Nutrition%20in%20Global%20Health

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Nutrition in Global Health
Part 1 Roadmap to the worlds nutritional
health Causes, mechanisms, solutions
Allan J Davison PhD, Professor,
Biochemist, Faculty of Sciences, Simon Fraser
University Department of Biomedical Sciences
Kinesiology January 2011
Prepared as part of an education project of the
Global Health Education Consortium
collaborating partners
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Nutrition in global health - Overview

• Inequities in food distribution ? global hunger
  starvation
• One billion are too hungry to live productive
  lives - an equal number are adversely affected
  by overweight!
• 6 major deficiencies impact health through the
  life cycle water, protein, iron, vitamin A,
  iodine, folic acid
• Childbearing women their children are hardest
  hit
• Meanwhile, overnutrition inactivity? risk of
  heart disease, osteoporosis, cancer, diabetes,
  strokes, etc.

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Fundamentals and emphasis

• As we consider cause and effect we must ask
  How why have such inequities come to be? Who
  and what factors impede solutions? What
  current initiatives will bring the resolution?
• To help answer these, we must will
  emphasize Immediate causes - scarcity of
  specific nutrients Primary and secondary
  prevention Public health approaches to solutions

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Other GHEC modules contribute to our
understanding of Nutrition in Global Health

• This module 41a does not stand alone. 41b
  Roadmap to a world without hunger will follow
  (see note)
• Two other GHEC modules deal with poverty hunger
• Module 48 Acute malnutrition Clinical aspects
  (deals with treatment)
• Why is the 3rd world the 3rd world? (causes of
  poverty hunger) http//globalhealthedu.org/res
  ources/Pages/default.aspx

To see this module in the context of what will
follow, see Note A
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Pre-quiz

• As a reality check, and to create teachable
  moments for what follows, we now invite you to
  take a 5-minute pre-quiz
• You will be offered 10 true-or-false questions to
  dispel some common misconceptions
• Some of this misinformation is spread by those
  who have something to gain from it
• After completing the pre-quiz, we hope you will
  continue this module with greater interest and
  renewed clarity
• LINK TO THE PRE-QUIZ HERE

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Learning objectives
After completing this module you should be
able to

• Describe the extent of malnutrition its impact
  on people of the planet, understand how MDGs
  depend on nutrition
• Analyze the factors that determine nutritional
  health
• Identify nutritional problems among individuals
  populations, identify causes, appropriate
  solutions
• Assess risks at various stages of the life cycle
  recommend strategies for diminishing risk
• Compare competing theories accounting for the
  inequities
• Predict outcomes by projecting current trends
  into the future
• foresee a pathway toward a world without
  hunger

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To get the most out of this module

• If you are..

• You will want to

• a nutritionist or student of nutrition
• a student of one of the health professions
• planning a project in regions with severe
  nutritional problems
• a public health practitioner

• Pay attention to global public health policy
  implications.
• Pay attention to perspectives realities in
  desperate situations
• Emphasize check-lists to prepare for field work
  gather information to recommend advocate for
  intervention.
• Use slides resources in your information /
  teaching sessions

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Preface Nutrition is crucial to global health

• Among the immediately modifiable factors that
  affect individual public health nutrition is
  of prime importance
• Nutrition at every stage of life lays a
  foundation for health in the ensuing stage
• For all nations, rich poor, nutrition
  determines physical health development through
  the life-cycle, including
• Success in childbearing, cognitive function,
  socio-economic independence, education, disease
  resistance employability
• Health economic development are contingent on
  provision of adequate food, nutritional resources
  support

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A vicious cycle economics, hunger, health
Poverty ? diminished access to agricultural
food resources ? malnutrition
Physical cognitive impairment, susceptibility
to disease, early death ? inability to earn an
income
nutrition
Economic marginalization ? inability to provide
for self or family
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The Millennium Development Goals

• At a UN Millennium (2002) summit, the nations of
  the world set eight MDGs to be achieved by 2015
• The world's main development challenges were
  identified
• Specific actions and targets (the MDGs)
• A commitment to provide the means was made by
  189 nations signed by 147 heads of state
• The MDGs break down into
• 21 quantifiable targets
• Targets are measured by 60 time-lined indicators

Some nations have kept their trust. But some of
the richest in the world have announced that
they will not meet their commitments
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Nutrition Millennium Development Goals
Primary goal is to eradicate extreme poverty
hunger
see next 2 slides
Nutrition is a direct prerequisite to goals 1,
3, 4, 5 6 indirectly to 7 8
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Centrality of nutrition to MDGs 1, 2, 3
1. Eradicate extreme poverty hunger. Poverty
is the main determinant of hunger. In turn,
malnutrition irreversibly compromises physical
cognitive development thus transmits poverty
hunger to future generations. 2. Achieve
universal primary education. Malnutrition
diminishes the chance that a child will go to
school, stay in school, or perform well in
school 3. Promote gender equality, empower
women. Womens malnutrition impairs the whole
familys health nutrition
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Centrality of nutrition to MDGs 4, 5, 6

• 4. Reduce child mortality. Delivery of a live
  healthy child is dependent, above all, on a well
  nourished mother. Protein folic acid are
  critical here
• 5. Improve maternal health. Malnutrition
  accentuates all major risk factors for maternal
  mortality, e.g., inadequate protein, iron,
  iodine, vitamin A calcium
• 6. Combat serious infectious diseases.
  Malnutrition aggravates infections, ?immune
  competence, ?transmission mortality in HIV,
  malaria, tuberculosis
• Adapted from Gillespie and Haddad (2003)
  http//web.worldbank.org/

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Slow progress toward the MDGs
At mid-way, most MDGs are partly met. Only
goal 2 is fully within reach!
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Nutrition in Global HealthCourse overview

