1. Division of Nutritional Sciences
Water and Food Safety are Essential to Nutrition Goals for Women and Children: A Health Sector Perspective
Rebecca Stoltzfus
Program in International Nutrition
College of Agriculture and Life Sciences
Cornell University

2. 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

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

4. Stunting: Invisible Malnutrition
105 cm cm cm
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
Here is invisible malnutrition.
The two children on the right are well nourished. The child on the left was severely malnourished. In this picture he is 7 years old, but is only as tall as a four year old child who never had malnutrition. In Guatemala, from which I think this picture comes, many children are like this stunted child without ever having kwashiorkor or marasmus. They never appeared malnourished to the clinical eye. Their malnutrition is invisible
7 years
7 years
4 years

6. What is causing all this stunting and wasting?

7. 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
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.

8. 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%

9. Cause #3: EE Environmental 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

10. The dual contributions of food safety to child malnutrition
Liver Toxicity
Liver Cancer
Toxins
(mycotoxins)
Stunting & Wasting
Enteropathy
Microbes
& Worms
(fecal-oral)
Diarrhea
Illness & Death

11. The dual contributions of food safety to child malnutrition
Liver Toxicity
Liver Cancer
Toxins
(mycotoxins)
#1 risk factor for all child deaths (malnutrition)
#2 cause of all child deaths (diarrhea)
Together: about 2 million child deaths / year
Stunting & Wasting
Enteropathy
Microbes
& Worms
(fecal-oral)
Diarrhea
Illness & Death

12. The dual contributions of food safety to child malnutrition
An unknown fraction of 700,000 adult deaths/year
Liver Toxicity
Liver Cancer
Toxins
(mycotoxins)
#1 risk factor for all child deaths (malnutrition)
#2 cause of all child deaths (diarrhea)
Together: about 2 million child deaths / year
Stunting & Wasting
Enteropathy
Microbes
& Worms
(fecal-oral)
Diarrhea
Illness & Death

13. (Breastmilk is the fundamental safe and nutritious food)
Safe Food and Nutritious Food are 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)

14. Relevance to food security initiatives

16. Foods safe from
Microbes and Toxins
Household
Hygiene behaviors

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

18. Source: World Bank, accessed 6.23.11

19. Good dirty fun ... Bronte Good and Sebastian Livisianos
Playing in the dirt makes kids smart
Letitia Rowlands
From: The Daily Telegraph
November 24, :00AM
Good dirty fun ... Bronte Good and Sebastian Livisianos
Pic: 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):

20. Feeding young children in rural Zimbabwe, 2010. M Mbuya

21. 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

23. Case Study: Pilot testing of a fortified instant porridge designed for complementary feeding of infants in Tanzania
“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.”
Food insecure population
High prevalence of stunting
Feeding frequency of infants too low
Micronutrient deficiencies common
“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.”
Instant porridge designed by Instalife, Inc.
Paul KH et al., J Nutr 2008; 138:1963-8

24. 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 :41-52

25. 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

26. Forthcoming randomized trial in rural Zimbabwe, highly food insecure
Outcome: stunting in infants from 0-18 months
Control
WASH:
Integrated Water, Hygiene & Sanitation
Infant Feeding: Education + Nutributter
WASH +
Infant Feeding
Principal Investigator: J Humphrey
Funders: Gates, DFID, NIH, UNICEF
Grantees: Zvitambo, Johns Hopkins, Cornell