by Wilson, Bee
“You’d eat it if you were really hungry,” I hear myself saying to the child who is pushing the remains of the mashed potatoes around on his plate, angling to be offered something better. “If you were really hungry, you’d be happy with a slice of bread,” I snap at the ravenous teenager who has already eaten a full supper, plus pudding, plus a supplementary bowl of yogurt, fruit, and honey, plus a toasted cheese sandwich, and who now says he can’t sleep until he has one last snack. I hate the naggy way my voice sounds when I say this “if you were really hungry” line—which I only come out with at the end of my tether. It’s as if I am blaming my children for not being more like those other, more deserving children in the world, the “really” hungry ones. The implication is that “if you were really hungry,” you’d eat anything. Which isn’t actually true.
What is true is that hunger teaches people to accept a wider range of foods. In one experiment from 2009, people were either deprived of food for fifteen hours or given plenty to eat. Afterward, when they were shown pictures of unappetizing food—stews reminiscent of vomit, spinach pulp—the hungry people showed less activity in the levator muscle of the mouth that signals disgust. Conversely, when shown pictures of appealing food—pasta, pizza—the hungry subjects showed more activity in the zygomaticus muscle, which makes us smile. In short, hunger made the nasty food seem nicer and the nice food seem nicer still.
But there are limits. Even in a state of abject food deprivation, there are certain taboo things that people tend not to eat—witness the fact that cannibalism is so rare. Hungry or not, few in the developed world would resort to a dinner of insects, or eyeballs, or dog. In most situations involving unusual foods, disgust easily trumps hunger. It is false to think that there is a state of absolute hunger in which children would eat anything. Among the hungriest children of the world, hunger is still concrete and not abstract. It cannot be satisfied by just any old thing.
Over the past ten years, the treatment of acute child malnutrition—the sort of hunger that carries an imminent danger of death—has been revolutionized by the invention and distribution of a peanut-based paste called Plumpy’Nut. This is an energy-dense mixture: a kind of supercharged peanut butter. Delivered in little foil-wrapped packages that children can squirt straight into their own mouths, it was the brainchild of André Briend, a French pediatric nutritionist. He came up with the idea after testing numerous less successful malnutrition foods that already existed, including doughnuts and pancakes. Briend supposedly had his “aha moment” about developing a nourishing paste by looking at a jar of Nutella chocolate spread. On a trip to Malawi, where both peanuts and hungry children are plentiful, he borrowed an electric blender from a local restaurant and whipped up a nutty cocktail of peanuts, milk powder, vitamins, minerals, sugar, and oil.
Before Plumpy’Nut, when children under the age of five arrived at feeding centers with suspected acute malnutrition, the safest option was to admit them to the hospital for tube-feeding. A high percentage—as many as 75 percent in some centers—died anyway. Because it was so hard for mothers to be separated from their children, they often delayed bringing them in for help until it was almost too late. Another option was to give families a dried fortified milk mixture (called F100) that could be administered at home, but that had to be diluted with water, a dangerous proposition in most of the developing world due to the lack of reliably safe drinking water. Also, the dosage and dilution of the milk powder were left up to the families, and many overdiluted it, to make it go further, so that it could be shared among all the children in the family, rather than just those at high risk of death.
One of the great advantages of Plumpy’Nut is that as a paste it does not have to be diluted, so it can safely be given at home, avoiding the need for a hospital stay. It is what is known as an RUTF: Ready to Use Therapeutic Food. The first trials with Plumpy’Nut yielded results that were miraculous. Mark Manary, an American pediatrician working in Malawi, field-tested it in 2001. In defiance of medical orthodoxy, he sent all the children on his ward home with a six-week course of peanut paste. Ninety-five percent of them made a full recovery, as against an average of just 25 percent of those being treated for malnutrition in a hospital. Six months on, the Plumpy’Nut children were still healthy. Peanut RUTFs are now the main way that acute child malnutrition is treated around the world. In African countries, these sweet pastes are popular with both children and mothers. Children like the sticky nutty taste. Mothers like the convenience. And doctors and aid workers like the fact that rates of recovery are so high.
