As nutritionists and paediatricians across the globe once again brought the subject of child rights and child health to the discussion table yesterday when we celebrated World Children’s Day, a subject now drawing increasing attention is the rising levels of malnourished children in mostly the underprivileged sector globally and in Sri Lanka.
To find out why Sri Lanka which has excellent parameters of health in every other area, continues to have unacceptable levels of malnutrition among our child population, and its adverse short term and long term health impacts, the Sunday Observer spoke to Senior Professor in Paediatrics, University of Colombo and Hony Consultant Paediatrician Lady Ridgeway Hospital, Prof.Pujitha Wickramasinghe.
Excerpts
Q: Yesterday ( Oct 1) as we observed yet another World Children’s Day. The main focus was on a subject that continues to persist both globally and in Sri Lanka : namely, Malnutrition. That priority has been given to this particular health issue has been welcomed by Lankan nutritionists and paediatricians as a timely significant step forward in a country where child nutritional levels according to recent reports including the nutritional estimates of the Demographic and Health survey 2016/19 have not improved considerably over the years, despite countless interventional initiatives by the Health sector. Do you agree?
A. Nutrition indicators mainly wasting and stunting had not improved beyond a certain point where both have been hovering around 15% or so. Why it did not improve has been a debatable point for many years due to the wide range of likely causes which could be biological rather than just a nutritional problem. I feel that one major fact is low birth weight- the improvement of which is not merely giving nutrition supplements, but improving the health of the girl child and thereby improving the weight of her offspring.
Q: Some recent studies have also attributed persisting malnutrition in children as being mostly linked to evolving socio economic conditions prevailing in our country at present. What is your opinion on this?
A. I agree that under any circumstances, any disturbance to the usual supply of food would lead to malnutrition especially sectors who are marginally malnourished who are at imminent risk of developing malnutrition with the slightest disturbance in food supply. Lack of cooking fuel including kerosene used by the poorest and transport fuel could lead to this. City dwellers are the most vulnerable to these shortages living as they are in overcrowded surroundings with no access to alternative fuel, while those living in semi urban or villages would be less affected, provided they could ensure some local food as well as firewood for cooking.
Q: Rising living costs have also forced both parents to work outside their homes in most households. This has led to a switch from healthy home cooked meals to instant foods which don’t consume much time to enable working parents to reach their workplaces in time. What are the adverse physical and mental impacts that such unhealthy diets can have on the family as a whole including children in the short term and long term. ?
A. The well being and health of both children and adults deprived of freshly cooked home made meals could be affected in many aspects. Firstly, commercially prepared food are mainly targeting business development rather than improving health and nutrition, and therefore lacking in nutrition unlike those freshly plucked from a home garden. In these commercially prepared foods most of the micronutrients required for proper development and growth in children are lacking. Then there are the unhealthy eating habits caused by wrong notions which also adversely impact on children’s health, such as consuming large portions of starch mainly rice with added oil, which increases the calorie content. Consuming such foods over a long period of time could lead to excess calorie consumption which in turn leads to overweight and obesity in the short term. Also many of these foods are high salt, high fat and sugar. Salt and oil addiction takes place where children in short term as well as long term dislike home cooked meals, but demand for outside meals, leading to overweight and obesity problems.
Q: Any toxic elements in one’s daily diet prepared commercially which are likely to lead to short term or long term adverse impacts on both adults and children’s health ?
A. Many of these commercially prepared foods contain chemicals to enhance the flavour, which could pose a health threat in the long term such as cancer. Since many commercial outlets reuse oil it could increase trans-fat content, create reactive oxygen species, destroy favourable molecules such as antioxidants of the food, which would lead to adverse health outcomes such as increase in cholesterol and its related complications, like cardiovascular disease, cancer, hypertension etc. All these factors prove that eating fast foods will lead in the short term to develop micronutrient deficiencies, overweight and obesity and food addictions, while in the long run it would lead to increased incidence of non-communicable diseases.
Q: Recent reports have shown that Sri Lankan children are becoming increasingly obese due to unhealthy eating habits and lack of exercise. Is obesity a symptom of malnutrition?
A. Malnutrition is wrong nutrition. Being overweight or obese is not only a malnutrition state but has been identified as a disease itself. The effects are not sudden and short, but slow and long term . Change of lifestyle not only affects eating habits but also physical activity and sleep, while lack of physical activity increases sedentary behaviour and lack or incorrect patterns of sleep collectively contribute to both forms of malnutrition. To give you an example, lack of physical activity leads to poor appetite as well as poor bone and muscle growth which again contributes to undernutrition. On the other hand late night sleep leads to a significant drain of energy which also Q. Q. So what is the best form of sleep for children ( and adults)? Why?