• Overview of nutrition across humankind
• Nutrition fundamentals in global context
• Top six nutrition problems, their solutions
• Nutrition across the life cycle in rich poor
  nations
• Cause effect in population nutrition
• Overview and where we are now
• Bridge to Part 2 Roadmap to a world without hunger

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Universal limitations health consequences

• We cant survive without about 15 essential
  mineral elements, so they are needed in our
  diets, most in trace amounts
• We cant manufacture about 15 vitamins, so they
  must be provided in our diets
• And in addition

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Universal limitations health consequences

• In addition We lost key metabolic abilities our
  evolutionary ancestors had. Thus we are
  vulnerable to 2 dietary risks
• In early life a period of rapid growth, we are
  vulnerable to kwashiorkor (protein
  insufficiency) because we cant synthesize 8
  essential amino acids missing from our diet
• 2) In later life we are vulnerable to obesity
  diabetes in part because we can make fat from
  carbohydrate, but we cant easily convert stored
  fats back to carbohydrates

Note B
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Categories of nutritional status

• Nutritional status is assessed as one of four
  categories
• Good nutritional status All nutrients (right
  quantities, time place) allow optimal, growth,
  maintenance, reproduction
• Overnutrition An excess of a nutrients (usually
  calories) is being consumed, so that health is
  negatively impacted
• Undernutrition Insufficient food is consumed to
  allow for the energy needs of the individual.
  Inevitably dietary ( then body) protein is
  burned for energy. A secondary protein deficiency
  ensues thus "protein-energy-malnutrition"
• Malnutrition Energy consumption is adequate, but
  there is an imbalance among constituents of the
  diet and health is impacted

Note C
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Worldwide distribution of malnutrition

• Over 20 million children suffer from acute
  malnutrition WHO.

Scientific American, Sept 2007
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Worldwide, nutritional inequities follow
poverty(as do health inequities life
expectancy)

• Globally, there is plenty of food for everyone
  but those who have more than they need find
  reasons not to share
• The result in the time you spend on this module
  over 1000 children will have died of hunger
• Each day 1500 children go forever blind from lack
  of vitamin A
• The poorest are 50-200x more likely to die in
  pregnancy (more than half these deaths are
  attributable to iron deficiency).
• About 2 billion people (56 of pregnant women)
  have iron deficiency. Their babies have low
  birth-weight, ? mortality

Note D
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The bottom billion (title of a book by Paul
Collier )

• The poorest of the poor, Public health
  nutritionists identify a subclass of the hungry -
  those who try to survive on resources worth less
  than 1 per day
• We define this subclass as people who don't get
  enough to meet the ordinary demands of life
• They lack the resources to earn a living, or
  obtain whats needed for normal, growth,
  maintenance reproduction
• It goes without saying that they are unable to
  provide the necessities for those who depend on
  them

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The bottom billion (title of a book by Paul
Collier )

• Their lack of access to resources is such that a
  significant fraction will be unable to stay alive
• They live mostly in isolated rural areas and most
  are subsistence farmers
• This means that what they eat this month is
  what they can take out of the ground from last
  month's planting

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Unhelpful misconceptions about aid
False Most aid money goes into the Swiss bank
accounts of corrupt African dictators Aid
creates dependence impedes self-sufficiency De
spite all the aid , the problems are only
getting worse The truth is Overwhelmingly
African leaders are not corrupt. When they are,
most bribes come from the West Well planned aid
builds capacity self-sufficiency Overall,
hunger worldwide is diminishing. MDGs go forward
because of the countries that honour their
pledges!
Note E
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Money? Useless - no nearby shops

• Its hard to imagine a malnourished community and
  you may want to experience field conditions in
  advanceNo commerce! Try it at a Medecins sans
  Frontieres site http//www.starvedforattent
  ion.org/
• No shops to spend money in, no one to employ
  anyone, no one to sell things to
• Hungry children are all too visible, and those
  who didnt survive are in tiny unmarked graves
• Their needs are much more immediate than money
• We dont need studies to learn what they need -
  read on!

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If they dont need money what do they need?

• Short term they likely need emergency rations,
  safe waterIn conflict zones, shelter safety to
  live, plant, harvest
• Medium term they need to become self-sufficient,
  withgood seeds, fertilizer, usable water,
  sanitation, low technology agricultural info
  resources, health services, mosquito nets,
  pharmaceuticals
• Long term they need the prerequisites of
  sustainable economic development - tools for
  development see Part 2
• Kids need particular attention see note below
  later slides

Note F
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The goal is to see everyone self-sufficient

• People in the poverty trap live from hand to
  mouth, with no opportunity to put resources aside
  to build a better future
• Such communities cannot access the ladder of
  economic development without external help.
• The MDG promises of 0.7 of rich country GDP for
  aid was chosen to eliminate extreme poverty
  hunger in 3 decades
• But there are some nations whose promises mean
  little. Long before 2008, US Canada changed
  their minds
• Thanks to the nations that keep their promises,
  widespread hunger will be eliminated, but only
  after 30-50 years

This is not, however, cause for undiluted joy.
See Note G
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Some communities subsist in the poverty trap

• Even among the richest there are some individuals
  so marginalized that there seems little hope for
  them The larger culture, if it is compassionate,
  takes long-term responsibility for ensuring them
  the necessities of life
• Globally there are communities that have been
  denied the resources to ever become wealthy.
  Often from geography, climate, invasion, or
  appropriation of their natural resources
• Regardless, a world community of compassion can
  provide the necessities of life, offer new life
  to the dispossessed, as North America once opened
  its doors to the poor

Note H
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Nutrition in Global HealthCauses, mechanisms,
solutions Nutrition is crucial to global health
MDGs

