Hunger

1
Hunger

• We define individual hunger as consumption of a
  diet insufficient to support normal growth,
  health, and activity.
• This definition leaves open questions of whether
  norms are fixed across populations and over time,
  and of what nutritional requirements are
  associated with them.
• DeRose and Millman

2
Hunger

• Analytical Problems
• Measurement
• Trends and Patterns
• Explanation
• Intervention

• Thematic Frames
• Political Economy
• Health and Nutrition
• Social Conditions

3
Topics in Political Economy

• Food Shortage area and population.
• Food Poverty household.
• Food Deprivation individual
• Famine and Calamity
• Episodic, Seasonal, Chronic Hunger
• Provisioning Institutions Markets, States, NGOs,
  development agencies
• Interventions Programs and policies, Structural
  Adjustment

4
Topics in

• HEALTH
• Birth
• Growth
• Development
• Mortality
• Morbidity
• Capability

• NUTRITION
• Protein-energy malnutrition
• Micronutrient Deficiency
• Iron
• Iodine
• Vitamin A
• Disease Interactions
• Environmental Interactions

5
Social Conditions

• Inequality
• Nationality, Class, Race Gender, Ethnicity
• Girl, Woman, Mother
• Fetus, Newborn, Infant, Child
• Minority, Discrimination, Disability
• Dislocation, Displacement, War

6
Nutrition and Health

• Some basic issues

7
Protein-energy malnutrition (PEM)

• Combined insufficiency of calories and protein
• the most widespread form of hunger.
• kilocalories daily requirement collapses
  protein/calories into single calories measure
• Food-based poverty lines based on PEM threshold

8
Food Requirements and Poverty Lines In Bangladesh

• DCI Direct Calorie Intake poverty line
• 1,805 kcal/day for the hardcore poor
• 2,122 kcal/day for the absolute poor
• FEI Food Energy Intake poverty line
• monthly expenditure (income) required for
  calories food/energy requirement at 2,122
  kilocalories/day in rural areas and 2,112
  kcal/day in urban areas.
• 1995 FEI poverty line Tk 419.70 per month in
  rural areas and
• and Tk 707.8 per month in urban areas
• CBN Cost of Basic needs poverty line
• FEI poverty line PLUS non-food poverty line.
• Non-food poverty line is set at two levels (upper
  and lower) for each of 14 regions.
• Absolute poor are people below the upper line,
  and hardcore poor are people below the lower
  line.
• In 1995, the upper lines ranged from Tk563/mo in
  rural areas of Khulna, Jessore, and Kushtia, to
  Tk 950 per month in Dhaka (standard metropolitan
  area).

9
1985 WHO Minimum daily caloric requirements by
sector and gender
Urban
Rural
Age categories
Male
Female
Male
Female
0 to 1 year
820
820
820
820
gt1 to 2 years
1,150
1,150
1,150
1,150
gt2 to 3 years
1,350
1,350
1,350
1,350
gt3 to 5 years
1,550
1,550
1,550
1,550
gt5 to 7 years
1,850
1,750
1,850
1,750
gt7 to 10 years
2,100
1,800
2,100
1,800
gt10 to 12 years
2,200
1,950
2,200
1,950
gt12 to 14 years
2,400
2,100
2,400
2,100
gt14 to 16 years
2,600
2,150
2,600
2,150
gt16 to 18 years
2,850
2,150
2,850
2,150
gt18 to 30 years
3,150
2,500
3,500
2,750
gt30 to 60 years
3,050
2,450
3,400
2,750
gt60 years
2,600
2,200
2,850
2,450
Source
Caloric requirements are from WHO (1985, Tables
42 to 49).
Notes
Requirements used are for men weighing 70
kilograms and for women weighing 60 kilograms.
Urban
individuals are assumed to need 1.8 times the
basal metabolic rate (BMR), while rural
individuals are assumed
to need 2.0 times the average BMR. Children under
one year of age are assigned the average caloric
need of
children either 36, 69, or 912 months old.
10
Head-count of Absolute Poverty for Bangladesh
Year Sector BBS FEI 1991 method Ahmed et al. (1991) Ravallion Sen (1994) Rahman Haque (1988) Hossain Sen (1992) Sen Islam (1993) Muqtada (1986)
1973/ 1974 Rural Urban 82.9 81.4 (5.6) - - 65.3 62.5 71.3 n.a. n.a. 63.2 55.9 37.8
1981/ 1982 Rural Urban 73.8 66.0 71.8 65.3 - 79.1 50.7 65.3 n.a n.a. 48.4 -
1983/ 1984 Rural Urban 57.0 66.0 n.a. n.a. 53.8 40.9 49.8 39.5 50.0 n.a. n.a. 42.6 -
1985/ 1986 Rural Urban 51.0 56.0 51.6 66.8 45.9 30.8 47.1 29.1 41.3 n.a. n.a. 30.6 -
1988/ 1989 Rural Urban 48.0 44.0 - 49.7 35.9 - 43.8 n.a. n.a. 33.4 -
1991/ 1992 Rural Urban 50.0 46.8 - 52.9 33.6 - - - -
 
