A Vision for Nutrition Research in Asia

Introduction

Asia is the largest and most populated continent in the world with 2 very large countries, India and China, accounting for over 2 billion people. The continent of Asia covers 29.4% of the Earth’s land area and has a population of around 4.5 billion (as of 2015), accounting for about 60% of the world population. The combined population of both China and India are estimated to be over 2.7 billion people as of 2015. Asia is home to 49 countries usually grouped under 6 main regions: Central Asia (Turkic peoples, Iranian peoples, Mongols, Russians); East Asia (Chinese ethnic groups (historical), Sino-Tibetan peoples, Japanese people, Koreans); Northern Asia (Indigenous peoples of Siberia; Finno-Ugric peoples; Tungusic people); South Asia (India, Pakistan, Dravidians, Indo-Aryans, Munda people); Southeast Asia (Austronesian peoples, Tai peoples; Cambodia, Indonesia, Laos, Philippines, Vietnam); and West Asia (Arab people, Jews, Samaritans, Druze, Peoples of the Caucasus [transcontinental], Ethnic minorities in Iran, Ethnic minorities in Iraq; Iranian peoples, Turkmen, Turks). With rapid industrialization, Asian countries are facing both undernutrition and overnutrition or the so-called double burden of malnutrition.¹

Large discrepancies in the prevalence of maternal and child undernutrition are observed among countries in this region. The prevalence of low birth weight, stunting, and wasting were 3 to 6 times higher in south Asia than south-east Asia/Pacific regions, whereas overweight/obesity was comparable (4%-5%). The prevalence of low birth weight ranges from 3% in China to 28% in India. Low birth weight is associated with later adult chronic disease, and there is good biological evidence for fetal programming for later risk of chronic disease as well as intergenerational passage of risk. Pregnancy during adolescence poses an important additional risk to poor fetal growth, especially where stunting and anemia among young girls are high/severe. Gestational diabetes mellitus (GDM) is a major concern for high-risk pregnancies. Recently, GDM was reported to be increasing in China, Hong Kong, Thailand, India, and Pakistan but not in Japan and Korea. The overall prevalence was 3% to 5% in many countries but much higher in India. Studies in the United States, which include race/ethnicity, reported that Asians seemed to be more prone to developing GDM. Higher prevalence of GDM was found among Asians (9.9%) and Filipinas (8.5%); occurrence of GDM was at relatively lower body mass index (BMI) thresholds (22.0-24.9 kg/m²).²

Although micronutrient deficiencies and under-nutrition, wasting, and stunting are quite high, increasing trends of obesity and related chronic diseases are being noted among most countries in Asia.³ The overall prevalence of under-5 stunting was 26.8%, wasting 10.1%, and overweight 5%. The prevalence of stunting ranges from 10% in China to 58% in Timor-Leste and for wasting ranges from 2% in China to 20% in India. Recent surveys among children in 4 countries (Indonesia, Malaysia, Thailand, and Vietnam, the south-east Asia nutrition surveys) have also revealed that micronutrient deficiencies persist, although the severity was mostly mild to moderate. Anemia was still prevalent and complicated by other causes in addition to iron deficiency. In Vietnam and Indonesia where vitamin A supplementation has been a national program, the prevalence of vitamin A deficiency was low; subclinical vitamin A deficiency was present in all Asian countries. Insufficiency of vitamin D has been reported to be surprisingly quite high, including in the more tropical regions of Asia, and its cause needs to be elucidated. Exclusive breast-feeding (EBF) varied widely with a regional average rate of early initiation of breastfeeding at 41% for both East Asia and Pacific and South Asia, whereas EBF prevalence was only 30% and 49%, respectively. High EBF until 6 months was observed in a few countries, namely, Bangladesh (64%), Cambodia (74%), Nepal (70%), and Sri Lanka (76%) although much lower.⁴

