Published: March 2, 2006

Rampant child malnutrition in poor countries is usually not caused principally by lack of food, nor are large, politically popular programs to feed schoolchildren the right way to tackle a problem stunting the intellectual and physical development of more than 100 million children worldwide, a new World Bank report says.

The irreversible damage malnutrition causes to children occurs by age 2, long before they begin primary school, and the bank contends that efforts to combat this scourge must concentrate on the brief window of opportunity between gestation and age 2, with a focus on teaching mothers to properly feed and care for babies and toddlers.

While many experts would agree with the bank’s assessment of the evidence on malnutrition, its policy recommendations are sure to be controversial at a time when the world is pushing to halve poverty in the coming decade and school feeding programs are often seen as part of the solution.

The bank, the largest financier of antipoverty programs in developing countries, maintains in the report released today, “Repositioning Nutrition as Central to Development,” that countries like India with staggering rates of malnutrition need to change their approach to speed up progress.

Nutritionists at the bank say programs should emphasize changing the behaviors of mothers — for example, to breastfeed exclusively for the first six months of life or seek quick treatment for their children’s diarrhea and other common childhood illnesses, rather than directly providing food.

Providing school-aged children with nutrition education, iron supplements and deworming medicines are better ways to improve nutrition than simply providing them with meals, the report also says.

The lead author of the report, Meera Shekar, said feeding programs are costly and vulnerable to corruption, with publicly provided food too easily given to better-off people rather than to the poor, or siphoned off to be sold.

“You get more bang for your buck without the food,” she said. “The food brings in votes for politicians. We have very little evidence it improves nutrition.”

Advocates of feeding programs reply that food can be a magnet that draws mothers and children to centers where nutrition counseling is offered and that nutritious food provided early enough in life can also help.

“If you feed the children well, they’ll all be there,” said Jean Dreze, an economist and leading advocate of free school lunch programs in India who conceded that effects of such early feeding programs on nutrition can be difficult to capture statistically. “The response to food is phenomenal.”

Some of the facts about malnutrition, familiar to experts but not widely understood, seem counterintuitive. For example, rates of malnutrition in South Asia — including India, Bangladesh and Nepal — are nearly double those in sub-Saharan Africa, which is much poorer.

In fact, in India, where almost half the children are stunted by malnutrition, the problem is far from limited to the poor. A quarter of the children under age 5 in the richest fifth of the population are underweight and more than half of them are anemic.

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