Why a holistic approach is vital to tackling childhood malnutrition

Mam Nodanile lives in a so-called last-mile community in Nomadolo, South Africa. The grandmother cares for 12 grandchildren in a rondavel, a traditional one-bedroomed circular hut. The parents of her grandchildren have all either died or left the remote homestead for the city. “I struggle to put together food, to feed them even simple porridge,” she told staff from charity One to One Africa, which is addressing cases of malnutrition among the family. Since 2000, global cases of stunting and wasting — common measures of childhood malnutrition — have reduced. But jointly-researched data from UNICEF, the World Health Organization, and the World Bank warns alarming rates among children aged under 5 still persist. Stunting affected an estimated 22.3% of children in this age group in 2022 — about 148 million. Wasting threatened the lives of an estimated 6.8% or 45 million. But beyond the statistics, the reality is that tackling poor early childhood nutrition is highly complex — solving physical deficiencies alone does not address the extent of the problem. Devex spoke to global development professionals in South Africa, Haiti, Bangladesh, and Colombia who describe how malnourished children can face a lifetime of physical and mental health challenges, even after they receive treatment. They argue that the way to achieve long-term improvements for children is through holistic, community-led interventions that include an educational or stimulating aspect. These include teaching parents about play and encouraging children to speak, as speech and language skills can be delayed by poor nutrition. Holistic care In South Africa, 22.8% of children aged under 5 experienced stunted growth in 2022 due to poverty and food insecurity. “The communities we work in are almost cut off from the world,” says One to One Africa’s head of programs Emma Chademana. “There’s no electricity, no running water, the roads are really bad, there’s literally nothing.” One to One Africa has trained a team of women in the O.R. Tambo district to provide door-to-door care to 5,100 people, including 2,215 children, according to their data. They are known as “mentor mothers” and they walk between villages to prevent, detect, and treat cases of childhood malnutrition. They deliver a broad spectrum of help — from providing antenatal vitamins to pregnant women to rehabilitating children by providing multiple micronutrient supplements, or MMS. They also help to address the manifold problems that result from poor nutrition. “Some severely acutely malnourished children who have since been rehabilitated have multiple health issues,” said Chademana. These children are more at risk of catching infections and may have ringworm, diarrhea, and skin problems, as well as being more likely to have asthma and allergies. They have often missed immunizations. Tuberculosis and HIV affect many households, too. In addition, psychologists and public health experts have also found malnutrition can trigger a toxic stress response — referring to the impact of prolonged stress on health and brain development — in children when experienced in the first few years of life. A study in the British Medical Journal states that malnutrition, among a host of other psychosocial hazards related to experiencing poverty, can “affect a child’s developmental trajectory.” In childhood, this can lead to learning and behavioral problems or early use of alcohol or drugs. In adulthood, such children are more likely to experience poor mental health, be violent, or attempt to take their own lives. “Developmental delays are huge,” Chademana said. “We see delay in their fine and gross motor skills, their language and communication skills, as well as their social relationships skills.” The nonprofit provides food parcels when needed, but it aims to help families support themselves. For example, it helps them to obtain official identification, such as birth certificates, so they can access a government child support grant of 500 rands ($26) a month per child. It also provides carers with nutritional literacy coaching, as well as lessons on budgeting, and giving them seedlings to grow their own vegetables. Chademana explained that carers must understand healthy choices around food. “You need to empower them with what is important … [it needs] a holistic approach,” she said. Changing attitudes In Haiti, cases of severe acute malnutrition, or SAM, among children have “sky-rocketed” following two years of armed violence, according to UNICEF. More than 115,600 children are expected to suffer from severe wasting in 2023, compared to 87,500 last year — a 32% increase. Almost half, 49%, of the country is living in a crisis or emergency food security situation according to the Integrated Food Security Phase Classification. There were also numerous preexisting reasons for poor nutrition including poverty, lack of clean water, limited accessibility in remote regions, cholera outbreaks, and a catastrophic earthquake in 2010. Dr. Anany Gretchko Prosper, country director of the Children’s Nutrition Program of Haiti, or CNP, told Devex that changing cultural approaches to food are worsening the problem. “The new generation believes it is the social aspect of food, more than nutritional aspect, of the food [that matters],” he says. He explained that in households where grandmothers are present, they pass on knowledge about choosing local, seasonal produce. By contrast, young parents living alone buy