• Overview of nutrition across humankind
• Human nutrition fundamentals in global context
• Top Six nutrition problems, their solutions
• Nutrition across the life cycle in rich poor
  nations
• Cause effect in population nutrition
• Overview and where we are now
• Bridge to Part 2 Roadmap to a world without hunger

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Human Nutrition Fundamentals in Global Context
The next set of slides covers the critical skill
set needed for understanding nutritional issues
in the context of global health They are not a
substitute for nutritional training, but rather a
catalog of nutritional tools applicable to
problems a health practitioner might encounter in
the field From this you can learn when to call in
a nutritional expert, what kind, what to you
might reasonably ask for receive If you have
learned nutrition in a developed country, this
may help you to expand your knowledge of
nutrition and public health in the context of 3rd
world health problems
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Dietary patterns across cultures

• 1. Hunter gatherers the earliest category
• Benefits mixed diet, well nourished in good
  times
• Risks famine or drought, warfare plunder,
  resource- depletion through population
  pressure
• Prevalent problems starvation, thirst, ?
  life-expectancy

Note I
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Dietary patterns across cultures

• 2. Peasant agriculturalists successful small
  scale farmers (currently the largest group)
• Benefits close to food sources if no punitive
  taxes or rentsusually well adapted to their
  traditional diets
• Risks single crop emphasis ? malnutrition,
  plagues (locusts, rodents), exploitation, warfare
  and plunder
• Prevalent problems vitamin deficiency,
  starvation, alcoholism

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Dietary patterns across cultures

• 3. Indigent, landless crop planters
• Benefits Community, share with family,
  neighbors, income is typically less than a dollar
  a day
• Risks Crop failure, drought or famine, erosion,
  soil-exhaustion, pestilence, economic
  exploitation (by landlords, seed providers,
  loan-sharks), displacement, forced migration,
  civil unrest or foreign invasion
• Problems multiple vitamin deficiencies,
  kwashiorkor (protein malnutrition), infectious
  disease epidemics. Too poor, powerless to help
  themselves, most of them will never escape their
  circumstances, nor achieve full health

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Dietary patterns across cultures

• 4. Urban slum dwellers fastest growing group
• Benefits hope for jobs, escape from drought or
  crop failure
• Risks overcrowding, poverty, poor hygiene,
  limited food choice, social disruption ? loss of
  traditional diets, crime
• Prevalent problems deficiencies of essential
  nutrients, alcoholism, obesity, kwashiorkor,
  epidemics

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Dietary patterns across cultures

• 5. Affluent urbanites most recent category
• Benefits many food choices (appropriate and
  inappropriate)
• Risks inactivity along with high fat, sugar,
  alcohol intakes
• Prevalent problems overnutrition, obese babies
  and adultsdiabetes (carbohydrates), cholesterol,
  atheroma (lipid), strokes, heart disease
  diabetes, gout (uric acid - meat sources)

Note J
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Nutrition in Global HealthCauses, mechanisms,
solutions Nutrition is crucial to global health
MDGs

• Overview of nutrition across humankind
• Human nutrition fundamentals in global context
• Top six nutrition problems, their solutions
• Nutrition across the life cycle in rich poor
  nations
• Cause effect in population nutrition
• Overview and where we are now
• Bridge to Part 2 Roadmap to a world without
  hunger

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Top 6 global manifestations of malnutrition
We begin with a perspective, then we take each of
the 6 in turn

• Water is a food (food is the material we eat
  drink)In hot climates, we can die in a few
  hours from a lack of it
• 2) Protein-energy malnutrition
• The machinery of life, sculpted from 20 different
  amino acids
• Deficiency is most serious in children (time of
  fastest growth) ? "failure to thrive", stunted
  growth

The material in this section is well reviewed
at http//www.pitt.edu/super1/lecture/lec0141/
index.htm Iron, vitamin A, iodine check the
latest information at http//www.micronutrient
.org/English/view.asp?x1
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Top 6 global manifestations of malnutrition
(cont.)

• 3) Iron deficiency - prevalent in Africa and
  Asia
• Women children are the most seriously affected
• In parts of Africa 60 of children have ? blood
  iron
• About a quarter of these have symptoms of anaemia

• 4) Vitamin A deficiency
• Over 100 million children under 5 suffer vitamin
  A deficiency
• In high deficiency areas vit. A tabs ? child
  mortality by 23
• ? child blindness by 80. Night-blindness is
  an early sign

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Top 6 global manifestations of malnutrition
(cont.)

• 5) Dont underestimate iodine deficiency
  disorders
• WHO 2003 1.6 billion people dont get enough
  iodine. This is the major cause of preventable
  brain damage.
• Thanks to MDG programmes the problem is
  shrinking! http//www.who.int/vmnis/iodine/statu
  s/en/index.html
• In addition nutrition determines chronic disease
  risk
• Heart disease, osteoporosis, cancer, diabetes,
  strokes, etc.
• Well go through these one at a time in the
  following slides

For categories of at risk people across
countries, see Note K
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Top 6 global manifestations of malnutrition
(cont.)

