A low maternal mortality rate and a low infant mortality rate are two of the healthcare achievements Sri Lanka has historically been best known for. However, a report compiled by the Family Health Bureau of the Ministry of Health in October 2022 highlighted that malnutrition among children under five years of age in Sri Lanka has increased up to 15%. The report also shows that 43.4% of children under five years of age exhibit some form of nutrition-related problem. Further, it highlights that 42.9% of children under five years of age suffer from some form of under-nutrition. The percentage of underweight children under five years of age was reported to be 15.3% and the report also points out that all districts except Kilinochchi, have shown an increase in the percentages of those who are underweight in this age category.
The soaring prices of essential food items have adversely affected low-income groups distinctively. A 41-year-old mother of two children of the ages 6 and 13 years, Nishani Samarasekara (41) lives in a housing scheme in Borella. Speaking to The Morning, she said that her eldest son Nuwan Samarasekara, an aspiring cricketer, is facing difficulties in obtaining his daily intake of protein as recommended by his school.
“My son is very good at cricket and the school has recommended him food items with a high nutritional value, especially high protein meals. But I am unable to purchase them. We have to pay double the price for most vegetables and fruits compared to last year (2022). I used to give him two eggs per day, as he needs energy to play his sport, but now, I can afford to give him only one egg. I used to give him chevon (goat meat) as well, but it’s very expensive and hard to find too.
“There’s a big difference in the number of vegetables on the plate now, in comparison to last year. We used to have three or four vegetables along with rice. But now, we have to be satisfied with one vegetable and lentils along with rice. We cannot afford to prepare meat items, even though my kids are still at the age of rapid physical growth. We resorted to eggs, which were the only source of protein. But now, we cannot afford the price of eggs either.
“We used to buy fruits such as bananas and apples. Now, we cannot remember a time when we had fruits. A kilogram of bananas used to be around Rs. 60, but now it has increased up to about Rs. 220. My husband sends a monthly lump sum from abroad, which is not enough now.”
She also highlighted that the incidence of her children falling sick has rapidly increased due to the lack of immunity and that notably, during the flu season, it is rather difficult for them to recover.
A thin line between disability and poverty
Sri Lanka’s deepening economic crisis has disproportionately affected the parents of children with special needs and disabilities as well. Another mother of three (of the ages of 3, 11, and 14 years) with the youngest being autistic at birth, Dulari Nuwanthika, who also spoke to The Morning, is struggling to feed a family of five.
“We are struggling to feed five people in the family especially because of my youngest son’s health condition. He has special needs and specific dietary requirements. His birth weight was very low and he was unable to be breastfed as he was physically weak, so he was recommended powdered milk from birth. The doctors advised to add grains, vegetables, greens, meat, fish, eggs, and milk to his diet, but we can hardly afford to give him those. We give him Samaposha (a pre-cooked, cereal based, nutritious food supplement, made of corn, soya, green gram, and rice) for all three meals. A packet of Samaposha used to be Rs. 80, but now it is Rs. 165. A 200g packet is not sufficient for a day.”
She further explained the gruelling challenges she faces as a mother of an autistic child.
“Earlier, we used to give my children meat, fish, or an egg at least once a week. The price of an egg has gone up to about Rs. 65. Even dry fish is very expensive. I try to grow as many fruits and vegetables in my garden as I can. But often, we eat rice with just dhal. I am able to give milk or tea only to my youngest, because he really needs milk with his condition. The brand of milk prescribed for him by the doctor costs Rs. 3,500. Therefore, we resort to giving him normal milk powder, even though it does not give him the required nutrients.
“The two older children who are schooling, satisfy their hunger by eating only biscuits when times get extremely difficult. We are grateful for their friends from school who share food with them, but many other students faint in school during the morning assembly. In my opinion, this issue of malnutrition is compounded when families are battling with prolonged alcoholism, cigarette use, and drug abuse on the part of a breadwinning parent, where, as a result, there is less money left to spend on essential household expenses such as food, and this can in turn be another reason for the economic hardships that lead to starvation and malnutrition,” she added.
She further highlighted that they are unable to afford at least one-third of the amount of food that they consumed before the economic crisis hit Sri Lanka, which has resulted in people focusing on consuming food as a method of satisfying their hunger, rather than being selective on their daily nutrient intake – now commonly regarded as a secondary requirement.
Many incidents were reported islandwide throughout last year where many parents attempted to take their own lives as a result of the unprecedented stress levels caused as a result of the economic recession.
Why is merely filling empty bellies not enough?