As countries have industrialized, traditional dietary patterns have changed toward market-oriented food availability. Purchasing foods has replaced their production in the home to the extent that fewer foods, and those with higher energy density, are more commonly consumed than in the past. Consumption of (processed) vegetable oil/fried foods, animal food sources (meat and milk), sugar/sweetened beverages as well as salty savory snacks has increased. Eating away from home and purchasing readily cooked, processed foods, and street foods are common in Thailand and other countries in south-east Asia. This transition, combined with a sedentary lifestyle (ie, less daily energy expenditure), results in an energy imbalance. The Cebu Longitudinal Health and Nutrition Survey⁵ showed a shift in dietary patterns associated with changing socioeconomic status and urbanization. Both mothers and offspring consumed more energy-dense foods with higher contributions from fat and lower contributions from carbohydrates. At present, the prevalence of overweight/obesity was only 1% in Sri Lanka but 12% in Indonesia and has the potential to grow much further into a public health problem. In addition, it is likely that in South Asia, the prevalence of excess adiposity is likely to be high at normal BMI in children and adults.⁶ This has also been associated with early onset of insulin resistance, type 2 diabetes, or even metabolic syndrome among South Asians.^7,8 Thus, monitoring the weight and perhaps even the adiposity of children, while public health efforts to reduce stunting are implemented, is a critical part of reducing the double burden of malnutrition.

Below, some case studies are presented from the region to highlight/illustrate the public health and nutrition (PHN) scenario in Asia, although these are limited to the most populous countries, South Asia, and some South-East Asian countries. Northern, West, Central, and East Asia have not been represented here.

China

With about 1.4 billion people as per United Nations (UN) estimates and life expectancy of approximately 75 years, China is experiencing multiple forms of malnutrition. The Fourth National Nutrition and Health Survey showed that China is facing the dual challenges of nutritional deficiencies and overnutrition.⁹ In 2013, the prevalence of stunting, underweight, and wasting among children younger than 5 years in poor areas were reported to be 18.7%, 5.2%, and 3.0%, respectively, in contrast to the prevalence of 8.1%, 2.4%, and 1.9% in the overall China. The under-5 mortality reduced from 45.7 and 13.8 (per 1000 live births) in rural and urban areas in 2000 to 19.1 and 7.1 in 2011, and the maternal mortality reduced from 69.6 and 29.3 (per 100 000 live births) in rural and urban areas in 2000 to 26.5 and 25.2 in 2011. However, inequalities in maternal and child health (MCH) between urban and rural areas, between different regions, and between different population groups still exist, and the overall development of MCH service network is lagging behind.⁵ China is also facing a severe decline in breast-feeding. Statistics show that the proportion of EBF among infants younger than 6 months dropped to 20.8% in 2013 from 27.8% in 2008, much lower than the world average of 38%.⁴ On the other hand, the prevalence of child overweight and obesity has been rising rapidly—from about 5.4% in a poor area of mid-western China in 2009 to about 13.5% and 9.9%, respectively, among a small sample of children in low-income groups in 2011.¹⁰ The dramatic increase in nutrition-related chronic diseases, such as obesity, hyperlipidemia, diabetes, cardiocerebral vascular disease, and cancer, has raised the demand for PHN services in China.⁹

India

India, like China, is simultaneously battling several nutrition issues—undernutrition on one hand and rising prevalence of overweight and obesity on the other. Latest figures¹¹ reveal that of the total 150.8 million stunted (low height for age) children in the world, India is home to 31% of them (approximately 47 million), while half of all wasted (low weight for height) children (approximately 25.5 million) across the globe are in India. In India, per the National Family Health Survey 4 (NFHS-4), only 41.6% children younger than 3 years were breast-fed within 1 hour of birth, while only 54.9% children were exclusively breast-fed until 6 months. This is further exacerbated by the wide prevalence of multiple micronutrient deficiencies in both the abovementioned clusters of malnutrition. There is considerable variation across districts (from 12.4% to 65.1%)—239 of the 640 districts in India have stunting levels above 40% and 202 have prevalence of 30% to 40%.¹² A granular analysis of NFHS-4 data shows spiraling overweight and obesity trends, and not even a single state in India (of 29 states and 7 union territories) has reported a decline in overweight/obesity in the past few years. It is well known that these multiple forms of malnutrition (MOM) predispose the population to the noncommunicable diseases and shorten their productive years of life and overall health.¹³ In agreement, the prevalence of diabetes and hypertension rates is increasing, especially among the younger populations and pushing them toward earlier cardiovascular morbidity and mortality.¹⁴ Almost every benevolent policy to improve the state of nutrition in poverty has been considered and passed into legislation in India.¹⁵ These range from micronutrient supplementation in pregnancy, early childhood, and adolescence, to cooked food provisions for very young and for school children, to the provision of subsidized grain and employment for the families in poverty. That poverty and malnutrition persist are symptoms of a systemic failure of implementation. In addition, PHN policies for food security that address only calorie sufficiency do not guarantee nutrition security. On a positive note, these programs have recently been buttressed by the beginning of universal health coverage that provides for health and wellness centers for the provision of comprehensive primary health care.¹⁶