• 6) Folic Acid is required for healthy babies
• A deficiency causes spina-bifida a common birth
  defect
• Supplements are recommended before start of
  pregnancy
• 50 of pregnancies are unintentional!
• Women who might become pregnant, need advice
• More details on these nutrients in the ensuing
  slides

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Water one of our most important foods

• Adequate safe water is most important dietary
  component
• 9 million worldwide have water-borne diseases
• In India, contaminated water kills 300,000
  children annually
• Problems relating to water supply safety have
  simple, relatively inexpensive solutions
• Water ownership is, however, contentious
  usually follows military power (e.g. in Middle
  East)
• In hot humid conditions workers may need over 5 l
  / day also need to replace the NaCl lost along
  with water in sweat

http//www.who.int/water_sanitation_health/mdg1/en
/index.html
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The special importance of proteins

• Proteins are the machinery of life. We have no
  storage form. If we must use our protein
  stores, our tissues lose function
• Plasma, liver and kidney lose function first.
  Their proteins are the most labile. Then,
  digestive tract, muscle heart
• Proteins are made up of 20 amino acids. 12 are
  non-essential they can be made from other
  dietary components
• 8 amino acids are essential. If even one is
  missing, no protein can be synthesized. A protein
  lacking any one essential amino acid has zero
  biological value

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Dietary deficiency of proteins is deadly

• When any essential amino acid is missing, all the
  rest are burned no protein synthesis can occur
  zero!
• All essential aas must be there at the same
  time. Meeting an amino acid need 1 day later is
  useless
• A diet previously adequate in essential amino
  acids becomes inadequate if non-essential amino
  acids are removed. Because, although the body can
  make missing non-essential aa, it uses up
  essential amino acids to do so
• Protein complementarity, de-emphasized in
  nutrition courses, can be vital where protein
  intake is compromised

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Humans adapt to low protein intakes ...

• ... otherwise impact of protein deficiency would
  be even higher
• Endocrine changes improve the recycling of
  proteins. As tissues repair, the released amino
  acids are reused more efficiently
• In the African presentation of kwashiorkor, a
  child is exposed to a protein deficient diet (age
  1 to 5) adapts successfully
• Then a 1-week lack of protein (parent loses job,
  baby is fed glucose-water only, or a
  gastro-intestinal infection) ? kwash
• Child is treated for kwash, sent back to the home
  to same diet, reaches adolescence, usually
  without recurrence.

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Protein energy nutrition are inseparable

• When the diet lacks carbohydrates, it uses some
  amino acids to make glucose for brain, muscle,
  etc.
• When a diet lacks total calories, proteins are
  co-opted, first dietary, then plasma, liver,
  kidney, etc.
• For these reasons, a diet previously adequate in
  essential amino acids becomes inadequate if
  carbohydrate or calories are removed.
• Google protein-sparing effects of carbohydrates
  if you want to understand this further

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Protein-energy malnutrition - in adults

• Tissues are raided, with the following
  consequences
• Loss of plasma proteins ? oedema
• Loss of liver kidney function ? diminished
  inactivation excretion of carcinogens and
  toxins
• Loss of immune function ? gastro-intestinal
  infections
• Loss of digestive tract / liver function ? amino
  acids cant be utilized for proteins. No
  treatment can prevent death
• Loss of muscle and heart tissue ? weakness, heart
  failure

Oedema or edema abnormal accumulation of fluid
beneath the skin or in body cavities
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Hungry kids difficulties in diagnosis

• Marasmic babies may not seem undernourished until
  a check for pitting oedema reveals that what
  appear to be strong arms and legs, are in reality
  oedematous
• Another diagnostic complication is that most
  deficiencies are combined, as in protein energy
  malnutrition PEM with multiple vitamin
  deficiencies
• The distinctions are crucial both in determining
  treatment, and in determining if the underlying
  problem in the community is scarcity of food, a
  protein, or many nutrients

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Protein malnutrition is different

• In uncomplicated kwashiorkor, only protein is
  lacking - Malnourished, not undernourished
• The risk of death or permanently retarded
  development is great, and the risk is increased
  because its easier to miss the diagnosis
• Kwashiorkor babies may have more than adequate
  calories in their diets. They may be chubby, with
  substantial subcutaneous fat
• Kwashiorkor may go unnoticed even when urgent
  hospitalization is needed, or when death is
  imminent

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Protein malnutrition diagnosis

• When there are many sick kids in a community, but
  none look undernourished be sure to look for
  protein deficiency. Why?
• Its important not to miss the diagnosis.
  Kwashiorkor has a high fatality rate even with
  hospitalization
• The 1st symptom to present is often diarrhoea, or
  oedema
• The child may be treated for a gastrointestinal
  infection while the underlying cause,
  kwashiorkor, goes undiagnosed
• Oedema is an early symptom, and may be mistaken
  for chubby limbs, so test if nutrition may be
  compromised

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Tracking protein-energy malnutrition in kids

• Failure to thrive may be an early warning of
  flagrant PEM in an individual child or a
  community. Always investigate the cause
• Growth charts give weight for stature / length
  across age. They provide criteria to estimate
  severity. Proper use requires training!
• Change in position on a chart shows effectiveness
  of treatment probability of survival
• If many children in a community show up at risk
  on growth charts, authorities must be alerted to
  endemic problems

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Early measures required on PEM diagnosis

• Treatment is urgent - hospitalization is
  preferred if available
• Delayed physical growth is often restored in
  catch-up growth when a good diet is provided
• Cognitive disabilities may be irreversible if
  prolonged
• Ready-to use foods (RTUF) for PEM have saved many
  lives
• Oral rehydration salt (ORS) therapy is also
  life-saving when there is accompanying diarrhoea
  (which is usually the case)

Note L
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Early measures required on PEM diagnosis

• Both RTUF and ORS can be given at home in a
  bottle (Wikipedia). World production of ORS is
  around 500 million sachets / year. Improvisation
  of ORS is described at http//rehydrate.org/ors/ma
  de-at-home.htmrecipes
• Powdered milk protein in boiled water can be very
  helpful as an emergency measure
• Acute fatality rate can be 25 even with prompt
  treatment

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Iron deficiency affects 500 million globally
http//www.micronutrient.org/English/view.asp?x57
9

