million.

Kenya made progress in reducing stunting in children from a high of 33 per cent in 1994 to 26 per cent in 2014, even though the stunting rates are still high.

The country’s 2014 statistics show that stunting affects one in every four children under five years.

 This means that out of 7.22 million children under five years in 2014, nearly 1.8 million were stunted (26 per cent); 290,000 were wasted (4 per cent) and 767,927 (11 per cent) were underweight.

The situation is made worse by poverty.

In the 2015/16 financial year, 36.1 per cent of Kenyans were living below the poverty line. The incidence of poverty is higher in rural areas and is estimated at 40 per cent. Approximately 80 per cent of the Kenyan population lives in rural areas. This presents a higher burden of food deprivation among rural communities, which results in undernutrition.

It was further estimated   that 12.9 million of the working age population (15-64 years old) suffered from undernutrition before reaching five years of age and this represented 41.4 per cent of the working age population who were in a disadvantaged position compared to those who were not undernourished as children.

“Further, undernutrition can be associated with low progression in the education system, with only three out of every 10 learners enrolled in Grade One progressing (pass level) to Form Four. This can be attributed to low cognitive skills. Child undernutrition affects health, education and productivity differently,” the brief discloses.

The most pressing form of malnutrition in Kenya is protein-energy malnutrition, which largely affects infants, preschool and school children according to Dr Bashir Issak, the head of the department of family health at the Ministry of Health (MoH).

Dr Issak discloses that currently, the most urgently needed micronutrients by Kenyans include iron, folic acid, vitamin A, iodine and zinc. Their absence is detrimental to growth, health and immunity.

“An estimated 41.6 per cent of pregnant women are anaemic, which means one in four (26.3 per cent) of preschool children are anaemic,” Dr Issak said during this year’s Food Fortification Summit.

Dr Veronica Kirogo, the nutrition director at the Health ministry, says that over half (52.6 per cent) of preschool children and 37.6 per cent of school age children suffer from marginal vitamin A deficiency.

“Majority of the population is zinc deficient regardless of sex, residence or family’s income and the major factors leading to micronutrient malnutrition are inadequate access to a variety of foods, lack of knowledge on optimal dietary practices and a high incidence of infectious diseases,” says Dr Kirogo.

Dr Issak further explains that malnutrition places children at increased risk of morbidity and mortality and is also related to impaired mental and physical development.

“Childhood is the foundation for later life, so it is a very critical stage in life,” he says. “Undernourished children have a higher risk of illness and death often associated with incidences of common childhood illnesses such as diarrhoea, acute respiratory infections, pneumonia, malaria and anaemia.”

The ministry believes that every shilling invested in high impact nutrition intervention has the potential to generate Sh2,200 shilling in economic returns.

Potential savings

Nutrition experts are of the opinion that if the country implements various measures to reduce child undernutrition, there are potential savings to the economy based on a number of policy scenarios. These scenarios are constructed based on the estimated net present value of the costs associated with undernutrition of the children born each year from 2014 to 2025.

“Progress in reducing the prevalence of child undernutrition in Kenya stops at the levels achieved in 2014; that is, the stunting rate stagnates at 26 per cent while the underweight rate remains at 11 per cent. It also assumes that population growth would maintain the pace reported in 2014.

As this scenario is highly unlikely, its main purpose is to establish a baseline to which any improvements in the nutritional situation are compared to determine the potential savings in economic costs.  Under this baseline scenario, the cost of undernutrition could increase by up to 4.26 per cent by 2025 compared to the values in 2014,” the policy brief explains.

“This is to say that the prevalence of stunted and underweight children would be reduced by half (50 per cent of their 2014 values, which would mean a constant reduction of 1.2 percentage points annually in the stunting rate) from 26 per cent in 2014 to 13 per cent in 2025,” Dr Kirogo explains. She agrees it is an ambitious target, considering that the average annual rate of stunting reduction between 2005 and 2010 was estimated at 0.52 per cent.

The underweight rate is set to be reduced from 11 per cent in 2014 to 5.5 per cent in 2025, meaning a constant annual reduction of 0.55 per cent.

“Under this scenario, the cost could decrease by up to 49 per cent by 2025 compared to the values in 2014, with annual savings being estimated at Sh39.7 billion according to the government.

Kenya is a signatory to the Malabo Declaration on nutrition security to which she committed to end child stunting by bringing the prevalence down to 10 per cent and underweight to 5 per cent by 2025. This requires an annual reduction of 1.5 per cent and 0.6 per cent for stunting and underweight, respectively.

This necessitates urgent action and recommitment to enhance investment in nutrition. It represents an important national and regional challenge for which countries in the region could join hands. If this happens, experts believe that the cost could decrease by up to 65 per cent by 2025 compared to the values in 2014, with annual average savings estimated at Sh57.4 billion.

The Kenya Vision 2030 goal of reducing stunting to 14.7 per cent and underweight to 8.4 per cent requires an annual reduction of 0.71 per cent and 0.16 per cent, respectively, and for powders used in the prevention of malnutrition to be included in the school feeding programme.

The nutrition department at MoH is of the view  that the products (micronutrient powder, ready-to-use therapeutic foods and fortified blended foods) used in the treatment and prevention of malnutrition should be included in the essential drugs list.

Other key players have joined the fight against malnutrition.

Last week, UNITLIFE, the United Nations fund dedicated to preventing chronic malnutrition, was officially launched on the side-lines of the Generation Equality Forum.

Chronic malnutrition develops when children do not receive the nutrients they need during the first 1,000 days of life (pregnancy until the child’s second birthday). Its consequences – stunted growth, impaired brain development and a weakened immune system – are largely irreversible, preventing those affected from reaching their potential.

Ecobank Group CEO Ade Ayeyemi urged the private sector in Africa to get actively in the fight against chronic malnutrition.