Bangladesh

Bangladesh is seen as a successful example of considerable progress in nutrition in the recent years.^17,18 For example, the proportion of children younger than 5 years moderately or severely stunted has declined from 55% in 1997, to 41% in 2011, and 36% in 2014 (17). A study conducted in Dhaka city illustrates that the height of mothers, birth weight of children, education level of fathers, knowledge of mothers on nutrition, and frequency of feeding have been identified as significant factors that have independent and direct influences on the stunting of preschool children.¹⁹ Breast-feeding rates are increasing such that the prevalence of EBF has been reported to be 55%.³ But high rates of undernutrition still exist. In 2009, 9.5% of children aged 6 to 15 years were overweight and 3.5% were obese. In 2013, 23% of women were overweight or obese (BMI at or above 25 kg/m²), an increase of 6% points from 2011.²⁰

Nepal

In the 1990s, Nepal had some of the highest levels of undernutrition globally, with almost two-thirds of young children being stunted.²¹ However, from 2001 to 2011, Nepal experienced the fastest recorded reduction in stunting in the world despite political and social turmoil.²² Improvements in child growth scores and stunting rates are strongly associated with health and nutrition interventions, particularly utilization of antenatal and neonatal care, which have expanded rapidly over time. Major government programs have explicitly targeted ambitious improvements in antenatal, neonatal, and postnatal care through rapid expansion of health extension workers as well as financial incentives. Maternal education gains and wealth accumulation are other salient factors predicting sizable nutritional gains. Rapid improvements in sanitation, especially reduction in open defecation, have also contributed to this success.²¹ A lot still needs to be done in Nepal. According to the Nepal Demographic and Health Survey 2016,²³ about 17% adults were underweight while 31% were overweight/obese, confirming the coexistence of double burden of underweight and overweight/obesity among Nepalese adults. The prevalence of both underweight (women 18.30% and men 15.83%, P < .001) and overweight/obesity (women 32.87% and men 28.77%, P < .001) was higher among women.²⁴ The survey also reported that the initiation of breast-feeding within the first hour of life ranges from 45% to 70% in different provinces of Nepal. About 66% of children aged 0 to 5 months are exclusively breast-fed. Only 47% of children aged 6 to 23 months are receiving diversified diets, and 36% of them receive a minimum acceptable diet. Anemia is a major issue—53% of children younger than 5 years and 69% of children aged 6 to 23 months are suffering from anemia. Similarly, 44% of adolescent girls, 46% of pregnant women, and 41% of reproductive-age women are suffering from anemia.^25,26

Sri Lanka

The Global Hunger Index 2017 puts Sri Lanka in 84th position among 119 countries. The same index ranked India as 100, Pakistan 106, Nepal 72, and Bangladesh 88.²⁷ Although Sri Lanka performs well in most health indicators, child nutrition is still a major challenge. Sri Lanka Human Development Report 2012²⁸ revealed that poor nutrition is the chief cause of multidimensional poverty based on 10 indicators representing health, education, and living conditions. Recognizing the importance of improving the nutritional levels, National Nutritional Policy (NNP) was initiated in 2010. However, recent nutritional estimates of Demographic and Health Survey 2016/2017²⁹ reported that among children, stunting was 17.3% prevalent, wasting 15%, and underweight was 20.5%. While thin (BMI <18.5) women were 9%, overweight (BMI≥25) were more than 45% according to the survey.