• Causes insufficient availability of dietary
  iron, or increased iron requirements to meet
  reproductive demands, haemmorhage, parasitic
  infections (often concurrently).
• The result is an increasingly severe anaemia,
  reduced work productivity ? poverty, diminished
  learning ability, increased susceptibility to
  infection
• For more on consequences of iron deficiency, see

Note M
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Iron deficiency affects 500 million globally

• Iron deficiency is best diagnosed in the
  preclinical stage, by measurement of transferrin
  saturation
• Females gt males due to iron loss at menstruation
  -- 56 of pregnant women are affected 3 x as
  many as in developed countries
• 25 of men also are deficient in iron in the
  developing world

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Treatment of iron deficiency rebuilding iron
reserves

• Iron tablets are effective within weeks, but
  non-compliance is common so compliance must be
  checked
• Increase iron intake through combining iron-rich
  foods with agents that ? iron absorption (like
  vitamin C)
• Encourage availability and consumption of
  iron-fortified foods

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Treatment of iron deficiency rebuilding iron
reserves

• Weekly / daily supplementation is recommended for
  vulnerable groups in areas with intractable iron
  deficiency
• Treat causes of diminished iron reserves
  haemorrhage, parasites (including malaria), and
  hemolytic conditions.
• Be alert! Iron may be lethal in some inherited
  anaemias (thalassemias, sickle cell, or Hb M)
  common in Africa Asia

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Iron excess - dangerous to some

• Those with haemolytic anaemias (eg thalassaemia
  common in people of African or Asian descent).
  Iron should not be prescribed until the cause of
  an anaemia is known
• Where iron pots are used for cooking or beer
  Siderosis iron deposition in liver, kidney,
  heart, pancreas ? organ failure
• Children Parents' iron pills are attractive to
  kids in developed countries. The most common of
  fatal childhood poisonings
• Those with familial haemochromatosis This common
  inherited disease has symptoms similar to
  siderosis (above)The first sign of this disease
  is often inoperable liver cancer

Note N
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Vitamin A deficiency in public health

• Vit. A deficiency is a public health problem in
  over 70 countries, especially in Africa, SE Asia
  the W Pacific where it affects 250 million
  mostly aged 0-4 years
• Night blindness may predict vitamin A deficiency,
  with risk of permanent total blindness if it
  progresses.
• There is also increased risk of severe illness
  and death from infections such as diarrhoeal
  disease and measles
• Vitamin A supplements can be beneficial when
  given as seldom as once a year. Check the latest
  information at
• http//www.micronutrient.org/english/View.asp?x57
  7

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Vitamin A deficiency perinatal health

• Vit. A is crucial for maternal child survival,
  supplements in high-risk areas can dramatically
  decrease maternal mortality
• In pregnant women Vit. A deficiency is seen in
  the last trimester when demands by unborn child
  mother are highest
• Partnerships for progress in vitamin A
  nutritionIn 1998 WHO, UNICEF, CIDA, USAID (ia)
  launched a global initiative in 40 countries that
  has to date averted 1.25 million deaths, by
  giving vitamin A to kids at clinics

This issue is under active investigation. For
the status at time of writing see Lancet, Volume
376, Issue 9744, p 873 - 874, 11 September 2010
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Vitamin A deficiency perinatal health

• Night blindness in pregnant women - an early
  danger sign
• In children, the cost-effective prevention is
  breast-feeding
• Genetically engineered high Vit. A rice crops
  could help
• Caution Vit. A supplements as retinol are
  controversial. It can be toxic teratogenic (?
  birth defects). However, given as carotene,
  vitamin A supplements are safe, leading only to
  an orange tinge in skin colour.

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Iodine deficiency disorders

• The worlds major cause of preventable brain
  damageIn 1990 1.6 billion people were at risk
  in over 100 countries, mainly in parts of Africa
  and Asia where soil is iodine-deficient
• 38 Million children have mental impairment from
  lack of iodine
• As a result of the micronutrient initiative, this
  number is falling

For latest data, see http//www.micronutrient.org
/english/View.asp?x578
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Iodine deficiency disorders

• Consequences start before birth and continue
  afterward
• In utero, spontaneous abortion, congenital
  abnormalities retarded foetal development
• In early childhood and progress toward
  adolescence iodine deficiency causes cretinism,
  an irreversible retardation. Impacts home,
  school, work
• Today we are on the verge of eliminating iron
  deficiency --- a major public health triumph
  like getting rid of smallpox polio

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Toward iodine sufficiency iodized salt

• A cost-effective low-tech therapy, iodized salt
  costs just 0.05 per person per year
• UNICEF, ICCIDD (International Council for Control
  of IDD), the salt industry have set up
  iodization programmes.Globally, 66 of
  households have access to iodized salt.
• As of 2009 the number of at risk countries has
  been halved!
• However, progress has slowed and we are a decade
  behind promises of the international community.
• 54 countries are still affected efforts must
  continue

63
Nutrition in Global HealthCauses, mechanisms,
solutions Nutrition is crucial to global health
MDGs

• Overview of nutrition across humankind
• Human nutrition fundamentals in global context
• Top 6 nutrition problems, their solutions
• Nutrition across the life cycles of rich poor
• Cause effect in population nutrition
• Overview and where we are now
• Bridge to Part 2 Roadmap to a world without hunger

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Nutrition through the life-cycle
65
Factors in perinatal nutrition (see also Acute
malnutrition module)

• Nutritional health begins in the womb a healthy
  outcome to a pregnancy requires that mother be
  well nourished good feeding must initiated early
• The most common birth defects result from a
  deficiency of folic acid in the diet of the
  pregnant mother, Best outcomes require folic acid
  supplementation before conception!