A. Night sleep is the healthiest sleep as it provides rest with the time for body repair and growth.
Q: So in order to prevent malnutrition in children, could you recommend a balanced diet to give them to ensure they get adequate minerals, starch ,carbohydrates ,calcium and proteins needed for their growing bodies?
A. A balanced diet means having food belonging to 6 main food groups in the daily meal (cereals and starchy food, fruits, vegetables and green leaves, Pulses and animal food (fish/egg/lean meat), nuts andoily seeds and fresh milk and its fermented products). Many believe rice should be the only cereal that one should eat to get energy, but there are many substitutes available such as yams, tubers and fruits that could provide the energy at least for one daily meal.. Challenges we face here is that some foods are restricted owing to certain taboos.
Q: What about fruits?
A. When consuming fruits, its always better to eat them whole and raw, even with the skin after cleaning and washing them well as they provide many health benefits.
Q: Fish and eggs?
A. Small fish as well as dry fish are relatively cheap and affordable and consuming the whole small fish including the center bone would be a good source of calcium. Also use inland freshwater fish. Eggs are also a good protein source. People must look for alternative food, to be the staple rather than depending on rice. Jack, bread fruit, yams, tubers are well known substitutes for rice to provide the much needed. use many alternatives rather than the conventionally determined foods.
Q: Milk ? How essential is it in a child’s daily diet?
A. There are many taboos against the use of liquid milk, but that is the best for consumption. Other nutritious and healthy substitutes for whole milk are yogurt and curd- both of which, in addition to nutrients, also provide healthy bacteria which helps the gut function.
Q: As the poorer sectors of society are the ones who are most affected by the economic crisis, do you have any suggestions on how best they could face this challenge?
A. The poorer sectors will get affected most mainly due to lack of purchasing power. Purchasing essential food items may be difficult due to exorbitant prices of rice, vegetables, fruits, egg and fish. They should try to buy seasonal foods freely available during the harvesting season which are cheaper .
Q: Any skills they need to develop to overcome their seemingly never ending daily struggle to make ends meet?
A. Most of the time where masses have gone wrong is due to poor skills in managing their finances and wrong notions of what are and what are not essential to provide a wholesome meal. They may give more priority to imported foods like milk thinking it is healthier when our locally produced milk is much better.
Similarly they should purchase seasonal fruits and vegetables that are cheaper rather than off season fruits and vegetables which are costlier. There is the question of household food wastage. People in affluent homes especially serve more than they can consume at each meal and throw the rest. Others don’t eat leftover food for various reasons.
The best way to face the current crisis is for people to be flexible in their food choices where at least one meal of rice to be replaced by some other starchy food (jackfruit, yams and tubes) and use available seasonal fruits and vegetables instead of imported ones.
Q: Will strengthening educational programs that correct wrong notions on food, giving priority to nutritional foods and how to cook them healthily, as well as identifying areas for intervention and remedial action help?
A. Not knowing the nutrient and health value of many of the locally available as well as seasonal food is one of the main causes for low nutritional levels of Lankan children.. In addition there are many misconceptions about food and taboos that surround the whole issue of nutritious food.
For example, many mothers still consider a lot of food as ‘heaty’ or ‘cold’ foods and thus prevent children from eating them. These wrong ideas need to be corrected and top priority should be given for this in any educational programme for parents and pregnant women.
This will help to resolve problems that are linked to the pregnancy and lactation period and will help the fetus to have a healthy start especially since food selection during pregnancy and lactation begins in the womb and after birth as well when the fetus and newborn conditioned to certain tastes and leads to food preferences. For example, when children are introduced to certain selected complementary foods early they cultivate a taste for them and refuse to take any other food outside their limited selection.
Q: What is your advice?
A. That parents encourage children to eat ALL varieties of foods instead of selecting a few.
Q: The practice of breast milk feeding has had a favourable coverage in our country with most mothers breastfeeding their newborn upto the first six months. However, in the recent past, some mothers have started switching to artificial formulae earlier citing various reasons. Paediatricians are concerned that this will lead to malnutrition in the infant. Your comments?
A. The benefits of breast milk over artificial formula is a well proven fact. Formula milk can lead to allergies, excessive growth leading to many illnesses later in life. Improper constitution of milk could lead to under and over nutrition and as it provides only a limited number of nutrients could cause many nutritional deficiencies. Children overfed with formula milk could also develop wrong food habits and become overweight and obese.
Q: Your message to parents on preventing malnutrition in their children?
A. Choose a variety of food as it will bring health benefits. No one food item is superior to another. Price does not determine nutritional or health value of food but market forces. Try to find food from around your locality and produce your own whenever possible. Always try to give more priority to balanced meals for the family within your limited budget. Most importantly , give your child a healthy start to life with breast milk which contains all the nutrients he/she needs upto the first six months of his life.