The image of an emaciated, almost wasted, skinny child comes to mind when we talk of malnourished children -- children with thin arms, protruding bellies, and light-coloured hair. Yet, the price malnourished children, their parents, and entire nations pay is far more than just what is apparent.

A malnourished child’s ruling organ, the brain, does not develop at an optimal level due to lack of sufficient nutrition. All stakeholders continue to pay the price for decades to come -- both on a personal and a collective economic level. Malnourishment, then, may be the silent and neglected brain drain that no one is talking about.

According to Dr Irshad Danish, National Coordinator, Scaling up Nutrition (SUN) Civil Society Alliance, Pakistan, stunted children have 7-months delay in starting school, have lower intelligence quotient (IQ), are more likely to repeat a grade of school, complete one year less of schooling on an average, and are less likely to graduate high school.

"The effects of malnourishment include a low IQ, poor concentration, attention deficit, and memory disorders," he says. Mentioning the findings of a report launched by the Pakistan Scaling Up Nutrition (SUN) Secretariat at the Ministry of Planning Development & Reform, in collaboration with the United Nations World Food Program (WFP), he adds that the consequences of malnutrition -- including healthcare expenses and lower productivity -- cost Pakistan US$7.6 billion, or 3 per cent of GDP, every year.

He says that children who are malnourished learn less at school and earn less when they grow up. Iron and Iodine deficiency in childhood reduces IQ by up to 25 and 13 points respectively. Cognitive deficits from childhood stunting, anemia and iodine deficiency disorders depress future adult productivity, valued at Net Present Value of $3.7 billion per year.

Brain development of the foetus starts in the womb of the mother, particularly in the third trimester, explains Dr D.S. Akram, Founder, Health, Education & Literacy Programme (HELP). "If the mother is malnourished and anemic, there are more chances that the brain growth will not be optimal as insufficient hemoglobin in the mother’s blood means insufficient oxygen for the foetus," she says, further adding that between the age of three to six months, the baby’s brain grows rapidly, and if there are factors like a malnourished mother, premature birth of the child, or the mother not exclusively breastfeeding the child for the first six months, brain growth may slow down.

Dr Akram also says that if the child does not receive enough food as well as brain stimulus in the first two years, it may lag behind in its key developmental milestones. "When the child goes to school, his ability to perceive, to memorise, his motor skills -- all will be slow. This will result in a lack of motivation in the child who will not experience the pleasure of learning. It’s a vicious cycle," she says. For optimal brain development, according to her, it is imperative that timely introduction of a balanced diet of solid food is introduced, containing micro-nutrients, proteins and fats.

Quantifying the link between brain function, academic performance and malnourishment, the Hunger in the Classroom report, 2015, by Food Bank Australia, stated that over two thirds of students who miss out on breakfast can find it difficult to concentrate (73 per cent) or can become lethargic (66 per cent), with over half experiencing learning difficulties (54 per cent) or exhibiting behavioural problems (52 per cent).

Perhaps this is why for Saeed Qureshi, the most rewarding part of his decade-long service of leading Aman Ghar (an initiative of the Aman Foundation), was working on feeding underprivileged school-going children in Karachi.

Since last year, Aman Ghar joined hands with Saylani Welfare International Trust, and meals are distributed to deserving students of 15 schools, which serves both as an incentive for children to come to school, as well as helps them perform better at school. Aman Ghar’s motto has been "food for education".

Qureshi explains that before the inclusion of the lunch programme, the students were reported to pass out during school hours due to hunger, especially in the summers. Since the lunch programme started, there has been a significant change in the academic performance of the students. "I have seen children come to school on a hungry stomach, eating only paapay (rusks) and chai (tea) at most. Their decision power is impacted as is their ability to shine academically. They are dull and tired, and cannot participate in sports."

Qureshi says that they mix four kinds of grains to make roti for the wraps for the children, which make up for deficiencies like iron and niacin that boost brain activity. "We have also tried to incorporate leafy vegetables, pulses, and meat in the diet," he informs.

The crippling effects of hunger on brain development, and in turn on education, employment and quality of life, become worse if certain vitamins and nutrients are missing. Neurologic deficits can be a result of deficiencies in micronutrients like folic acid, iodine, iron, zinc, selenium, copper, magnesium, vitamins A, C, D, E, B6 and B12.

These deficiencies can result in learning disabilities, mental retardation, abnormal levels of cognitive and mental functioning, and even depression, anxiety and withdrawal, all detrimental to a child’s focus on academic activity. Malnourishment can also result in behavioural issues, and lapses in memory and concentration.

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When asked how parents can avoid this happening to their children, Dr Danish says that "the first 1,000 days between pregnancy and a child’s 2^nd birthday sets the life-long foundation for human capital. After two years of age, the impacts of stunting are irreversible".

In his opinion, solutions include early initiation of breastfeeding, exclusive breastfeeding for six months, starting complimentary feeding after six months, and continuing breastfeeding for two years. Also, it is important to avoid junk foods and sugary drinks, provide diverse and nutritious balance food which should have necessary amount of proteins, vitamins, minerals and carbohydrates, and consume milk, fruits and vegetables.

"If all relevant stakeholders work together and implement joint interventions for nutrition, we can avoid bad impact of malnutrition on learning, earning and health," says Dr Danish.