11
LBW, Wasting, Stunting, obesity BMI MUAC
obstetric risk, inf and mat mortal, child
development

• http//www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
  RetrievedbPubMedlist_uids12259584doptAbstrac
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• Child development indicators and public health.
• Measurements of physical development - height,
  weight, cranial circumference, and arm
  measurements - are called better predictors of
  nutritional and developmental status than
  mortality and morbidity figures.
• Low birth weight is directly associated with poor
  maternal nutrition while poor development is
  associated with malnutrition or undernutrition of
  the child.
• There is a critical period from Month 6 of
  pregnancy to about Year 2 of life when brain
  cells develop poor nutrition during this
  critical period will result in permanent lack of
  mental capacity.
• Studies in Africa, Latin America, and Asia all
  point out the extremely damaging effects of poor
  nutrition during this critical period.
  Malnutrition or undernutrition occuring later in
  life can be reversed with proper feeding.
• The problems of obesity are as serious as those
  of malnutrition. The baby who collects a surplus
  of fat cells under the skin during the 1st year
  of life is likely to be overweight most of the
  rest of his life. Lowering age of maturation is
  another indication of improving nutrition. This
  phenomenon has been observed in all
  industrialized countries and is the basis of much
  of the adolescent PROBLEM.
• Child development indicators should be used to
  point out areas of a country or sectors of the
  population in need of additional health or
  nutritional aid.

12
Wasting and Stunting

• PEM reduces growth in children
• Energy expenditure in excess of consumption leads
  to metabolizing nutrition reserves in the form of
  stored body fat.
• Lean body mass in the form of muscle and even
  organ tissue will also be consumed if PEM
  persists.
• Weight loss accompanies the initial stages of
  inadequate energy intake but, if prolonged, is
  followed by wasting, called in its severe
  clinical form, marasmus.
• In children, PEM delays or permanently stunts
  growth and increases morbidity and mortality.

13
Measuring Healthy Growth

• Body Mass Index (BMI)
• BMI is a measure that adjusts bodyweight for
  height. It is calculated as weight in kilograms
  divided by height in meters squared. Overweight
  for children and adolescents is defined as BMI at
  or above the sex-and age-specific 95th percentile
  BMI cut points from the 2000 CDC Growth Charts.
  Healthy weight for adults is defined as a BMI of
  18.5 to less than 25 overweight, as greater than
  or equal to a BMI of 25 and obesity, as greater
  than or equal to a BMI of 30.
• http//www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm
• BMIWeight Status
• lt Below 18.5 Underweight.
• 18.5 24.9 Normal.
• 25.0 29.9 Overweight
• 30.0 and AboveObese
• lbw in US lt 5 lbs 8 oz or 2500 g
• very low birth weight (VLBW) lt1500 grams
• The following charts are from NATIONAL CENTER FOR
  HEALTH STATISTICS http//www.cdc.gov/nchs/

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34
Child Morbidity and Mortality

• Health statistics tend to ascribe child deaths to
  malnutrition or infectious disease, but causes
  tend to be interlinked.
• Using case studies from poor countries, David
  Pelletier concluded that malnutrition contributed
  to 56 per cent of all child deaths, owing to its
  interaction with infectious disease.
• About 83 per cent of these malnutrition-related
  deaths were attributed to mild-to-moderate
  malnutrition.
• Elevated morbidity and mortality are also
  associated with micronutrient malnutrition,
  especially vitamin A and iron deficiencies.

35
Disease Interactions

• The relationship between malnutrition and
  infection is reciprocal and synergistic.
• Disease leads to a deterioration in nutritional
  status at the same time that malnutrition
  increases susceptibility to disease.
• Effects of disease on nutritional status involve
  shifts in the types and quantities of foods
  consumed (whether due to custom or loss of
  appetite) and to decreased absorption and
  diarrhea.
• Parasitic organisms, as in malaria or
  schistosomiasis, or intestinal worms, divert
  nutrients for their own use.
• Energy, protein, and micronutrient needs are
  elevated in order to fight off infection.
• Immune function deteriorates with extreme PEM
  evidence is more mixed as to possible increases
  in susceptibility to infection with mild to
  moderate malnutrition.

36
water sewage pollution parasites diarrhea
malnutrition dehydration sickness(WDR2000/1)
37
Iron Deficiency

• Iron deficiency is believed to be the most common
  micronutrient deficiency in the world today.
• It appears most common in South Asia and Africa.
• About 22 per cent of the world's population is
  thought to have deficiencies of iron extreme
  enough to cause anemia.
• Iron deficiency is especially common among
  reproductive-aged women, whose requirements are
  higher than those of others.