processed food and lose out on this information. “It is in those houses that we see the most SAM children,” he said, giving an example of a family that spent its limited income on cans of Coca-Cola, as opposed to prioritizing food purchases, because of the status attached to the brand. CNP has recruited over 100 women from communities across Haiti’s Ouest Department — the most populated region and home to the capital Port-au-Prince — who do home visits and hold group meetings to provide health advice and education. These women, called “monitrices” — similar to the mentor mothers in South Africa — educate families about nutrition as well as monitor sick children. Their 12 weeks of training includes learning how to do health screenings, observing immunizations, making trips to food markets, learning how to deliver family planning advice, and studying water, sanitation, and hygiene good practice. “They are like community health workers with a specialty in nutrition,” said Prosper. When they detect a case of malnutrition, they refer the child to clinics or hospitals. CNP also partners with other organizations to provide families with therapeutic foods — a nutrient-dense dietary supplement. However, Prosper emphasizes that having an educational component in the charity’s intervention is critical in the long run. “You spend a lot of time and money to get a child out of a death penalty,” he says. “If you send that child back into the same social context and knowledge system that failed that child previously, there is a high probability of relapse.” Achieving sustainable results Many home-visiting intervention programs to tackle malnutrition alongside cognitive development trace their origins to the Jamaica Home Visit Program, developed in the 1970s by Sally Grantham-McGregor, emerita professor of international child health at University College London. In recent years the model, now known as Reach Up, has been implemented in 16 countries, some with nutritional components. In Bangladesh, Jena Derakhshani Hamadani, an emeritus scientist in the Maternal and Child Health Division at the International Centre for Diarrheal Disease Research, worked with Grantham-McGregor on several trials. In 2012 they published a study of severely underweight children aged between 6 and 24 months found that children receiving stimulation — meaning educational or social activities — or food and stimulation, showed an improvement in their growth in weight. The group that only received food did not. “We don’t emphasize this project, because it is the only project where we found an improvement in the growth of children,” Hamadani says. However, her studies consistently show malnourished children who receive stimulation can improve their cognitive development. “The child who gets more stimulation has a higher IQ, irrespective of their nutritional condition,” she says. “Some nutritionists believe it's only nutrition, and if the child is well nourished, you can improve everything. That's not true: stimulation and paying attention to the child is a lot more important.” Costas Meghir, the Douglas A. Warner III professor of economics at Yale University, has also conducted experiments with Grantham-McGregor in Colombia and India. These focused on early childhood development and nutrition. They showed improvements in children’s cognitive development and language following stimulation interventions. However, anticipated increases in children’s height or weight after receiving nutrients showed no effect. Meghir believes addressing nutrition should be a combination of interventions that always include stimulation. “If you go to a starving population, you have to deal with that because it's an emergency,” he said. “But you shouldn't stop there. It’s not totally clear what their effects are on things like brain development beyond the emergency level. Consequently, a holistic program for child development should include both stimulation and nutrition.” Hunger and learning Is momentum building around this idea? At the U.N. Food Systems Summit stocktaking event in July, the U.N. Deputy Secretary-General Amina Mohammed gave a prominent call to action on childhood nutrition, saying that providing school meals to all children is “the biggest public safety net that we have available to support future generations.” This is the aim of the School Meals Coalition led by the World Food Programme. However, evidence from the professionals in Haiti, South Africa, and beyond, is that it’s important that programs provide more than just food, and reach children before they start primary school too. Brain development research has shown how critical a child’s first 1,000 days of life are for optimal brain development, particularly the role of nutrition. According to UNICEF, “Science suggests that it is far better policy to build the brain right in the first place through nutritional deficit prevention programs than to depend on replacement therapy once a deficit has occurred.” “We’re not saying that food doesn’t matter — being hungry is not a good way to learn,” Meghir adds. “On its own, it solves the hunger problem but, sadly, doesn’t do much more. What we need is strong early childhood programs from birth.” Visit Food Secured — a series that explores how to save the food system and where experts share groundbreaking solutions for a sustainable and resilient future. This content is produced in partnership as part of our Food Secured series, which is funded by partners. To learn more about this series and our partners, click here.