And yet Plumpy’Nut has not been so welcome everywhere. While it has been an unequivocal hit in Africa, in India and Bangladesh the mothers and children do not respond to it so well. It’s not that they are not hungry enough to appreciate it. There are around 8 million children in India at risk of death from severe acute malnutrition. Bangladesh has one of the worst levels of childhood hunger in the world, with 46 percent of under-fives “stunted,” according to a UNICEF report, and 15 percent “wasted.” “Stunting,” according to the definitions used by aid organizations, means not growing or developing properly owing to years of poor nutrition. “Wasting” is a more acute kind of hunger that can kill in a matter of weeks; it can be brought on by sudden food shortages or disease, and it’s exactly the kind of critical hunger that Plumpy’Nut is designed to combat. But in Bangladesh, a peanut-based paste does not fit with local ideas of what “food” is, and specifically, which foods will appease a child’s hunger.
Jose Luis Álvarez Morán works for the charity Action Against Hunger, which fights child malnutrition in more than forty countries. He has witnessed firsthand how successful Plumpy’Nut can be in the treatment of acute malnutrition. But India and Bangladesh are different: no matter how extreme the hunger, our cultural ideas about food do not go away. Indian mothers, on the whole, would rather feed a hungry child something made from lentils or rice than peanuts, which are not part of the everyday diet. “And in Bangladesh, they just don’t like it,” says Álvarez Morán. “They want only locally produced food.”
When researchers went into an urban Bangladeshi slum in Dhaka in 2011, they found a very low level of acceptance of Plumpy’Nut among parents and children. If it were true that a “really hungry” child would eat just any food, then the slum-dwellers of Bangladesh should be only too happy to receive free sachets of calorie-dense Plumpy’Nut. But this was not the case. Out of 149 Bangladeshi caregivers of malnourished children—mostly mothers—6 out of 10 said that Plumpy’Nut was not acceptable as a food. Many hated the peanutty smell; others reviled the sweet taste and the sticky, thick texture. The dark brown color looked like excrement to three of the parents. Twenty parents said their children needed encouragement to eat it, and fifty had to be forced. It was as if they refused to accept that this strange brown paste—so unlike food as they knew it—could satisfy a child’s hunger. Thirty-seven percent said it made their children vomit, and 13 percent said it gave them diarrhea, even though 112 of the parents also admitted that their children were gaining weight while consuming it.
This rejection of Plumpy’Nut is potentially a huge problem for charities such as Action Against Hunger, whose workers speak of a small “window of opportunity” for reaching hungry children. Their task is not to dole out workhouse rations but to establish a bank of nutrition at just the point when a child’s brain and body are developing most rapidly. To alleviate the hunger of a child, aid workers first have to reach the mother. It starts with nourishing women before they become pregnant—another reason why the high prevalence of anemia among girls is so detrimental. The window closes when a child is around two. If you can cancel a child’s hunger during the first three years—from conception to toddlerdom—you create possibilities that stretch decades into the future. If not, the consequences can last for generations.
During the Dutch Hunger winter of 1944–1945, when German occupying forces blocked food supplies, 22,000 people starv
ed to death, and a further 4.5 million people suffered terrible malnourishment. Children born to mothers who were pregnant during that hungry winter—on rations of as little as 400 to 800 calories a day—were low birthweight and went on to have a host of health problems, including diabetes and obesity. And their children, in turn, were low birthweight, too. No matter what they ate later on, these people were blighted for their whole lives by the hunger their mothers experienced before they were even born. The power of early intervention with RUTFs—for both pregnant women and children—is that it can prevent this kind of “irreversible harm.”