Explaining this escalating crisis from a nutritionist’s point of view, especially protein-based malnutrition, and emphasising the need for parents to make informed spending-related choices based on basic nutrient literacy, Nutrition Society of Sri Lanka Vice President, Wayamba University Department of Applied Nutrition of the Faculty of Livestock, Fisheries, and Nutrition Senior Lecturer, and the author of Nutrition for Health, Prof. Ananda Chandrasekara noted thus: “Eggs are the highest-quality and most-affordable protein source that is available in the market. Even though there is a hike in egg prices, egg protein is a comparatively cheaper protein available. In comparison to vegetable-based proteins, egg proteins can be considered to be of superior quality.
“From a nutritionist’s point of view, I can point out that consumers are not making the correct choices in selecting food with a higher nutritional value when purchasing food items. If the consumers can make educated choices to manage their limited financial resources wisely, they will be able to obtain the maximum use of the money spent. Most people tend to purchase food items that can satisfy their hunger without considering the nutritional value.
“Sri Lanka was ranked 64th in the Global Hunger Index last year. People often buy more carbohydrates such as rice that are comparatively cheaper and bulkier, as it is the most convenient method to satisfy their hunger. Calories can be acquired in the form of carbohydrates, proteins or fat. But carbohydrates are the cheapest form of calories one can purchase. This mostly happens due to the lack of nutrient literacy.
“Another common belief is that having rice for all three meals is a sufficient source of good nutrient supply. Apart from rice, the other commonly consumed substitute is bread. For people who engage in non-labour intensive jobs, it is best to replace similar carbohydrates with high quality, affordable proteins. This can be either animal or plant proteins such as egg, chicken, or other meat (if affordable), and local freshwater fish as well. Protein malnutrition can have long-term effects on children.”
Even though stunting, which is a result of chronic malnutrition, has not affected the population severely, there could be a possibility of it having an impact in the future if the situation persists. Prof. Chandrasekara highlighted: “Therefore, our schoolchildren should be safeguarded from this threat as they are in their developmental stages. There can be a micronutrient deficiency as well which is called a ‘hidden hunger’ which is not apparent, but is prevalent. My advice is for the parents to obtain proper advice from a nutritionist on how to get the maximum nutrients out of limited resources and to be informed on the best substitutes for expensive food items.”
Further, Prof. Chandrasekara pointed out that malnutrition during pregnancy can create a generational problem in children after birth and that they can be more prone to cardiovascular diseases.
“It is the responsibility of the Government and each individual to take care of those who are susceptible to malnutrition. If not, the future generations will be adversely affected in another 30 or 40 years. As nutritionists, it is our responsibility to educate the general public, especially during a crisis. We are currently having discussions with Government officials on introducing and educating the public on low-cost alternatives for nutritious food in the market.”
The nutrition package distribution programme for pregnant mothers, organised by the Health Ministry, was also discontinued, which has affected the nutrition level of pregnant women of low-income groups. Infants with a low birth weight can be a root cause for many subsequent nutrient related deficiencies and disorders. Protein is an essential component of an infant’s diet and it cannot be replaced with carbohydrates.
A General Practitioner (GP) from the Kurunegala District, speaking to The Morning on the condition of anonymity, shared his sentiments with regard to the price hike in medicines and its lack of availability, noting that besides schoolchildren, infants, expectant mothers, and the elderly are the other main vulnerable groups of people. Pregnant women and the elderly are unable to gain their nutrient supply due to the increase in prices of medicinal drugs as well, the GP claimed, explaining that certain nutrients and micronutrients including vitamins and minerals and supplements are obtained in the form of medicines.
The way forward
The Emergency Nutrition Plan developed by the Ministry to prevent the deterioration of the nutritional status due to the economic crisis, highlights that the average price of a nutritious meal has increased by 156% according to an analysis carried out by the Department of National Planning and the World Food Programme (WFP).
The proposed strategies of the plan include measures such as providing households with a poorer income and pregnant women with food-based support in the form of food baskets or cash transfer schemes with the collaboration of the Ministry of Women's and Child Affairs, school meal programmes, the promotion of community kitchens in estates and selected rural and urban areas, freshwater fish breeding, and multi-nutrient security by promoting home gardening. The Government also plans to restart the Thriposha (an additional nutritious food made of maize, soya beans, full-cream milk powder, vitamins and minerals which is issued free of charge to all beneficiaries who have nutrition-related requirements, including pregnant women and breastfeeding mothers up to the infant completing six months of age) programme with assistance from non-Governmental organisations and donor agencies.
With life-threatening shortages of essential items, reduced domestic agricultural production and the skyrocketing prices of food items, Sri Lanka is not too far away from manifesting malnutrition which is becoming a world health crisis. Even though the symptoms are not clearly visible at the moment, the future generations will be evidently affected if no urgent preventive action is taken.