66
Factors in perinatal nutrition (see also Module
on Acute malnutrition)

• Delaying clamping the umbilical cord until it
  stops pulsing ?iron stores see
  www.naturalchildbirth.org/natural/resources/labor/
  labor04.htm http//apps.who.int/rhl/pregnancy_chil
  dbirth/childbirth/3rd_stage/jccom/en/index.html
• Ideally, babies should receive vitamins E K
  injections at birth
• A baby whos healthy at birth may experience
  "failure to thrive" (or "growth faltering") in
  the first year of life. So ..
• Good infant feeding behaviors must start early.
  Most importantly, breast-feeding should be
  initiated within an hour of birth maintained
  exclusively for 6 months.
• Breastfeeding could prevent 1.3 million deaths
  each year http//www2.unicef.org/nutrition/index_
  22657.html

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Perinatal nutrition requires attention1

• Malnutrition in pregnancy ? birth defects low
  birth-weight
• Failure to thrive is an early danger sign,
  requiring investigation
• Nutrition in infancy to early life impacts
  physical cognitive development. It determines
  immediate future risks of blindness, thyroid
  function, bone development, more
• Under-nutrition or deficiencies of many
  micronutrients can cause failure to thrive
• Iron, vitamins K and E are of particular
  importance. Refer to
• 1http//www.who.int/nutrition/topics/infantfeeding
  _recommendation/en/index.html

68
Malnutrition in early childhood

• Children are at special need because they are at
  the fastest-growing stage of life. Problems an
  adult could survive can be lethal to a child
• This is the most vulnerable period a child is
  developing physically mentally. Damage can be
  permanent
• Most importantly, they are unable to fend for
  themselves depend on others (parents, others)
  for health survival
• They are the planets future. We owe it to them
  to ourselves to ensure that they grow well, with
  a sense that they have reason to invest in the
  future, in a caring world

69
Parenthetically a personal perspective

• How easily we see the moral failings of the past.
  Slavery, the holocausts genocides, conquests
  motivated by greed
• When future generations look amazed at the moral
  blindness of this generation, what will stand
  out? Clearly child hunger
• Where life expectancy is short, toddlers are
  orphans. In war or famine a region may lack
  necessities. You cant blame a child
• Yet in rich countries, yes, the US Canada, we
  turn our empty eyes and hands away from those
  outside our borders
• A napalmed child turned a nations mind to peace.
  What will it take to open our eyes to children
  dying of hunger?

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Nutrition through the life cycle - adolescence

• Adolescence carries risks for both poor
  affluent
• Adolescent adult patterns of food consumption
  activity massively impact immediate future
  health risks
• Adolescents are notoriously careless about
  health. Their eating patterns can lead quickly to
  obesity or anorexia.

71
Nutrition through the life cycle - adolescence

• Adolescence carries risks for both poor
  affluent
• Dieting can lead to deficiencies of vit. C,
  protein, folic acid in a sedentary person. Even
  if a good mix of foods is consumed, total food
  intake may be insufficient.
• A pattern of healthy eating in adolescence sets a
  pattern that can promote lifelong health
• A foundation for healthy bones is set by
  exercise, calcium, vitamin D. After early adult
  life, bones go slowly downhill

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Nutrition through the life cycle adult life

• Nutrition acute infectious diseases
• Malnutrition depletes immunity leading to
  increased risk severity of infections
  parasites AIDS, malaria, etc.
• Flagrant deficiencies of specific micronutrients
  can put at risk the life health of the mother
  in pregnancy lactation
• Nutritional anaemias, pellagra, blindness, skin
  disordersberiberi, scurvy, etc, can range in
  severity from mild to fatal

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Adult life - degenerative diseases

• In late life, risk of breast, prostatic, most
  other cancers are predicted by diet, obesity,
  inactivity or smoking in adult life
• Also heart disease, strokes, osteoporosis,
  diabetes
• Cancers and diabetes are now leading causes of
  death disability in low- and middle-income
  countries (see Lancet August 13, 2009)
• Nearly two-thirds of the worlds 7.6 million
  cancer-related deaths now occur in developing
  nations.

74
Differential nutritional vulnerability of females

• Women are much more prone to nutritional anaemias
  since they need to replace red cells lost in
  menstruation
• Women are the majority of elders, increasingly so
  in Asia and Africa. Osteoporosis is more common
  in the elderly
• Osteoporosis is a major cause of illness,
  disability and death. The annual number of hip
  fractures worldwide will rise from 1.7 million in
  1990 to around 6.3 million by 2050.

75
Differential nutritional vulnerability of females

• Women suffer 80 of hip fractures lifetime risk
  30 - 40 compared with 13 for men.
• Osteoporosis prevention (exercise, calcium,
  vitamin D) must start well before age 30 when
  bones still respond.
• Negative calcium balance in later life is not
  very responsive to nutritional measures.

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Under- over-nutrition occur in all cultures

• Disparities in income, nutrition health care
  are increasing between countries within groups
  in the same country
• In addition, in low and middle income countries
  diseases of overnutrition are increasingly common
• Obesity related disorders, including diabetes,
  are now as important in some lower to middle
  income countries as in North America and the
  European Union

77
Also, under-nutrition occurs in many rich nations

• In rich nations, enormous wealth for some has
  left others ravaged by health costs,
  unemployment, foreclosures
• Developed countries have marginalized cultural
  groups. Hunger is common in N S America, China
  E Europe
• For example, 49 of US children (and over 80 of
  black children) require food-aid at some time
  during childhood
• Scandinavia few western European countries are
  almost the only exceptions

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Overnutrition is no longer limited to rich
countries

• Obesity is a growing problem worldwide,
  particularly among those who lack resources for a
  wide range of food choices.
• All too often, the cheapest foods are high
  calorie, poor in nutrients, rich in sugar, salt,
  fat, trans-fats
• The predominant cause of obesity is
  under-exercising rather than overeating. On
  average, overweight people eat slightly fewer
  calories than lean people, but are much less
  active
• Obesity increases risk of many disorders, most
  notably cardiovascular disease, cancer,
  adult-onset diabetes. Prevention is much better
  than cure.