But it only works if the mothers and children will accept that the food will help solve their hunger problem. By the time someone is offering you Plumpy’Nut, by definition your hunger is far advanced, and you need a lot of calories, fast. “People forget,” says Álvarez Morán, “that malnutrition is about disease rather than just lack of food. Many of these children have diarrhea and actually need far more food than a child who isn’t malnourished.” Contrary to the popular view, malnutrition is very seldom about an absolute lack of food. “These families usually have farinas and porridges,” according to Álvarez Morán, or rice and pulses in India and Bangladesh, “but both the quantity and quality are lacking.” These farinas are rich in carbohydrates but deficient in essential micronutrients and protein. In this respect, they have something in common with the foods eaten by obese children in First World countries.
Development experts and pharmaceutical companies are now urgently looking at alternatives to peanut paste to assuage the hunger of children in India and Bangladesh. Some have suggested it would be more effective and sustainable to work with Bangladeshi mothers in the home to teach them how to make energy-dense foods—such as sweet, sticky halva, or milky puddings—rather than relying on commercial RUTFs made by big pharmaceutical firms. But the obstacles to mothers being able to cook the right foods to treat acute malnutrition in the home—lack of clean water, kitchens, or basic sanitation—were among the reasons that Plumpy’Nut was invented in the first place. There have been experiments with RUTFs based on local ingredients, such as sesame seeds or chickpeas, instead of peanuts. The International Centre for Diarrhoeal Disease Research in Bangladesh is testing some RUTFs that have “a lot of potential,” says Álvarez Morán. They are made from rice, lentils, chickpeas, oil, milk powder, and sugar and designed to have the same nutritional value as Plumpy’Nut.
The real test will be trials in the community. Will the mothers and children accept this rice, lentil, and sugar mixture as something that might alleviate their hunger, rather than making it worse? It is hard to say. A child’s hunger cannot be canceled by food per se. It matters very much what the food is.
One of the reasons that hunger is so hard to pin down is that it is a negative concept, an absence. It is not-food, not-contentment. The real thing we all want in our different ways is fullness: that blissful state where we do not desire another bite. But physical fullness has at least two aspects. The first is the short-term fullness that makes us decide a meal is over: satiation. The second is the longer-term fullness that tides us over during the hours between meals: satiety. When it comes to avoiding overeating, it is satiety that is the more useful. It is satiety that will—in theory, at least—stop you from impulse snacking or getting desperate for lunch half an hour after breakfast. Many dieters now obsess about satiety, searching out the meals that will deliver the maximum hours of fullness for the minimum calories. But as a child, I don’t remember once choosing what I ate on the grounds that it would make me full in three hours’ time. I was only interested in whether it would make me full now, this instant.
When we are young, our idea of fullness does not tend to look far ahead. The child’s idea of fullness corresponds to “satiation”: that feeling of being satisfied that the meal is done. Children point to different areas of the body to show how full they are: up to their belly button, up to their neck, up to the sky over their head. In theory, satiation is what causes us to stop eating, though in practice, it’s always more complicated. When we are short of food, we may stop eating long before we are satiated. When our food supply is abundant, conversely, we can find it hard to convince ourselves to stop, even after reaching satiation. We can be full and not full at the same time. Our waistbands may feel tight, but that bowl of roasted potatoes on the table calls to us. Hara hachi bu is a Confucian principle, popular in Japan since medieval times; it means that you should eat until you are only eight-tenths full. This principle has since been given backing by nutrition scientists who note that when we eat, there is a time delay between the body receiving the food and the brain registering that we are full. When the urge comes to have a second helping, it’s worth waiting twenty minutes, and the feeling may pass. If we carry on eating until we are full up to the sky, then we will, in fact, be overfull.
All over the world, children gesture that a meal has satisfied them by rubbing their rounded tummies. This means “I am full.” Children are correct to think that satiation mainly happens in the stomach. When food makes its way to your stomach, the vagus nerve tells your brain that you are starting to feel full. The feeling of “distension” in the stomach is a crucial element in satiation. This is one reason that weight gain is so hard to reverse—particularly when it is caused by binge eating: the obese have increased gastric capacity, meaning that it takes longer for the stomach to feel full. And if the stomach doesn’t feel full, the brain can’t feel full either. One study found that when subjects received an infusion of tomato soup through a tube to the stomach, it gave them a feeling of fullness; when the soup was administered to the intestine, it did not satisfy to the same extent, though the body was receiving the same nutrients. As nutrients are released from the stomach to the intestine, however, the brain begins to get messages from hormones in the gut that it is time to stop eating.
