Dr. Zulfiqar A. Bhutta on new nutrition research: ‘Have we been looking at the proverbial elephant?’

Exemplars in Global Health is building on its research on childhood stunting, anemia in women of reproductive age, women’s health and well-being, and neonatal and maternal mortality by expanding its scope of work to include Maternal and Infant Nutrition and Growth (MiNG).

As this new research project launches, Exemplars News asked Dr. Zulfiqar A. Bhutta, who will be leading the research with his team at the SickKids Centre for Global Child Health in Toronto, where he is the Robert Harding Inaugural Chair in Global Child Health, about how MiNG differs from these other research topics and how such an approach might help identify and understand powerful levers for improving health outcomes over generations.

Dr. Bhutta, who was also the founding director of the Centre of Excellence in Women and Child Health at the Aga Khan University from 2013-2024 and currently heads its Institute for Global Health and Development, explained that the MiNG approach recognizes the interconnectedness of women and child health and nutrition. According to Dr. Bhutta, at a time when progress on nutrition has stagnated in many countries, building momentum for generational change requires the more holistic approach to health, nutrition and development that MiNG offers.

Your team at SickKids Centre for Global Child Health is collaborating with Exemplars in Global Health on research on Maternal and Infant Nutrition and Growth (MiNG). Could you tell us what your research will specifically focus on?

Dr. Bhutta: We started working with Exemplars in Global Health to help us understand positive deviance in child nutrition and what other countries could emulate and replicate. We've now just concluded that work and it's been hugely educational and productive. As part of that process, we've also realized that, looking at undernutrition in women and children through a narrow lens of one syndrome, which is stunting, does not capture the entirety of the adversity that many families and children face across the world.

Undernutrition in many instances precedes a woman becoming pregnant. It starts with an undernourished girl child who becomes an undernourished adolescent, and then an undernourished mother producing an undernourished newborn baby. It is an intergenerational cycle of adverse transfer of nutritional status, as well as human capital. Recognizing this, through our work on childhood stunting and maternal anemia, has led us to look at the interface of maternal and young infant nutrition.

How do these tie together? Have we been looking at the proverbial elephant – each of us describing a different part of the elephant’s anatomy because we are looking narrowly at the issue, when in fact, it's the totality of that organism that is worth looking at?

Through our work studying MiNG, we hope to understand how countries have improved or not improved critical features in maternal nutrition; how birth outcomes relate to growth and well-being in the very early period of six months after birth; and how that dovetails into growth and development in the first two to three years of life. Also, how do contextual factors and social determinants of health and nutrition affect this important mother-baby dyad over time.

Historically, nutrition has treated stunting and wasting as separate issues. Why is that?

Dr. Bhutta: One has to go back to over a century ago, when child undernutrition was largely viewed through the lens of severe acute malnutrition in children, such as Kwashiorkor protein malnutrition or edematous babies. Wasting is also something that you can see readily and cannot ignore. That's why a lot of focus has been on that for a while. Then we recognized that some of those babies were also stunted because they hadn't been growing for a while before they became acutely malnourished.

We created these artificial categories – stunting and wasting – because we wanted to slice and dice data. But in nature and in human biology they are intertwined. And prevention of both of these conditions is also completely intertwined. Poverty, poor sanitation, poor hygiene and poor-quality water are all just as important for linear growth and addressing stunting as addressing wasting or acutely undernourished children.

How can we balance MiNG's more holistic approach to nutrition and still address specific conditions of malnutrition that may require more focused interventions?

Dr. Bhutta: Once we have finished our research, I am reasonably confident that what will emerge is a much more holistic, logical, feasible and pragmatic way forward. We will probably determine that we need more holistic solutions to addressing nutrition of the mother, baby, and early childhood, through interventions that will come through the health and nutrition pathway, but also pathways that have to do with the social determinants of women's health and well-being such as women's empowerment, education, employment opportunities, gender equity, and sexual and reproductive health. Some of these disciplinary boundaries are entirely artificial. This would mean that we should ideally address maternal undernutrition, child undernutrition, adolescent undernutrition in their totality as they impact each other over time.

These so-called dual or triple-benefit interventions should optimize nutrition for the mother, the young child, and infants, without the undue risk of producing overweight and obesity at the other end. Addressing undernutrition, optimizing nutrition and prevention of obesity and overweight concurrently is the way forward.

There are 150 million more women suffering from undernutrition or food insecurity globally compared to men. Why do women bear the greater burden of malnutrition?

Dr. Bhutta: Gender disparities are, unfortunately, in front of us every day in our lives everywhere. Societies typically do not provide girls and women as much support, food, nurturing care, and attention as boys. In some households, the mother could be starving but make sure that her husband is fed because he is the breadwinner.