79
Overnutrition is no longer limited to rich
countries

• Previously, the poorest were almost immune to
  diabetes, hypertension, gout, atherosclerosis
  heart disease
• No longer. These are growing problems, impacting
  health worldwide. In the next few slides well
  consider prevention.
• Diabetes has reached epidemic proportions
  threatening, vision, kidney function, mobility,
  heart-health life itself.
• A cluster of symptoms, hypertension,
  hyperlipidemia, and hyperglycemia is sometimes
  called metabolic syndrome
• Each of them increases risk of heart disease, and
  together the risk is greatly amplified. Read on..

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Prevention of heart attacks and strokes

• Risk factors hypertension, hyperlipidemias (LDL
  / bad cholesterol), inactivity diabetes. All
  correlated with obesity
• Smoking is the most life-shortening risk factor
  of all
• These risks can be changed earlier or later, by
  modification of diet other life-style changes
  or medication
• In the past 5 years research has established that
  exercise a lean body are the most powerful
  predictors of a long healthy life, and also of
  clear thinking into old age

81
Prevention of heart attacks and strokes

• There is no easy solution to obesity. In a
  typical study lt10 of people dieting, lt10 of
  those exercising, and lt15 of those exercising
  dieting, lost weight.
• However, over 80 of those who underwent stomach
  stapling or banding lost weight!
• Not very encouraging, for lifestyle treatment.
  Many argue that surgery to control weight should
  be done more often

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Measures to diminish cardiovascular risks

• Lifestyle measures have greatest impact in older
  people!
• Increasing consumption of fruit vegetables by
  one to two servings can cut cardiovascular risk
  by 30
• Reduction of blood pressure by 6 mm Hg reduces
  stroke risk by 40 heart attack by 15.
  Hydrochlorthiazides (diuretics) are inexpensive
  and effective
• Moreover, a 10 reduction in LDL cholesterol
  reduces the risk of coronary heart disease by 30

83
Measures to diminish cardiovascular risks

• Modest cutbacks in saturated fat salt improve
  blood pressure lipids diminish risk of
  cardiovascular disease
• Lifestyle measures are, optimally, combined with
  pharmaceutical intervention
• Best practices in the area of diabetes
  cardiovascular disease are a moving target.
  Anyone teaching or practicing in this area needs
  skills in finding evidence-based information in
  an ocean of misinformation.

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Nutrition in later life and old age

• Worldwide, the proportion of people over 60 is
  increasing. By 2025, the world will have more
  than 1.2 billion older persons two-thirds of
  them in low income countries
• The foundation laid in earlier life determines
  risk ofdiabetes, heart disease, hypertension,
  strokes, osteoporosis, cancer, etc. All these
  bring special nutritional concerns.
• Many of the diseases of late life are diagnosed
  too late for effective treatment. Prevention at
  an early age is the goal

85
Nutrition in later life and old age

• Old age can be cut short by many kinds of
  malnutrition
• Deficiencies of calcium, iron, water, vit. B12
  can severely compromise old age
• Loss of taste and smell can render the elderly at
  risk for food poisoning from spoiled food
• Loss of thirst sensitivity in this age group
  makes dehydration (inadequate water intake) a
  common cause of confusion, headache,
  occasionally kidney stones
• Prevention is better than cure, symptomatic
  treatments that are effective ,are often
  unavailable to the aged in LMICs

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86
Nutrition in Global HealthCauses, mechanisms,
solutions Nutrition is crucial to global health
MDGs

• Overview of nutrition across humankind
• Human nutrition fundamentals in global context
• Top six nutrition problems, their solutions
• Nutrition across the life cycles of rich poor
• Cause effect in population nutrition
• Overview and where we are now
• Bridge to Part 2 Roadmap to a world without hunger

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Determinants of population nutrition
Any broken link can ? nutritional
inequities. (think about how )
88
The mechanisms of hunger many paths
Notice how one path can feed-back to affect
others As diagrammed by WHO in
Repositioning Nutrition as Central to
Development  A Strategy for Large-Scale Action
89
Sub-determinants of nutritional sufficiency

• Each factor has its own contingencies. Here are a
  few
• Economic development depends on agricultural
  sustainability
• irrigation soil maintenance (crop rotation,
  contour plowing)
• seeds, fertilizers, appropriate insecticides
• Agricultural productivity depends on good
  harvests
• climatic drought and floods
• drought - and frost-resistant crops
• hybrid seeds and related biotechnology
• market for any excess crop, non-exploitative
  trade

90
Sub-determinants of nutritional sufficiency

• Each factor has its own contingencies. Here are a
  few more
• Stability includes freedom from disruptive forces
• war (revolts, invasion, political upheaval,
  social disruption)
• exploitation from outside unequal trading
  practices
• corruption externally multinational
  corporations offer bribes and rich nations
  tolerate this because it benefits them
• corruption internally where some developed
  nations set a poor example e.g.
  non-transparent procurement policies

Note O
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Poverty - greatest cause of malnutrition(hunger,
blindness, disease, birth defects,
maternal/neonatal death)

• The causes of poverty are disputed no one
  wants to be part of the cause. What we know is.
• Poverty doesn't just happen, it is caused by
  economic, political, social geographical
  circumstances decisions
• Usually these decisions are made outside the
  groups of people most affected by it!

