by Cathy Shufro
School has let out for the day in the Himalayan hill town of Sitapur.
Children in blue-and-white uniforms flood out of the school courtyard onto the only road running through this town in midwestern Nepal. A boy runs joyously, his backpack bouncing. A girl with black braids leads her little brother up the steep path to the neighboring village. A few boys send a volleyball back and forth over a net strung to a house. The children's voices overlay the faint shouts of men calling to their oxen in emerald rice fields in the valley far below.
These schoolchildren look like kids anywhere exulting in release from the classroom. But on this July afternoon, their familiar exuberance deceives. It's likely that nearly half these children have already suffered irreparable harm.
The cause is chronic malnutrition.
Some 41 percent of Nepali children under 5 are moderately or severely stunted, according to Nepal's 2011 national health survey. Long-term undernutrition coupled with recurrent infections and other consequences of poverty has caused them to be stunted-that is, markedly shorter than well-nourished children of the same age. Short stature is only the outward manifestation of how malnutrition damages children. Long-standing undernutrition thwarts the development of their brains and bodies, undermining their chances to prosper as adults.
There's no reason to think that the children of Sitapur have fared any better.
Hunger in a Nation of Farms
Nepal's slow progress against stunting contrasts with other health advances. The country cut both child and maternal mortality in half in the past 10 years despite ranking 157th out of 187 countries in the UN Human Development Index, and despite enduring a decade of political upheaval that only ended in 2006. This nation of 30 million also is a global model for preventing child deaths and blindness by giving vitamin A supplements to preschool children.
So why has undernutrition proved so intractable here? Why aren't people well fed in a country where 70 percent of the workforce is engaged in farming-in growing food?
To answer that question, researchers from the Bloomberg School and Tufts University's Friedman School of Nutrition have launched an ambitious nationwide study that pays attention not only to diet but also to a broad range of other factors that influence nourishment, including agriculture.
In May 2013, 66 interviewers and 30 supervisors and research assistants completed the first of three annual surveys. In 60 representative towns and villages and three neighborhoods in the Nepali capital of Kathmandu, interviewers talked to any woman who had a child under 5 or who had recently married. They also interviewed the head of each woman's household (generally her husband or father-in-law).
In 4,288 households across Nepal, interviewers asked a broad range of questions about factors that can affect nutrition for young children and their pregnant or nursing mothers: what children and their mothers eat, and whether they have enough; which foods families grow, and which they buy. When an interviewer asked, for instance, how much rice a mother and her children under 5 ate during the past week, the interviewer also asked if the household grew rice, if they owned the land where it was grown, and whether they ever got so hungry that they ate seeds intended for planting the next crop.
The survey teams raced to finish data collection before the midsummer monsoons made travel difficult. They visited communities in all three ecological zones-in the southern plains near the Indian border, in small towns in the hills (including Sitapur) and in high-altitude villages near Mount Everest-one of them was a five-day trek from the nearest road.
"It's a little breathtaking," says Keith West, DrPH '86, MPH '79, RD, director of the Bloomberg School's Center for Human Nutrition. West is the School's principal investigator for the study, called PoSHAN, an acronym that means "good nutrition" in Nepali. The $15 million, five-year USAID grant is led by PoSHAN principal investigator Patrick Webb, PhD, of Tufts.
Undernutrition causes stunting and increases the risk of death.
The aim of the Bloomberg School's team is to apply public health methodologies to mapping the complex interactions between nourishment and what's grown, what's eaten and what efforts have been made to improve nutrition, health and farming. The Tufts team, meanwhile, is analyzing how well policies and programs for improving agriculture and nutrition translate into action as they move from Kathmandu to towns and villages.
The interdisciplinary focus of the research makes the study unusual, according to West. "There's a deep sense that agriculture and nutrition have not talked to each other over the decades, and the centuries," he says.
Governments, nonprofits and community groups have repeatedly tried to address malnutrition by improving farming. And yet no one really knows what, if anything, has worked. When Webb and a colleague studied 10 reviews that had closely examined 250 of the strongest studies, they found all 10 reviews concluded that the studies provided little or no evidence that agricultural interventions improve nutrition. The reviewers found that most of the studies were badly designed or poorly analyzed.
"There are decades of claims that say, 'Do this, and we'll improve nutrition,' but actually very, very few studies have succeeded in documenting it," says Webb. "It's astonishing."
The stakes are high. Globally, undernutrition means death for 3.1 million children younger than 5 every year. It caused 45 percent of all child deaths in 2011.
Yet the factors affecting nutrition are numerous and difficult to isolate. For instance, a family might provide more protein for their children if they raised chickens. But that gain would be undermined if chicken droppings caused recurrent diarrhea in the children. Or, consider a family that chose to raise poultry rather than plant a garden. They would not have their own vegetables to eat but they might make enough money by selling eggs or meat to buy a mobile phone that would make a family business more competitive, increase income and allow them to buy vegetables. The linkages are complex.
With this study, says West, "we're embracing the complexity."
Shorter Stature, Shorter Lives
By September 2013, piles of completed surveys were stacked, waist-high, in an office in Kathmandu. There, Bloomberg School project scientist Swetha Manohar, MSPH '11, RD, and colleagues had begun analyzing the data.
In part, they were looking for stunting. Everywhere they'd gone, the survey teams had weighed and measured children, and those numbers would show the prevalence of stunting.
Stunting signals trouble: It results from poor nutrition over the long term, not just small setbacks caused by a recent food shortage or a child's transient illness. Stunting embodies chronic gaps between nutrition and agriculture. It is also important because it costs a child so much. For children who survive, the deprivations and insults that cause stunting not only hinder physical and intellectual development but also increase the lifetime risk of degenerative diseases and, ironically, of being overweight; genes are made "thriftier" by long-standing privation so that the body maximizes fat storage.
The 1,000 days that begin with conception are the most crucial: By age 2, stunting is largely irreversible. After that age, children can't catch up, says International Health Professor Robert E. Black, MD, MPH, a veteran health and nutrition researcher who directs the Institute for International Programs.
And stunting is insidious. In societies where stunting is pervasive, it may go unnoticed, says Black, adding "everyone looks small, so it looks normal. It's the usual pattern of growth." Though it may appear to be the norm, it substantially increases the risk of death. Nearly 15 percent of under-5 deaths stem from stunting.
Damage can begin at conception if the mother herself is stunted or underweight. She is more likely to give birth to a baby that is small for its gestational age. Restricted fetal growth accounts for 20 percent of stunting worldwide. If a stunted child is a girl, she will be more likely to give birth, in turn, to an underweight baby.
"It's an intergenerational issue," says Manohar.
Although stunting has declined worldwide by one-third since 1990, it still affected 165 million children in 2011, 69 million of them living in south-central Asia. The individual impairments that stunting causes, multiplied by these millions, affect national economies: pervasive stunting in a population reduces gross domestic product by an estimated 8 percent.
"Stunting is a reflection of loss in human capital," says Keith West. "And that human capital develops early in life. So preventing stunting is a metaphor for improving capacity."
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