Water and Food Safety are Essential to

Nutrition Goals for Women and Children:

A Health Sector Perspective

Rebecca StoltzfusProgram in International Nutrition

College of Agriculture and Life SciencesCornell University

Division of Nutritional Sciences

Outline

• Child stunting as a priority in global health and development

• Timing: the 1000 days

• The importance of food safety and gut health to overcoming child malnutrition

• Relevance to food security initiatives

• Key Interventions

Together with micronutrient deficiencies,responsible for 1/3 of child deaths globally

Stunting: Invisible Malnutrition105 cm 125 cm 100 cm

7 years 7 years 4 years

• 30% increase in risk of death from infectious disease

• 10% decrease in lifetime earnings

• 7 month delay in starting school

• 0.7 years loss of schooling• Increased risk of NCD’s in later

life

What is causing all this stunting and wasting?

Cause #1: Poor Diet

• Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries– Dewey & Adu-Afarwuah, 2008– 42 studies/programs, most published 1996-2006

• Children who received interventions gained:– 0.0 – 0.76 Z scores weight-for-age– 0.0 – 0.64 Z scores length-for-age

The best studies caused a 0.7 Z score improvement. BUT:

the average growth deficit of African and Asian children is -2.0 Z

At best, diet solved 1/3 of the problem.

Cause #2: Diarrhea

• Between 6-18 months of age, children in developing countries have around 9 episodes of diarrhea.

• Many authors reported that diarrhea accounts for 10-80% of growth faltering

• But others contend that children grow at “catch-up rates” between episodes, and thus recover these deficits

The Lancet Nutrition Series (2008) concluded that by implementing sanitation and hygiene interventions with 99% coverage, child malnutrition would be reduced by only 2.4%

Cause #3: EEEnvironmental

Enteropathy

• A subclinical condition of the small intestine, called environmental enteropathy (EE)

• Characterized by:– Flattening of the villi of the gut, reducing its surface area– Thickening of the surface through which nutrients must be absorbed– Increased permeability to large molecules and cells (microbes)

• Likely causes:– Too many microbes in the gut—worms may also play a role– Effects of toxins on the gut

Decreased nutrient absorption + Infiltration of microbes

Toxins(mycotoxins)

Microbes&

Worms(fecal-oral)

Liver Toxicity

Enteropathy

Diarrhea

Liver Cancer

Stunting & Wasting

Illness & Death

The dual contributions of food safety to child malnutrition

#1 risk factor for all child deaths (malnutrition)#2 cause of all child deaths (diarrhea)

Together: about 2 million child deaths / year

Toxins(mycotoxins)

Microbes& Worms

(fecal-oral)

Liver Toxicity

Enteropathy

Diarrhea

Liver Cancer

Stunting & Wasting

Illness & Death

The dual contributions of food safety to child malnutrition

An unknown fraction of 700,000 adult deaths/year

#1 risk factor for all child deaths (malnutrition)#2 cause of all child deaths (diarrhea)

Together: about 2 million child deaths / year

Toxins(mycotoxins)

Microbes& Worms

(fecal-oral)

Liver Toxicity

Enteropathy

Diarrhea

Liver Cancer

Stunting & Wasting

Illness & Death

The dual contributions of food safety to child malnutrition

Safe Food and Nutritious Foodare both essential to meet child nutrition goals

• Nutritious food is essential to provide nutrients needed for growth and development– Food Aid targeting– Quality of food: nutrients– Quantity

• Safe food is essential to prevent diarrhea and promote healthy gastro-intestinal function (prevent enteropathy)– Quality of food: free from toxins and microbes– Household technologies and behaviors– Prioritizing those behaviors in the feeding of young children

Just a reminder:(Breastmilk is the fundamental safe and nutritious food)

Relevance to food security initiatives

Foods safe fromMicrobes and Toxins

HouseholdHygiene behaviors

Food safety interventions,focusing on microbes and soil-transmitted helminths (worms)

Source: World Bank, accessed 6.23.11http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTWAT/EXTTOPSANHYG/

Playing in the dirt makes kids smart Letitia Rowlands

From: The Daily Telegraph November 24, 2010 12:00AM

Good dirty fun ... Bronte Good and Sebastian LivisianosPic: Nic Gibson. Source: The Daily Telegraph

Maybe in Australia . . . .

But not if the dirt contains pathogens and helminth eggs!

• 100% of household soil samples in rural Zimbabwe contained E. Coli

•Ngure et al., unpublished 2011

• 27% of infants 5-11 months old were infected with helminths in rural coastal Tanzania.

•Goodman et al., Am J Trop Hyg 2007;76(4):725-31.

Feeding young children in rural Zimbabwe, 2010. M Mbuya

If allowed, toddlers consume poultry feces

Peruvian shantytown families:– Households who owned free-range poultry:

• Average ingestion of poultry feces by toddlers per 12-hour observation period was 3.9 times

– Marquis GM et al., Am J Public Health 1990

Rural Zimbabwe:– Not selected for poultry ownership:

• 3 of 7 toddlers directly ate chicken feces during a 6-hour observation period.

– Ngure F et al., unpublished observations, 2011

Case Study:Pilot testing of a fortified instant porridge designed for

complementary feeding of infants in Tanzania

• Food insecure population• High prevalence of stunting• Feeding frequency of infants

too low• Micronutrient deficiencies

common

“This food relieves my problems. In the past the baby was crying of hunger, and I did not have any food to feed her. But nowadays, if my baby is hungry, I prepare the food and feed her and she does not demand eating other foods after eating the new baby food.”

“I like its preparation very much as you do not get in the kitchen to cook it; even her father can prepare it. Also its taste has impressed me; it is like groundnuts, beans, sour taste and maize.”

Paul KH et al., J Nutr 2008; 138:1963-8Instant porridge designed by Instalife, Inc.

Microbial contamination of infant foods in coastal Tanzania

Proportion of food samples with choliform counts exceeding acceptable limit

Kung’u et al., J Health Pop Nutr 2009 27:41-52

Food safety and hygiene interventions: Microbial

• Water treatment– At source

– At household

• Handwashing with soap after fecal contact and before

preparing/serving food

• Avoid feeding leftovers, or reheat

• Separate young children from poultry and household soil

• Safe disposal of feces—especially of children

Forthcoming randomized trialin rural Zimbabwe, highly food insecure

• Outcome: stunting in infants from 0-18 months

Control

Infant Feeding: Education + Nutributter

WASH:Integrated Water,

Hygiene & Sanitation

WASH+

Infant Feeding

Principal Investigator: J HumphreyFunders: Gates, DFID, NIH, UNICEFGrantees: Zvitambo, Johns Hopkins, Cornell