The double burden of childhood malnutrition

The first 1,000 days are among the most important in children's lives, and more needs to be done to ensure that they get optimal nutrition during this critical period. That is the opinion of Professor Terrence Forrester, an expert who has studied the impact of childhood malnutrition on a person's life.

His research has shown that under-nutrition during the early years, including in the womb, can lead to lifelong consequences such as a heightened risk of developing diabetes, high blood pressure, obesity and vascular disease.

Malnourished children's learning ability could also be impaired, reducing their job opportunities in adulthood and affecting countries' economic growth, he said during his lecture at the recent Commonwealth Science Conference 2017 held in Singapore.

Co-organised by Britain's Royal Society and Singapore's National Research Foundation, the four-day event from June 13 to 16 gathered more than 400 scientists from 37 Commonwealth countries, and included plenary discussions and breakout sessions on emerging infectious diseases, sustainable cities, the future of oceans and low carbon energy.

How under-nutrition affects babies

When babies do not receive enough nutrition in the womb, they undergo biological changes that hurt them later in life, said Prof Forrester, who is a professor of experimental medicine at the University of the West Indies (UWI) in Jamaica.

Their bodies learn to expect inadequate nutrition even after they are born, and adapt accordingly to survive, for example by retarding growth in the womb and by promoting the storage of excess energy as fat.

"This predisposes them to obesity later in life, which would also accelerate the elevation of their blood pressure over their lifespan," said Prof Forrester, who has studied the phenotypic differences between well-nourished people and malnourished ones.

He added, however, that such biological adaptation also improves their odds of survival if they experience severe acute malnutrition in the first few years of their lives.

Working with scientists from Britain and New Zealand, he had examined the records of the 1,336 children admitted with severe acute malnutrition to the Tropical Metabolism Research Unit Ward at the University Hospital of the West Indies in Jamaica between 1962 and 1992.

Children who suffer such malnutrition can develop syndromes with very different consequences. Some children develop oedematous syndromes, namely kwashiorkor and marasmic kwashiorkor, where fluid accumulates in their tissues.

These children may look fat or swollen even though they are malnourished, and they have a much higher risk of death compared to those who develop non-oedematous syndromes such as marasmus.

Prof Forrester and his team discovered that children with lower birth weight -- indicating less nutrition in the womb -- tended to develop the non-oedematous syndromes, while those with higher birth weight were more likely to develop the oedematous ones.

He said: "Our research showed that the children with lower birth weight had a metabolic response to severe under-nutrition that aided their survival, resulting in the more benign syndrome of marasmus."

His findings have tremendous implications for how aid agencies should approach famine situations: "We may need to pay more attention to children with higher birth weight, as they may be at greater risk of death."

The double burden of malnutrition

The complexities and nuances of childhood malnutrition is why more research is needed in the field, said Prof Forrester.

He noted that childhood malnutrition is a global scourge, with 159 million children worldwide stunted and another 50 million children wasted. Under-nutrition is also a factor in 45 per cent of all childhood deaths that occur under the age of five.

Even when children survive severe acute or severe chronic malnutrition, they suffer from poor brain development and cognitive impairment. This makes them more likely to fail in school, which in turn constrains their economic activity in adulthood.

This "double burden" of malnutrition can be very costly for countries. In African and Asian countries where malnutrition is a massive problem, labour productivity losses due to malnutrition have been estimated to range from 3 per cent to 16 per cent of their annual gross domestic product.

"We need to understand more about the molecular, metabolic and physiological substrates that underlie the adaptation to sustained under-nutrition. That knowledge will help us to customise not only life-saving care to reduce childhood mortality, but also to improve long-term health and performance outcomes," said Prof Forrester.

He is currently helping to develop research-based interventions to prevent the negative biological changes that occur as a result of severe malnutrition. He is also studying malnutrition in African origin populations living in different environments.

He continues to head UWI's Solutions for Developing Countries division, which aims to find answers to medical and socio-economic problems affecting small and developing countries. He was also the founding director of UWI's Tropical Medicine Research Institute.

Over the years, Prof Forrester has advised numerous health organisations, including Britain's Medical Research Council, the United States Centres for Disease Control and Prevention, the Caribbean Health Research Council and the World Health Organisation (WHO).

He has also served as an ad hoc working group member on the WHO's Commission on Ending Childhood Obesity. "That involved working with scientists from all over the world, to gather and interpret research and other data to inform strategies to end childhood obesity," he said.

He has more than 200 peer-reviewed publications to his name, and has received several awards, including the Anthony N. Sabga Caribbean Award for Excellence and the Order of Jamaica, one of the highest honours in the country.

He urged governments and organisations to invest more in childhood nutrition. He said: "By making sure that our children get optimal nutrition during their first 1,000 days of life, we can help to prevent the devastating, lifelong consequences of childhood malnutrition, and enable them to grow up to be healthy, educated and productive members of society."