Interview with malnutrition expert, Prof Mike Golden

Professor Mike Golden of Britain is a world-renowned expert in nutrition. While in Ethiopia, launching a new approach to tackle severe malnutrition, he told IRIN that the first step in a country’s development is to put good quality food in a baby’s mouth.

QUESTION: Is malnutrition just about not having enough to eat?

ANSWER: By the time a child becomes severely malnourished, at that stage it is a severe medical disease with all the organ systems in the body about to collapse. When we study children who reach this state the results you get back are not dissimilar to someone in an intensive care unit in the United Kingdom.

Q: What are the health problems associated with malnutrition?

A: They have gradually reached this almost terminal phase through a whole process of becoming malnourished. Much of the problem with nutrition is not the quantity of food but the quality of food. You need about 40 different nutrients to be healthy.

Q: What are the symptoms of deficiency?

A: The symptoms of deficiency of about seven or eight of these nutrients are lack of growth so people don’t grow properly and they end up stunted in height. Some 50 percent of Ethiopian children are stunted in height, they haven’t been growing properly. In Africa as a whole, just under 40 percent of its children are chronically malnourished. We are talking about very large numbers of children – not trivial numbers - and this is due to a poor quality diet.

Q: What impact will disease have on a malnourished child?

A: If you have a poor diet it makes you less able to resist disease, so the diseases come more frequently and they last longer. And when you get over your diarrhoea or respiratory chest infection or your coughing or cold, if you are on a poor diet you don’t have the convalescence so you don’t regain the weight you have lost. So you stutter from infection to infection. The underlying cause of malnutrition is not the infection, it’s the poor quality diet.

Q: So is malnutrition or disease the killer?

A: One of the problems is if you are on a poor quality diet you are not growing, you become immune competent and you catch measles and you die from measles, and measles in Africa is a real killing disease. In Europe it's not a killing disease... The difference is malnutrition. So if I am malnourished and get measles I die, if I am well nourished and I get measles I rapidly recover. What have I died from? Have I died from the measles or I have I died from the underlying cause that is malnutrition? It’s a bit like HIV. If you have pneumonia and the underlying thing is HIV, your death certificate will read HIV not pneumonia.

Q: If, as you say 40 percent of children are suffering from chronic malnutrition, that covers other areas not just drought-affected areas?

A: It covers the whole continent. There are some areas where it is very much higher. You go up to 80 or 90 percent of the children in the UNITA-held areas of Angola, for example, who are chronically malnourished. You go to the MPLA areas of Angola and we are talking about 37 or 38 percent who are chronically malnourished.

Q: So, you are saying it’s not to do with the drought it is political. Are there other reasons?

A: Of course. You will find something like 20 percent of the children in Nairobi to be chronically malnourished. There is no war, there is no drought, it’s an urban centre, but these people are living in slums, slum conditions, economic depravation and all the rest of it. It is going to get worse because of HIV and the removal of carers. Whether you are HIV negative or positive it doesn’t really matter if your mum and dad are dead, because you don’t have anyone to care for you or bring in the money to look after you. These can be HIV negative children who are not going to die from AIDS, but they are going to die from malnutrition.

Q: What would be the difference between a chronically malnourished five year old and one who is not?

The chronically malnourished child not only has stunted physical development, it also has stunted mental development. This tends to be long standing. There are really quite good studies done in Barbados, which had a chronic malnutrition problem, but with tourism, it has become a wealthy country. But you can still recognise the ones who were malnourished 40 years ago. They did worse at school, they have poorer work records, they are more likely to be imprisoned, they are more likely in this context be child soldiers, or prostitutes.

The most dangerous African animal is a 12-year-old with a kalashnikov who would have been a malnourished child. If a country in Africa really wants development, it has to put good food in the mouths of its babies. There is no other way to develop than to put good food in the mouths and build up the human resource of the country.

Q: What has gone wrong in the past in treating malnutrition?

A: Really what has been wrong in the past are the underlying concepts of the probation of malnutrition. If you think that the underlying concepts of kwashiorkor, that is where you swell up with too much fluid then your skin strips off, and you die very readily. It was thought this was due to protein deficiency. We now know it is not due to protein deficiency, it is due to deficiency of a series of micronutrients that protect us against oxidation, against going rancid. If you don’t have enough of these in your diet then your cell membranes and parts of your body can go rancid in the same way.

It is much more likely that this happens if you have measles or you have an infection which will precipitate the kwashiorkor. Indeed we now treat kwashiorkor with a low protein diet because we found the liver damage that occurs in kwashiorkor means the children can’t handle a high protein diet. So the old ideas of giving them a high protein diet actually caused their deaths. When we reduced the protein in the diet of children being treated for kwashiorkor to moderate or low levels, we cut the mortality by half.

Q: So why were mistakes made in the past?

A: I wouldn’t say they were mistakes, I would say that they were built on an incorrect theoretical framework which has arisen from before the second world war. During the second world war, during relief to prisoner of war camps, they were giving people high protein diets to recover and it wasn’t successful then. Then after that the idea that kwashiorkor was just a
protein deficiency arose and was going without serious challenge until the 1980s, and of course there are vested interests of all types of maintaining this idea. The textbooks are full of it. The teaching around the world hasn’t changed so the ideas, even the very word protein energy malnutrition, is an anachronism it is not correct. We should be calling it severe malnutrition, not protein energy malnutrition.

Q: Have the new methods been successful?

A: The answer is we went into Burundi in about 1997, set up a national protocol, all the NGO’s and the national institutes were using this and we were getting data back from the whole country. And between 30,000 and 60,000 severely malnourished people were being treated each year and the mortality rate was six percent.

Now this is to be compared with most hospitals in Africa, even mission hospitals and hospitals being run by European doctors, where the mortality rate is 30 or 40 percent. I mean the difference is absolutely startling. The national data for mortality for the treatment of severe malnutrition in Angola last year was seven percent. And in most places where they are introducing these protocols, they are getting mortality rates of 10 percent or less. We treat adults the same way and it works. We estimated we were saving something like eight to ten thousand lives in Burundi since 1997. So in Burundi, with this protocol, we have averted 50,000 deaths.

Q: With such success are you getting any resistance to implementing these techniques?

A: There is really no resistance when we come and talk to them. There is resistance when they get material to read from abroad, maybe it's in a different language which contradicts what is in their own text books, what their own teachers have been telling them. We also find there is an enormous resistance in the medical profession in particular, when nurses come and implement new methods and nurses try and tell the professors and the doctors what to do. There is a lot of arrogance and chauvinism and resistance to change in the medical profession. This is a major problem.

Q: In essence what is the new programme that you are talking about?

A: One of the major discoveries we made was the sensitivity of these children to sodium. If you over diagnose dehydration inappropriately, if you give them intravenous fluids, if you give them blood transfusions, they will die within 24 hours of getting these things. They are very sensitive to misdiagnosis.

Of course children with kwashiorkor have too much fluid in their body already and then you will get someone who will come along and put fluid into them which overloads their heart. Most of these children die from cardiogenic shocks, from overload of the heart. So at the moment we are restricting what we give in terms of sodium and we have designed new diets, one diet - the starter diet is very carefully designed with a balance of nutrients, which is effectively a drug to treat severe malnutrition.