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 starved 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 eat 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 prop
erly 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.
Surprisingly, however, two of the most powerful ingredients to use as “preload” for satiety are air and water, suggesting that fullness is not simply a matter of nutrients. When a group of twenty-eight “lean men” were given preloads of milkshakes, they ate significantly less lunch when the milkshakes were whisked up with air. They felt fuller after a milkshake whose volume was 600 milliliters as opposed to one whose volume was 300 milliliters, even though the energy content of the two milkshakes was identical. It’s possible that the increased air made their stomachs feel more distended. But the researchers concluded that “seeing the bigger volume” of milkshake made them feel they were consuming more.
If you want to trick your body into feeling fuller for longer, one of the best ways is to eat soup. When we consume liquid calories in the form of drinks—sugary sodas, say—they do little to fill us up, the supposition being that they pass through our mouths too quickly to signal to our pancreas, gut, and brain that we are receiving nutrients. But if we consume liquid calories more slowly—spoonful by spoonful—and call it food, it becomes very filling, often more so than solid food. Chicken soup, for example, was found in one study to be more filling than a grilled chicken breast. In another study, a starter of soup made people eat less of a main course than a starter of cheese and crackers, despite the fact that the cheese and crackers were more calorific. The filling properties of soup may be—as with airy milkshakes—partly a result of its large volume. There is evidence that—contrary to what our childish tummies might expect—we actually get more satiety from foods that are less energy-dense, and soup fits the bill here, unless it’s lobster thermidor or vichyssoise enriched with half a pint of double cream. We have a general tendency to eat roughly the same weight of food each day, regardless of its energy value, so it makes sense that watery soup should fill us up for fewer calories than other foods.
The filling properties of soup are not entirely rational, however. It is the
idea
of soup that makes us full, as much as anything. There’s a reason why those books are called
Chicken Soup for the Soul
. They could just as
well be called
Pho for the Soul
or
Clam Chowder for the Soul
, because all
soup is soul food. In pretty much every country in the world, something hot and brothy cooked in a pot and served in a bowl is viewed as uniquely nourishing. Soup places low demands on the eater. It treats you as a child, who may or may not know how to use a knife and fork. You do not have to chop, or even to chew. Soup is what our mothers gave us when we were ailing. It’s what we return to after a hard day at work, when all we want to do is curl up in a fetal position on the sofa.
A good homemade minestrone prepared with bone stock, pulses, assorted vegetables, olive oil, and pasta is a deeply nourishing meal, packed with fiber and protein, so no wonder it leaves you full. But our souls can be satisfied by lesser soups, too. Like many working women in the 1980s, my mother resorted to packet soups. When she had the time, she could make a mushroom soup, heady with cream, parsley, and shallots, as cosseting as a hug. When she was too busy, I was given a bowl of packet chicken noodle, consisting of potato starch, salt, flavorings, and MSG, with soggy pasta and tiny, unconvincing shreds of “chicken.” I looked up the nutritional values of packet chicken noodle, and if it hasn’t changed, my bowl of soup was a forty-three-calorie lunch: less than an apple. Yet I don’t remember leaving the table hungry. It was soup—and just as importantly, soup being given in a loving spirit in a Bunnykins bowl at the kitchen table—so it filled me up.