Thailand

From the late 1980s, Thailand made notable progress in child nutrition. The prevalence of stunting (low height-for-age) among children younger than 5 years declined significantly from 23% to around 16% from 1987 to 2006. However, such impressive progress experienced some stagnation between 2006 and 2012. Nevertheless, recent survey results indicate progress in reducing stunting prevalence. In 2015 to 2016, stunting prevalence among children younger than 5 years was under 11%. In a similar trend, the prevalence of child underweight (low weight-for-age) fell drastically from 16% to 7% from 1993 to 2006, and prevalence of wasting (low weight-for-height) fell from 7% to 5% in the same period. Yet from 2006 to 2012, the prevalence of both underweight and wasting rose slightly before seeing modest declines in 2015 to 2016. Iron-deficiency anemia has been rampant in Thailand.³⁰ The prevalence of anemia among children younger than 5 years saw huge reductions from 41% in 1990 to 25% in the early 2000s but has been gradually increasing to reach 30% in 2011.³¹ The prevalence of anemia in reproductive-age women was about 24%. In 2010, about 43% of pregnant women were found to have low urinary iodine concentrations. Overweight among children younger than 5 years has been steadily rising, from 1% in 1987 to 8% in 2006 and 11% in 2012, although with a recent decline to 8% in 2015 to 2016. While 12% of men and 17% of women were overweight in 1990, the prevalence is now 26% and 33%, respectively, as of 2014. In 1990, only 1% of men and 3% of women were obese; now, 6% men and 11% women were obese in 2014.³²

Indonesia

With a population of 240 million, Indonesia is the world’s fourth most populous country after China, India, and the United States. The national average population density is 109 people/km², but there are large differences between the islands, from Java with 951 people/km² to Kalimantan with only 20 people/km². There is evidence of overweight, underweight, and stunting among young children, indicating that the double burden of malnutrition is already a concern in Indonesia.³³ Traditionally, Indonesia has prioritized undernutrition, paying special attention to “Gizi Buruk” or severe underweight as a way to judge the national nutritional situation. However, by this measure alone, nutritional issues appear largely resolved, as the prevalence of gizi burukis just 5.4% in children younger than 5 years. However, 36% of children younger than 5 years are stunted and about 13% wasted. The Indonesian Family Life Surveys, representative of 85% of the population, indicate that over a 15-year period, the proportion of thin men and women decreased considerably while the proportion of “gemuk” (obese/overweight) men and women nearly doubled.³⁴ This suggests that underweight is declining and overweight is increasing in Indonesian adults.³³

Emerging Issues

Poverty and other social inequities are associated with poor nutrition in Asia. Migration and displacement are also important issues. As industrialization proceeds at a high rate, migration from rural areas to cities (or from city to city) is on the rise, with the expectation of better economic opportunities. This also creates a new class of urban slum poverty, in which substantial changes to a sedentary lifestyle and access to energy-dense processed foods occur. For example, an analysis of internal migration in India (urban to urban, or rural to urban migration) showed that it was associated with an increased risk of being overweight, particularly among women.³⁵

A lot of attention is being devoted to improving PHN. Leaders and experts in this space are now pushing for integrated holistic approaches over piecemeal solutions/interventions to solve MOM. Several sectors but especially nutrition, environment, agriculture, and health need to be together as integrated initiatives; this includes initiatives at the household level as well as those that address structural and social issues. One example is the World Economic Forum’s New Vision for Agriculture initiative,³⁶ which has been bringing together agents from private, public, and civil sectors to work on market-based solutions to the development of inclusive and sustainable agriculture in the region. With local leadership from governments and companies, these partnerships have been active in Vietnam and Indonesia and are being defined in Myanmar. Anchored within the country’s national agriculture strategy, they focus efforts to strengthen priority value chains—ranging from crops such as rice and potatoes to palm oil, coffee, tea, and cocoa—and aim to increase farmer productivity and profitability while reducing detrimental environmental effects. For example, in Indonesia’s rice partnership, a successful first trial resulted in 17% higher yield and income for farmers while reducing water usage by 20% and greenhouse gas emissions by 0.04 ton of methane/ha. The program aims to reach 5 million rice farmers on more than 1 million hectares by 2020. Some other ongoing initiatives or planned interventions in the area of PHN from China, India, and Sri Lanka are discussed below.

