Losing a generation: The expense of malnutrition

Managing Editor of the Global Village Space analyses who is malnutrition affecting, how society suffers, what are the major causes and what can be done to prevent malnutrition.

A child, more than all other gifts

That earth can offer to declining man,

Brings hope with it,

and forward-looking thoughts


These beautiful words by Wordsworth ring hollow in Pakistan where according to the government’s own statistics, over one‐third of children are underweight, 46% of children suffer from malnutrition (stunted) and over 10% are acutely affected (wasting), half of them are anemic, and almost one-third of the children have iron deficiency anemia.

This leads to significant percentages suffering from mortality and morbidity below the age of five. Over 177,000 children die each year, because they or their mother experienced malnutrition.

Malnutrition reduces the growth of the baby and increases chances of it having a low birth weight, and later suffering from childhood infections and mortality. For a country, whose leaders eulogize over its youth potential and upcoming youth dividend, its malnutrition statistics are worse than most sub-Saharan countries.

Who is Malnutrition Affecting?

Malnutrition does not affect equally across the country. There is a clear distinction between the urban and rural populations between the socio-economic distribution; with women and the poor more likely to be affected. Malnutrition is a major impediment to achieving the 2030 Sustainable Development Goals.

Goal 2 has the aim to achieve Zero hunger, it has set globally agreed targets to end hunger, achieve food security and improved nutrition and promote sustainable agriculture in order to achieve this. Malnutrition is not just restricted to children but is also widespread among women of reproductive age.

The National Nutrition Survey, the government study in 2011 (the latest date when one was conducted) – showed that 14% of women of reproductive age were undernourished and had a BMI less than 18.5 kg/m2, and this was predominant among the poorest, uneducated and rural-dwelling women.

Only 10% of the health budget is spent on nutrition; and of that, only 10 percent is spent by the government and 90 percent is actually disbursed by development agencies or related NGO’s.

Micronutrient deficiencies are also prevalent among women with 50% of women anemic, over 37% suffering from high rates of vitamin A and zinc deficiencies, and a further 62% deficient in iron. In children under 2 years, age iron deficiencies are likely to affect brain functions acutely and probably also chronically.

Malnutrition because of iodine deficiency especially in pregnant women and infants, lowers intelligence by 10 to 15I. Q. points. In the global food Security Index 2017, Pakistan was on the 77th position amongst 109 countries, a position which it has not improved in the past several years.

A study conducted for the Lancet Global Health in 2015 showed that stunting varies between districts in Pakistan ranging between 22% and 76%. Whilst, the lowest figures for wasting and underweight were both less than 2.5% and the highest was 42% for wasting and 54% for underweight.

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How Society Suffers?

The Economic Consequences of Undernutrition in Pakistan: An Assessment of Losses” report published last year by the Ministry of Planning Development & Reform, calculated the overall cost to society from malnutrition and its consequences, to be $7.6bn or the annual loss of 3% of Pakistan’s GDP.

This would be equivalent to setting up the Diamer Basha dam – which the government has delayed for over 20 years as they did not have the funds and were trying to get them from a donor agency.

The report issued by the Pakistan Scaling Up Nutrition (SUN) secretariat at the Ministry of Planning Development &Reform, in collaboration with the United Nations World Food Programme (WFP), revealed that more than two-thirds of Pakistan’s children suffering from stunting or iodine deficiencies will suffer from decreased mental and physical development, leading to lower school performance and lower productizes adults, depressing GDP by US$3.7 billion annually.

Systems for Nutrition shows that adult earnings are reduced by 2.4% for every 1% loss in potential attained height and the losses to individuals from undernutrition in low-income countries have been estimated as 10% or more of their lifetime earnings.

A Lance lot study published in 2013 showed that these percentages have not changed in the past twenty years. The value of the lost future workforce from the 177,000 children dying each year from malnourishment was estimated at $2.25bn. Children suffering from diarrhea and respiratory infections due to vitamin deficiencies and poor breastfeed in practices cost the country another $1bn.

Over 10 million working adults suffering from anemia suffer from lower productivity that further reduces the economic output of the country by over $650m.

“Malnutrition is a heavy burden – both for the mother of a weak baby, but also for the economy of Pakistan. And each time a malnourished child is born to a malnourished mother, the burden grows. It is possible to reduce these inequalities and to overcome the consequences of undernutrition, but we need to work together, we need to work at a local level, and we need to scale up our interventions for maximum impact.”

Pakistan’s WFP Deputy Country Director Stephen Gluning. A July 2016 study by Global Panel on Agriculture and Food Systems for Nutrition shows that adult earnings are reduced by 2.4% for every 1% loss in potential attained height and the losses to individuals from undernutrition in low-income countries have been estimated as 10% or more of their lifetime earnings.

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Major Causes of Malnutrition

Food: Diets lacking in a variety of healthy, nutritious foods.

Care: Poor infant and young child feeding practices, caregiving and hygiene.

Health: Lack of access to healthcare, diseases, and unhealthy or unsanitary environments.

