• Key growth indicators not updated since 1977

In the context of child nutrition and malnutrition, growth-related references used in Sri Lanka need to be locally validated, a paediatrician cum academic noted.

This observation was made in a guest commentary on "Childhood malnutrition in Sri Lanka: Past, present and future" which was authored by Senior Professor in Paediatrics at the Colombo University's Medical Faculty, P. Wickramasinghe and published in the Journal of the Ruhunu Clinical Society's (27)1 in December, 2022.

Sri Lanka adopted World Health Organisation (WHO) 2006 growth charts for children under five years of age, which primarily shows how children under five should grow. It has been quite useful in detecting growth faltering early and intervening in a timely manner. However, for five to 18-year-old children, the WHO references are based on the 1977 National Centre for Health Statistics data. Therefore, on the one hand, it is an old set of data and it is of a single country (South Africa). Growth patterns of children especially above five years differ across different populations. Therefore, per an Indonesian study, its applicability across different populations especially as a reference or standard is not satisfactory without being tested for its validity.

Growth charts developed in India, China, Indonesia, and Saudi Arabia have shown that Asian children have similar growth patterns while all of them differ from Caucasian children of European origin. Longitudinal data under two years of age in Sri Lanka have shown that they have a similar pattern of growth compared to the WHO charts, about one standard deviation below the WHO level, per N. Lucas. Further, in the five-15 years age group also, it has been shown that the distribution of Sri Lankan references is about one standard deviation below the level of the WHO references, per Wickramasinghe. This clearly shows that Sri Lankan children also need to have their own growth charts or at least validate a regional chart such as the Indian growth chart for the assessment of growth while further studies are also necessary on this aspect.

Improving the birth weight is one of the most important factors for the improvement of child growth. In order to improve intrauterine growth, it is imperative that a female embarks on a pregnancy with a sound nutritional and health status. Low height and wasting are risk factors for low birth weight. Embarking on a pregnancy with these high rates of under-nutrition increases the risk of giving birth to a low birth weight baby. The adolescent growth spurt is the last window of opportunity for the girl child to have an optimum growth. However, the local care services for the adolescent fall in no man’s land. Traditionally, paediatric care stops at around 14 years of age and adult care begins at around 18 years of age with minimum medical attention to this in-between group of adolescents aged 14 to 18 years. It is important that adolescent health is well managed by a multidisciplinary team with an adolescent health physician (paediatrician or physician), endocrinologist and a nutritionist in order to harness the optimum growth potential that they were born with and to prevent being overweight.

Pre-pregnancy counselling is an important aspect and through the registration of eligible couples, this occurs to a great extent. However, optimising the nutritional status, reducing either wasting or being overweight does not happen optimally. Per R. Jayatissa and W. Marasingha's "Nutrition status and gaps in the diet of Sri Lankans during the pre-economic crisis period", Medical Research Institute data shows that 3.9% of pregnant women were underweight. However, data from the third quarter of 2022 show that under-nutrition among pregnant females has gone up to 8.3%, which would forecast a bleak future for newborn babies. In contrast, adolescent obesity would lead to many young females embarking on a pregnancy being overweight and giving rise to overweight/obese newborns who are in turn at a higher risk of developing NCDs from a younger age. Per Jayatissa et al., the high prevalence of being overweight (42.2%) and obesity (19.6%) in pregnant mothers has shown some reduction (overweight – 33% and obesity – 14.5%) due to the current economic downturn. Women in the reproductive age should therefore be encouraged to attend well women clinics, especially to receive advice on the nutritional state.

Food production in Sri Lanka throughout the year should not be a problem. However, the optimum utilisation of soil and weather does not appear to occur. Further, the abundant inland water tanks are underutilised, which could provide a good solution to the protein related needs of the population in addition to the abundant marine resources all around the country. Most of the yield is not effectively distributed all around the country. Rather than a local distribution of the harvest, they are distributed to many central locations where the produce exchange hands with many middlemen, adding overheads and profits, thus increasing the final price of the commodity. Not effectively using the transport system such as the railway network adds a further cost when it reaches the consumer.