China’s National Program for Food and Nutrition (2014-2020)³⁷ recommends that food quantity and quality are equally important; production and consumption should be balanced; inheritance and innovation in development should be equally considered; and guidance and intervention should be integrated. It sets up clear food and nutritional goals for 2020, including food production, food processing, food consumption, nutrient intake, and nutritional diseases control. It proposes 3 major activities—building up a stable and effective food quantity security system with strong supervisory control; a complete food quality security with effective monitoring; and a nutrition improvement system that can guide people’s consumption and could be regularly evaluated. The Program singles out 3 food products, 3 key regions, and 3 vulnerable groups as priorities to improve food and nutrition. The 3 food products are high-quality edible agricultural products, instant and nutritional processed food, and dairy and soy products. Three key regions are poor areas, rural areas, and newly urbanized areas with a large migrant population. The 3 vulnerable groups are pregnant and lying-in women and infants, children and adolescents, and the elderly.

India has a bouquet of programs and policies designed to tackle malnutrition, especially undernutrition, wasting, and stunting. India is home to 31% of all stunted children and half of all wasted children across the globe. Lately, it took a major step in the direction of holistically addressing the mammoth multidimensional problem of malnutrition—the National Nutrition Mission (NNM, or POSHAN Abhiyaan) to achieve the goal of malnutrition-free India by 2022. The NNM is a recently launched ambitious holistic platform for promoting PHN by a wide list of activities and initiatives.³⁸ Maternal and child health and nutrition is also an important focus area. The Ministry of Women and Child Development has launched a Swasth Bharat Preraks (SBP) Program³⁹ as an opportunity for India’s young leaders to contribute to nation-building by catalyzing effective and successful implementation of the NNM. These SBPs are being trained and expected to be the game changers for fast-track implementation of the NNM. The programs addressing prevention and management of overweight obesity and NCDs are still evolving. A growing recognition and discussion around these topics in multiple government and nongovernmental forums are noted, but robust interventions are still awaited.

Sri Lanka also drafted its NNP in 2010, which has recognized the importance of targeting of nutritional interventions to underserved areas, the plantation community, urban poor, and conflict-affected areas. Further, it has identified the necessity to promote behavioral change among the population, enabling them to make right food choices and care practices. Such awareness programs on health and nutrition should also cover complementary feeding and health promotion among children and adolescents. The policy also emphasizes the role of local community organizations in program planning, implementation, and robust monitoring of nutrition intervention programs.²⁶ It was noted that traditional eating habits were being replaced by the globalized food system of ultraprocessed foods, which, in turn, was promoting rise in noncommunicable diseases, such as cancer, diabetes, cholesterol, and kidney disease epidemics, in Sri Lanka.⁴⁰