Tackling inequities is all about addressing unfair inequalities that are amenable to policy change and interventions. We need to focus on unfair differentials in undernutrition that can be reversed or mitigated by appropriate interventions.

To illustrate, in the first few months of life, you actually don't see gender differentials because girls have a biological advantage for survival compared to boys. We don't see differences in undernutrition rates stunting or wasting between boys and girls until they are a little bit older. By the time they are five years old, those differences become apparent. And by the time girls get to adolescence – and if you control for puberty and growth – girls are generally much more undernourished than boys in many places.

That's one of the reasons why when they get to motherhood, about half of all young women are anemic. That's not the proportion that we see in men or boys. Society does not provide safety nets or support or opportunities to adolescent girls and young women. That is something we need to change.

Is the gender nutrition gap getting worse?

Dr. Bhutta: It has plateaued and it's not improving in many places. There are a complex set of reasons for that. Women are most affected by polycrises and complex crises in many parts of the world because they have to look after families on the move. They'll starve themselves to first feed their children and husband.

In a study I did 15 years ago looking at the Asian economic crisis’ impact on women and children’s nutrition, we found that maternal undernutrition actually preceded child undernutrition quite significantly, by six or seven months. That was because the children were shielded from the impact of acute undernutrition and food insecurity by who else – their mothers. Until their shielding obviously wasn't adequate and then you began to see children becoming more undernourished.

We have not factored this reality in in our humanitarian programs adequately. I find it unconscionable that with starving families in conflict areas, migrant families on the move, those affected by climate change, that people will feed young children, but not offer anything to the mother, who is then expected to breastfeed a young infant with virtually no nutritional support whatsoever.

Often, the argument is we don't have enough ready-to-use foods or commodities to give to everybody. So, people say, ‘Let's just give it to the child and the mother can fend for herself.’ Most humanitarian programs need to consider adolescent girls, mothers and children together.

Are there any lower- middle-income countries where they've closed the gender nutrition gap and if so, how did they do that?

Dr. Bhutta: We are at an early stage of exploring this. We are looking at Cambodia, Bangladesh, and others such as Zimbabwe. The indicators suggest that both maternal nutrition and birth outcomes, as well as children’s nutrition, improved concurrently in these countries.

We will find important drivers but I'm also conscious of the fact we have so little information on maternal nutrition and indicators that capture change over time. The only indicator that we might have for maternal nutrition in the medium to short term is anemia and it's not a very good indicator. For other indicators like gestational weight gain in pregnancy or improvements in maternal health and well-being, we have very few indicators. Things like maternal height or stature are indicators that will only change over a generation or more. We must remember that we need a longer lens when we’re investing in improving child nutrition and maternal nutrition because the benefits accrue to the next generation. Sadly, very few governments and politicians have that staying power. They want to see changes tomorrow.

According to UNICEF, South Asia is the epicenter of the wasting crisis. Why are there high rates of wasting in South Asia?

Dr. Bhutta: The answer to that may lie, again, with the mother. Some 28 years ago, there was a seminal paper published by the late Dr. Ramalingaswami and coauthored by Jonsson and Rohde, called The Asian Enigma.

It asked why South Asia, with a relatively much better GDP per capita than Africa, has higher rates of low birth weight and higher rates of small babies in general? Now, they didn't have the tools and data at that time to be able to do a lot of inferential analysis. The paper has a simple regression analysis however that was very prescient because it showed that perhaps the answer lies in the status and social determinants of women's health and well-being. We now know this is hugely important.

What's the relationship between MiNG, maternal infant nutrition and growth, and neonatal health? Can you help people understand that?

Dr. Bhutta: If I had to live my life again, I would have done the whole MiNG project with a lens on newborn survival and nutrition outcomes, because I think they are so closely intertwined. I can tell you from other research I'm doing that the strongest interventions we are seeing for newborn health and survival include many maternal health and nutrition interventions.

Things like maternal balanced energy protein supplementation; giving calcium early to women who are at risk of preeclampsia and hypertension and consequently preterm births; ensuring that women have adequate, multiple micronutrients, which will reduce the amount of low birth weight; ensuring that women have adequate antenatal care all the way through pregnancy, but especially early in pregnancy; ensuring that women deliver in facilities; ensuring that you provide enough education in the antenatal period for women to be motivated, as well as having the support systems to breastfeed their babies. Now, you put it all together, and it is crystal clear that care and services provided to the mother are an investment in improved newborn outcomes, survival and human development over time.

Editor's Note: Learn more about the upcoming Maternal and Infant Nutrition and Growth (MiNG) research topic at Exemplars in Global Health.