Geoffrey Cannon replies
Sir,
It is a pleasure and a privilege to debate these important matters with a great nutrition scientist whose contribution in particular to world child health is fundamental. Others should join in.
John Waterlow points out that the intention of the consultation he chairedReference Waterlow, Buzina, Keller, Lane, Nichaman and Tanner1 in identifying the US NCHS growth curves as ‘references’, was not to be normative. Respectfully, this is by the way. What matters is what then happened: not intentions, but effects. What I said – as he does – is that the NCHS numbers inevitably became values as soon as his paper was endorsed and the growth curves issued by the relevant UN agencies. Plus, once the word ‘value’ is added, as in ‘reference value’, the term becomes normative – and, if the concept that ‘reference’ is neutral is preserved, a contradiction in terms.
The growth charts for infants and children derived from the NCHS studies of formula-fed babies2 became accepted as the norm – and still are, and will be, until they are everywhere discarded in favour of the new standards based on breastfed babiesReference de Onis, Garza, Victora, Bhan and Norum3. We now know that the numbers based on formula-fed children in the USA were an ‘overshoot’: the NCHS-derived charts identify a proportion of babies as ‘failing to thrive’ when they are actually growing at the natural rate, and as healthy when in fact they are overweight. As a result, paediatric health professionals all over the world, from chief government officers to volunteers equipped with a growth chart, a pencil, scales, a ruler and a dozen boxes of tins of infant formula and dried milk donated by the manufacturers, were – and still are – in the business of pushing growth. The human race has been and still is being reshaped, no doubt about that.
Yes, below a certain range of weight and size, infants and young children are in danger. Yes, children deprived of nourishment by intestinal parasites are liable to remain disabledReference Mata4. Yes, below a certain range of intake of food, adults become unproductiveReference Fogel5. Yes, public health nutritionists charged to formulate policy proposals should estimate what these ranges are, with necessary caveats. Yes, prevalent feeding practices from birth to early childhood, in communities without proper security, sanitation and often shelter, contribute to countless deaths and result in disabled children and adults. Yes, young children who are famished, and very likely to be infected and infested, need immediate nourishment.
I have travelled in the backlands of Brazil and seen what deprivation, food insecurity, gross inequity and misery does to communities and their children. What I also have seen in India and Sri Lanka, in line with what another consultation chaired by John Waterlow hinted6, is small skinny kids – who if netted, weighed and measured by a visiting expert, might well be marked down as two standard deviants, stunted, wasted or both, another ticked box then subjected to heroic extrapolation – who are more lively, talkative and energetic, and seem more sharp, sociable and enterprising, than big podgy kids.
It is one thing to state that countless babies and young children are born dangerously light and small. It is another thing to apply a statistical model and define all below the line as ‘wasted’ or ‘stunted’ irrespective of their state of health and well-being.
His students and readers know that John Waterlow's nature is challenging in the Socratic sense: he invites others to think, and to advance understanding. I sense he will agree that it is a completely different thing to assume that public health is best served by proclamations that promote the dumping of surplus energy-dense processed products on dispossessed populations in the name of aid (or Millennium Development Goals), with all the invalidation, dependency, helplessness and further transformation of poverty into miseryReference Rahnema7 this implies.
Specifically, has the supply of countless millions of tonnes of formula feeds and dried milk to Asia and Africa in the last half-century improved overall public health and well-being? Or contributed to the good governance and independence of any country? Or enabled communities to become more self-sufficient? If any reader thinks so, let's see an evidence-based case.
John Waterlow wonders if the new nutrition, which defines the science as three-dimensional – biological, and also social and environmental8 – casts any light on these issues. Yes, it does. In its social dimension it asks questions like those above. Its overall guiding principles are ethical, evolutionary and ecological. One specific principle in the biological dimension, with many others still subject to revision after discussion in three workshops, is: ‘The single nutritional factor that most protects human health lifelong is sustained exclusive breastfeeding. The practice of breastfeeding is also emotionally vital, socially valuable, and environmentally sound’. Or, in other words: ‘In biology, nothing makes sense except in the light of evolution’Reference Dobzhansky9. This was overlooked in the 1970s, as was the significance of human milk being uniquely low in protein.