Future Projections

There are 2 major areas in PHN that need attention from academics and researchers on the programmatic and policy fronts. A primary concern is the correction of and improvement in diets being consumed. In general, the Asian diet has placed less emphasis on meat and milk and more on cereals, fish, fruits, and vegetables. This is changing, as the economic growth in Asia along with greater urbanization has seen diets changing toward more processed foods with more fat and refined carbohydrates, along with more milk and meat, with less cereals.⁴¹ This change, along with the needs of an increasing population, has implications for greater water usage for food production⁴² as well as the greater production of greenhouse gases.⁴³ In South Asia, the diets are even more cereal centric, and although diversity has increased over time, this has not been sufficient, and poverty is still associated with less diversity. However, in urban areas, and as wealth increases, there is a similar change in diet toward less cereals, more refined and processed foods, eggs, poultry, and milk, with similar implications on the environment. As the population grows, more food must be produced. It is not clear how this could be managed effectively, given the potential for lower agricultural yields and lower nutrient content due to climate change and shocks as well as declining water availability. Addressing these gaps is very important, through intelligent land use, and the use of different input strategies to increase yield while being mindful of the nutrition content of the crops⁴⁴ as well as the impact on the environment.⁴⁵ Output strategies, such as procurement of produce, the appropriate minimum support price for crops and equitable access to markets is also important, as in many countries, significant agricultural production is through small farm holdings. Continuing with this theme, given the large numbers of small and subsistence farmers (as well as landless laborers who work on farms), a large proportion of food consumers are the farmers themselves. Most tend to sell all that they produce, assuming that channels for sale are available, keeping very little for their own consumption. In addition, the diversity of food production and consumption is low. Many factors conspire toward the low diversity of food production; this is weighted heavily in favor of the production of calories (cereals), rather than other quality foods such as legumes, which are beneficial to the land they are grown on. This is evident in other specific commodities, such as fruits and vegetables, where, for example, in India, their diversity is low and dominated by the primary production and consumption of starch-heavy potatoes and bananas.⁴⁶ The lack of diversity in the diet leads inevitably to micronutrient deficiencies and associated public health concerns such as anemia. One PHN strategy that has become popular is to fortify staple foods with these deficient micronutrients. As a stopgap and temporary strategy, this is useful in a limited manner, but eventually, structural changes are required in the way the production of food is diversified through incentivization as well as investment in research and development. This, along with the development of appropriate environment–agriculture–nutrition linkages, with strong agricultural and nutrition extension work, can only be beneficial and must be tested.

A second area of concern is pushing for better and integrated action around all 3 pillars of malnutrition: nutrition specific, nutrition sensitive, and enabling environment. No effective policy or program to alleviate MOM can be formed without integration of all abovementioned aspects.⁴⁷ This should be underscored and evaluated by effective data on nutrition and health, either through appropriately designed repeat surveys, and the institution of well-functioning registries of vital events. A specific focus on early-life nutrition from fetal to early childhood is necessary, as this has long-term physiological programming consequences on health, functioning, and chronic diseases. Therefore, the implementation of appropriate maternal and child nutrition policies and programs, focusing on preventing malnutrition in early life, should be a high priority. Maternal nutrition before and during pregnancy, postpartum/lactation with attention to optimal gestational weight gain, and the prevention/control of GDM in Asia need more attention. Improving the coverage, the timeliness, and the quality of antenatal care is urgent in many Asian countries. In addition to optimal baby services, additional care for postpartum women, extending from the current practice of 6 to 8 weeks postpartum to include follow-ups at 6 months or longer after child birth, should be considered and tested for operational feasibility in preventing the risk of obesity and related diseases among women in mid-adulthood. Even while babies are born reasonably close to normal length and weight-for age, it is clear from inspections of global data that growth begins to falter early, even before EBF is replaced by complementary feeding.⁴⁸ The diets of poor children are poor, lacking in protein and fat as well as several critical micronutrients. The promotion of optimal linear growth during the first 2 years therefore needs a combination of approaches to the house-hold as well as community child care, embracing careful attention to the diet, education, and the environment. It is important to be mindful of the consequences of overfeeding by monitoring children for appropriate weight gain to prevent adiposity rebound in later childhood. Thus, including the prevention of overweight and obesity into nutrition programs is a critical step and will potentially reduce the risks and consequent chronic diseases in later life. Adolescent nutrition, especially for girls and the delay of early pregnancy, is also very important.

In summary, there are several initiatives underway or being planned to improve public health nutrition in Asia. With multiple, complex, and mostly intertwined determinants, the progress on nutrition indicators has been slow and not as optimal as one would like, but there is scope and growing demand for improving processes and outcomes. Poverty underlies most problems, and poverty reduction through secular improvements or active poverty alleviation through guaranteed wages or direct cash transfers is important but also flags the very important issue of monitoring the weight of the population and undertaking measures to limit the exposure to ultraprocessed foods. Appropriate food production is critical, as well as the need for a diversity of foods to be accessible to all, while being mindful of the water footprint of production as well as Greenhouse gases emission. Finally, targeting beneficiaries and their households is only one aspect; structural changes at a macro-level and social reforms are also very important for lasting change. Thus, the vision for nutrition research in Asia is largely optimistic, but global and local attention, political commitment, and abundant resources should be available for making the dream to have nurtured and nourished populations a reality.