Poverty: Poor families often have limited access to nutritious foods, quality healthcare, and information about best practices;

Inequality: In many parts of the world, it is women and marginalized populations and ethnic groups that bear the brunt of malnutrition.

The first 1000 days of a child’s life and neurodevelopment sets them up for the rest of their lives. If they do not get the basic food nutrition it decreases their capacity to learn, increases their susceptibility to infection and disease and can lead to a lifetime of lost earnings through the poorer performance at school and lower productivity as adults.

A UN report published in February 2018, Turning Promises into Action: Gender Equality in the 2030 Agenda, as part of its SDG 2030 Agenda, showed that over 48% of Pakistani women have no say in their health. They also eat less nutritious foods than other members of the family as they give them priority over their own needs.

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What can be done to prevent malnutrition?

Unfortunately, public health issues are of least interest to leaders who are not voted for their efficiency or work on public interest and but on the basis of tribal loyalties and what they can deliver on ‘thana’ politics. Punjab, Pakistan’s largest province with over 100 m residents, has shown an overall decline in stunting, yet, has seen a rise in wasting in over two-thirds of its districts.

The Diamer Basha dam – which the government has delayed for over 20 years as they did not have the funds and were trying to get them from a donor agency.

On the other hand, the province has launched an orange Metro project with an estimated cost of Rs162 bn, by comparison, the Punjab government’s health budget is only Rs54 bn and in a province in which 3 out of 4 people do not have access to clean drinking water, only Rs12 bn is allocated to water supply for the over 100 m residents of Punjab.

Similar examples can be found in other provinces. According to a budget analysis done by a Pakistan government research institute only 10% of the health budget is spent on nutrition; and of that, only 10 percent is spent by the government and 90 percent is actually disbursed by development agencies or related NGO’s.

There are some very basic recommendations that the government could ensure through media coverage and its health system; especially by using its Lady Health Workers (LHW) to explain to patients’ optimal practices.

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  1. Improve the general lack of understanding on breastfeeding practices: Pakistan has the highest incidence of bottle feeding in South Asia –yet breastfeeding– nature’s way is the cheapest and easiest way to protect both the woman and her child. The recommended exclusive breastfeeding of children below the age of 6 months is only done in 38% of cases. After which it is recommended that children are given nutritionally rich foods along with breastfeeding.
  2. Fortified foods – explaining the importance of the right complimentary low cost fortified food to be given to babies after 6 months. As well as fortification of staple food for the general population including salt iodization. Treating malnutrition, mostly through fortifying foods with micronutrients (vitamins and minerals), improves lives at a lower cost and shorter time than other forms of aid, according to the World Bank.
  3. Food fortification is a very cost-effective way to reduce malnutrition and is used worldwide. In Pakistan, UKAID is supporting a $48 m food fortification program, where it will see nutrients added directly into staple food consumed in Pakistan into wheat flour, edible oils and ghee at source in mills and factories. They are working with over 1000 mills and over 100 oil producers directly. Providing fortified food and milk to children in schools was another targeted approach used in developed countries for decades.
  4. Distribution of some micronutrients as supplements (such as vitamin A, iron, folic acid and calcium). FAO has calculated that a global annual investment of US $1.2 billion in improving the micronutrient supply through a)supplementation, b) food fortification and/or c) biofortification of staple crops, would result in “better health, fewer deaths and increased future earnings” of up to US$15.3 billion per year: a 13-to-1 benefit-to-cost ratio. India has implemented a bi-annual vitamin A supplement program, something which Pakistan could pursue, similar to its polio drives when it sends polio teams across the country giving drops to children. The Copenhagen Consensus, which look at a variety of development proposals to improve the world, in their 2008 report identified supplementing vitamins for undernourished children as the world’s best investment. They reported that providing vitamin A and zinc supplements to malnourished infants and toddlers under 2 would cost $60 million annually. That would bring a return in lives saved, diseases averted and cognitive benefits gained of just over $1 billion. Similarly, providing iron and iodized salt would cost $286 million a year, with benefits of $2.7 billion.
  5. Improving women’s general condition in society – this would include access to healthcare and family planning, improving their right to economic empowerment, and the right and improving access to education. Studies on nutrition looking at the allocation of food often show that women receive a lower share of household food than men. Gender discrimination, gender roles, and social norms affecting women can lead to early marriage and childbearing, close birth spacing, and undernutrition, all of which contribute to malnourished mothers and children.
  6. Reducing Poverty– this is the root cause of malnutrition since it limits access to nutritious foods and quality healthcare for the poor.
  7. Show political commitment – to systematically address malnutrition and invest in nutrition interventions. This should be combined with clear focused and practical strategies to combat high levels of child malnutrition. With the 18th amendment, health has been devolved down to the provinces creating stakeholder coordination issues which combined with a general lack of importance given to nutrition from policymakers. Clear nutrition policy and national nutritional strategic plans need to be set up for addressing malnutrition in vulnerable groups. The government of Pakistan has worked in collaboration with international agencies and NGOs and implemented initiatives in a sporadic fashion which overall have had little impact on indicators.