Note P
92
Poverty - greatest cause of malnutrition(hunger,
blindness, disease, birth defects,
maternal/neonatal death)

• Old people, women and under-supported children
  are most likely to be impacted by poverty
• Uneven distribution 2/3 of undernourished people
  live in Asia
• Hunger is growing fastest in Sudan, Rwanda,
  Burundi, Chad D.R. Congo, Sierra Leone, Zimbabwe,
  Somalia

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Nutrition in Global Health Nutrition is crucial
Millions more are fed, but Nutrition is crucial

• Overview of nutrition across humankind
• Human nutrition fundamentals in global context
• Top six nutrition problems, their solutions
• Nutrition across the life cycles of rich poor
• Cause effect in population nutrition
• Overview and where we are now
• Bridge to Part 2 Roadmap to a world without hunger

Page 93
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Where are we? Considerable hope for the future,
with great distress urgency in the present

• Globally, more are now adequately fed than ever
  before.
• Many populations are growing ... and yet the
  percentage being fed continues to increase
• The MDGs will mostly be mostly met ... but not on
  schedule.

95
Where are we? Great hope for the future, with
great distress urgency in the present

• Does that mean we are doing enough? Absolutely
  not!
• Improvements in nutrition are not equally spread
  in Africa more are hungry
• Most of those born today will live to see hunger
  shrink to temporary pockets, managed by relief
  aid
• Meanwhile, even as extreme hunger decreases, its
  too slow to stop the needless loss of millions of
  lives each year

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What has changed? At last its clear
Disparities are now so great that there is almost
complete agreement that the plight of the poorest
must be addressed The cost of conferring great
benefits is a fleabite to the rich. 20 from an
individual can save a childs life and 0.7 of
GDP from the richest nations could, in two
decades, wipe out the deadliest disparities
97
What has changed? At last its clear
Whats needed was defined in 2001.
Amazingly 22 nations signed on to fund 7 MDGs
with 60 indicators of success, and to provide the
funds!1st aim eradicate extreme poverty
hunger
Weve seen what worked what didnt. The MDG
projections were accurate, but ...
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While some well-intended nations ...
... honoured their commitments in full, or at a
higher level (here we honour northern EU,
Luxemburg Netherlands) ... most provide
approximately half the aid that they undertook
and are increasing (here, much of west-central
EU) ... a very few provided a third or less are
decreasing (here we include the nations of N.
America Japan)
the consequences are unsurprising.
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The consequences are unsurprising

• Thanks to nations individuals who put
  worthwhile goals ahead of strictly national
  interests, a better nourished world emerges
• The majority of nations are now solidly on the
  development ladder and the number grows each year
• Millions die unnecessarily in E and S Asia,
  sub-Saharan Africa, and the major cause rests
  with a few nations

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Nutrition in Global Health Bridge to a roadmap
to a world without hunger

• Why nutrition is crucial to global health MDGs
• Overview of nutrition across humankind
• Human nutrition fundamentals in global context
• Top six world nutrition problems, their
  solutions
• Nutrition across the life cycle in rich and
  poor nations
• Cause effect Determinants in population
  nutrition
• Where we are now Overview Millions more are
  fed but without urgent action, millions more will
  starve
• On to Part 2 Roadmap to a world without hunger

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Roadmap toward a world without hunger
Weve concluded Part I of the nutrition
modules with a preliminary assessment of
prospects for eradicating extreme poverty
hunger. In Part II we ask what works and what
doesnt? We will

1. discuss the confounders wild cards
   elaborate on the range of possible future
   scenarios
2. contend that many controversies fail to see
   that many competing approaches are, in fact,
   complementary
3. ... categorize competing viewpoints as evidence-
   or ideology- based subject them to the test
   of science
4. survey current strategies, assessing their
   strengths, weaknesses, applicability to real
   life problems

102
Review your pre-quiz to confirm that you have
advanced your knowledge. As we move now to the
future, here is part of the pre-quiz for the Part
II Nutrition module

• Does globalization promote nutritional health?
  For whom?
• Is free enterprise good for everyone? If not,
  for whom?
• Are most African leaders dictators?
• Does most aid to Africa end up in Swiss bank
  accounts?
• Does food aid do more harm than good?
• Academics politicians argue about these
  questions and what should be done. Does that mean
  that we dont know what to do? We will see in
  Part II that the answers are clear

103
Summary What youve learned

• Nutritional health is not equitably distributed
  worldwide
• Correcting nutritional inequities is
  crucial to a viable future
• We've reviewed nutritional principles in global
  context
• Nutritional health, public health,
  economics are inseparable
• Worst nutritional risks water, protein, iron,
  vitamin A, iodine
• As you reframe this information in your own
  context , it will help you see what to look for,
  what to ask for, what to do

104
Applying what youve learned

• Ranking risks in the life cycle - kids mothers
  are top priority
• Help you set priorities best practices for
  risk mitigation
• We have seen setbacks, slow progress toward the
  MDGs. Yet
• There is substantial agreement about what
  needs to be done
• Reasons for hope Fortunes given away, crazy
  ideas, loans to the poorest repaid, workable
  strategies toward a world without hunger
  clear-sighted agents of change
• We return to our task with renewed clarity
  energy

105
Acknowledgments

• I single out a few of many whose insights,
  persistence, and courage dispelled the pessimism
  I felt when I began this task.
• Jeffrey Sachs, Yunus Muhammad, Raj Patel, Kumi
  Naidoo, Paul Collier, Howard Zinn, Vandana Shiva,
  Frances Moore Lappé
• Also the hundreds of passionate students,
  practitioners, and researchers at meetings of the
  Canadian Consortium of Global Health who passed
  on to me their energy vision. Pre-eminent among
  those who encouraged me are Vic Neufeld Tom Hall

106
End of module

• Please refer to the supplementary contents for
  more information about this module.
• Reserved for GHEC notes