One of the commonest ways our eating goes wrong is that we consistently choose foods that offer immediate satiation in the belly rather than longer-lasting satiety. When my eating was out of control, I remember thinking that a meal such as salad couldn’t possibly be substantial enough. A childish longing for satiation leads us to stodgy foods—soft, pillowy cakes and buns, jam tarts, fluffy baguettes, buttery noodles, doughy pizza—which we imagine will stuff us like the plush filling in a teddy bear. When we crave them, much of the appeal is how replete we predict they will make us; indeed, in the moments after consumption, such foods do increase blood sugar—fast. This appeal continues in adulthood, particularly for those on a low income. When you have little money to spend on food, it’s hard to risk it on a bag of broccoli, which does not look as if it will dent your hunger, as opposed to a package of instant noodles or processed cereal, whose starchiness holds out the promise of quick satisfaction. It has been well documented that poorer households often gravitate toward food that is calorie dense, low in fiber, and high in carbohydrate and fat, stuff that looks like it will be “filling.”
What these “filling” foods are not so good at—paradoxically—is keeping us full for a long time. Highly refined starches and sugars give us a spike in blood glucose followed by a crash. When nutrition scientists talk about fullness, they tend to be less interested in immediate satiation and more interested in satiety: that slow-burn feeling of fullness that carries on after a meal and delays your next intake of food. The most effective foods to choose for longer satiety are exactly the ones that many children think they will not be satisfied by: high-protein foods, especially fish; healthy soups; and high-fiber foods, such as the whole grains and vegetables that are now sometimes said to have a low “glycemic index.” Low-GI foods are ones that cause only a small rise in blood sugar. These include pulses and beans, salmon, and eggs. High-GI foods include white rice, sugary cereals, sliced bread—every kind of refined carbohydrate.
In 1994, a mother of an eleven-year-old despairingly told researchers conducting a survey on children’s food, “I just wish they’d e
at more fruit and veg but all she seems to like is chips and biscuits—all the filling-in foods.” The “filling-in” foods have a universal appeal. The actress and cookbook author Gwyneth Paltrow, whose family follows a low-carbohydrate, high-protein diet majoring on leafy vegetables, pulses, and fish, writes that every day her daughter begs for mashed potatoes, though they are forbidden.
The search for a food that will keep us fuller for longer has been the holy grail of recent nutrition research. Most of that research has been done in labs using “preloads” of various nutrients. “Preload” is a technical term for “starter” or “appetizer”: something you eat before a meal that takes the edge off your appetite. Subjects are told to eat a preload of a particular food and are then monitored to see how it affects their subsequent energy intake and hunger levels. In these studies, protein emerges as one of the likeliest candidates for helping with satiety, more effective than either carbohydrate or fat. When people in a lab are given a substantial protein “preload”—whether it’s tofu, meat, eggs, or the whey protein used by bodybuilders—they generally seem to eat less at lunch an hour later. Another factor that may make a “preload” more filling is how viscous it is. Certain new fibers have been created that form a viscous gel in the stomach to hold off hunger for several hours. The idea—which sounds a little creepy to me—is to drink an alginate liquid extracted from seaweed. On contact with stomach acid, the liquid forms a gel inside you, creating a sense of fullness.
Other studies have pointed to high-fiber grains as being good for satiety. A benefit of fibrous foods such as oats or crunchy fruit is that they take longer to chew, which gives the body time to register that it is properly full. That old warning shouted at children not to “bolt your food” was sound advice. It’s far harder to bolt a brown rice-and-kale salad than it is a white-bread ham sandwich.