Minimising the pre-harvest and post-harvest losses plays an important step in ensuring food security. Many farmers are given small plots of land for cultivation and dwellings, which further shrink with the generational handing over of these lands. Any pest invasion could affect the entire plantation which otherwise would have been insignificant if there is mass cultivation. A country with limited land, if not shrinking due to sea erosion, should rethink its land distribution policy of handing over small plots to individuals for both cultivation and dwelling, and instead build farming towns and separate farming land from inhabiting spaces and even construct multi-storied housing apartments rather than individual units for the farmer. Adopting better storage methods during the transportation of produce will help to reduce post-harvest losses and provide fresh food which is more nutritious. Adopting environmentally friendly farming techniques is also important as the livestock industry is one of the main factors that contribute to global warming and antibiotic resistance. The industry needs to develop to preserve the surplus of seasonal food to be used during the off season. The canned and dried food industry is not well developed in this country which has a huge potential and could easily contribute to solving many nutritional problems.

Gut microbiota are shown to play a significant role in the growth and health of children. It is quite clear that the food we take makes the gut microbiome and it is a signature of the local patterns of diet. Although many diets have been described, their effectiveness outside those geographies of origin is doubtful. The concept of ‘microbiota directed food’ has shown to improve child growth. J.L. Gehrig, S. Venkatesh, H.W. Chang, M.C. Hibberd, V.L. Kung, J. Cheng, R.Y. Chen, S. Subramanian, C.A. Cowardin, M.F. Meier, D. O'Donnell, M. Talcott, L.D. Spears, C.F. Semenkovich, B. Henrissat, R.J. Giannone, R.L. Hettich, O. Ilkayeva, M. Muehlbauer, C.B. Newgard, C. Sawyer, R.D. Head, D.A. Rodionov, A.A. Arzamasov, S.A. Leyn, A.L. Osterman, M.I. Hossain, M. Islam, N. Choudhury, S.A. Sarker, S. Huq, I. Mahmud, I. Mostafa, M. Mahfuz, M.J. Barratt, T. Ahmed and J.I. Gordon's "Effects of microbiota directed foods in gnotobiotic (relating to or denoting an environment for rearing or culturing organisms in which all the microorganisms are either known or excluded) animals and undernourished children" which used locally sourced foods that particularly enhance the gut microbiome, showed that food targeting the improvement of these microbiota, enhanced biomarkers of growth, bone formation, neurodevelopment, and the immune function in undernourished children. This highlights the importance of the use of locally available food for the improvement of the growth and health of children, whether undernourished or normal.

B. Bogin's "Social-economic-political-emotional factors regulate human growth" elaborates that socio-economic-political-emotional factors are aspects beyond nutrition which would affect the growth of a child. Therefore, providing nutrition alone is not sufficient to a child but securing a conducive, less stressful socio-political culture and ensuring a secure future would invariably help a child to be happy and thus encourage growth. The school environment and a happy schooling and education system in addition to the harnessing of skills and talents should help them become healthier. J.P. Habicht, R. Martorell, C. Yarbrough, R.M. Malina and R.E. Klein's "Height and weight standards for pre-school children. How relevant are ethnic differences in growth potential?" stated that the differences in anthropometry in well nourished children of different ethnicities are small (3-6%) compared to the different socio-economic status in the same ethnicities (12-30%) which led to the conclusion that growth standards for height and weight to represent optimal pre-school growth could be constructed from studies done on children with a good socio-economic status, irrespective of the ethnicity.

L.W. Sontag's "The history of longitudinal research: Implications for the future" states that the modern understanding of the growth, health, behaviour, and effectiveness of human beings could only be understood if the nature and significance of the individual characteristics of each child’s physiological, biochemical, nutritional, educational, and environmental characteristics could be assessed and integrated into a total picture.

Hence, those caring for health have a great responsibility in harnessing the optimum growth potential in children, thereby reducing malnutrition. Wickramasinghe concludes that towards this end, such carers need to empower all stakeholders involved in this process, directly and indirectly.