38
Anemia in Bangladesh Gender and Ethnic Inequality

• UNICEF/BRAC/BBS 2004 study of anemia prevalence
• urban adolescent girls 29
• urban adolescent boys 17 (lowest of all
  groups)
• Chittagong Hill Tracts adolescent boys 40
• CHT adolescent girls 50

39
Iodine Deficiency Effects are physical and mental

• Cretinism results from severe deficiency during
  gestation. It is irreversible and includes
  "profound mental deficiency.
• Goitre, a pronounced swelling of the thyroid
  gland, may develop at any time.
• High rates of milder mental impairment have been
  found in areas where goitre and cretinism are
  common.
• UNICEF estimated that 30 per cent of the world's
  population is at risk of mental and physical
  impairment due to iodine deficiency, though less
  than half that number manifest visible signs of
  goitre or cretinism.
• According to Stanbury (1991), "Iodine deficiency
  is the most frequent cause of preventable mental
  retardation today."

40
Iodine Deficiency

• The most severe problem is restricted to areas
  with iodine-poor soils, typically mountainous,
  glaciated, and/or subject to heavy rainfall or
  flooding.
• Milder forms may occur in these and other regions
  (including European countries) where intakes of
  iodine-adequate foods are low.
• The greatest concentrations of population in
  areas of iodine deficiency are in South-East
  Asia, and pockets of Africa and Latin America.

41
Vitamin A Deficiency

• Deficiency of vitamin A was estimated to affect
  some 231 million children in 1994, over half of
  them in just three countries - Bangladesh, India,
  and Indonesia.
• Vitamin A comes from a wide range of vegetable
  and animal sources but children, especially, may
  lack adequate access, owing to culture or
  economic restrictions in diet.
• Vitamin A deficiency is a major cause of
  blindness, mainly in childhood.
• Many of those blinded die shortly thereafter.
• It has been linked to increased vulnerability to
  infectious disease, with some studies claiming
  dramatic reduction in child mortality when
  vitamin A supplementation is provided to all
  children in areas in which even a few show the
  visible signs of vitamin A deficiency

42
Maternal and Child Malnutrition

• Malnutrition of pregnant women may lead to
  serious problems for children.
• Most dramatic is cretinism resulting from severe
  maternal iodine deficiency
• More commonly, children born to chronically
  undernourished women are likely to be small at
  birth.
• Low birth weight is associated with increased
  risk of mortality and with a range of health and
  developmental problems.

43
JAMA MUAC BMI (see link syllabus)

• MUAC measurement was easier to perform on
  severely malnourished adults than BMI assessment.
  
• For MUAC, the patient could be standing, sitting,
  or, in extreme cases, lying. For BMI, patients
  were required to stand. Measuring BMI requires a
  height board, weighing scales, and mathematical
  calculations to measure MUAC, only a tape
  measure is required.
• A correlation between measurements of MUAC and
  BMI was demonstrated (r0.88 95 confidence
  interval, 0.82-0.92 Plt.001). The proportions of
  the population and the actual individuals
  identified as malnourished by the 2 indicators
  were similar.
• CONCLUSIONS The MUAC measurement reflects adult
  nutritional status as defined by BMI. During
  famine, MUAC may be better suited to screening
  admissions to adult feeding centers than BMI.
  Studies to assess the capacity of MUAC cutoffs to
  predict mortality in severe adult malnutrition
  are needed.

44
Risk factors for stunting and wasting at age six,
twelve and twenty-four months for squatter
children of Karachi, Pakistan.Fikree FF, Rahbar
MH, Berendes HW.

• At two years the proportion of stunting and
  wasting was 41.8 and 10.6 respectively.
• Intrauterine growth retarded children had a
  higher risk of stunting and wasting at all
  reference ages as compared to children who were
  appropriate for gestational age.
• In the logistic regression models, intrauterine
  growth retardation was the only significant risk
  factor that remained in all models at each
  reference age.
• CONCLUSION The consistent association of IUGR
  for stunting and wasting adds to the growing body
  of evidence that by improving maternal health we
  will ultimately break the vicious cycle of
  malnourishment and improve the health and
  well-being of future generations.

45
Malnutrition among girls can affect their babies
later in life

• Undernutrition in childhood can cause growth
  stunting and influence the size of the child a
  woman can bear later in life.
• Maternal pelvic size is a strong determinant of
  neonatal survival and universally correlated with
  height in populations.
• The proportions of low birth-weight infants are
  much higher in populations identified as poorly
  nourished according to adult anthropometric
  indicators, ranging from lows of 4-6 in affluent
  countries to highs of 25 or more in Pakistan,
  India, Bangladesh, and Laos.

46
Food Shortage. Food Supply

• Is there enough food for population in given
  area?
• Global supply scenario is aggregation of
  national scenarios
• gross food supply (total production)
• net food stocks (after waste, import export,
  animal feed, etc)

47
How do markets influence food shortage? Discuss
(from Uvin)

• p.4. A low food self-sufficiency ratio is not an
  indicator of hunger within countries, nor is a
  high food self-sufficiency ratio a guarantee of
  the absence of hunger.
• The smaller and poor a country, the more
  pronounced will be its vulnerability to
  fluctuations in world markets, and the less it
  will be capable of influencing them.
• To the extent that declining food
  self-sufficiency ratios reflect declining
  entitlements to farmers and agricultural
  laborers declining rations can coincide with
  icnreasing hunger.

48
Countries with DES below requirement, 1988-90
(Uvin table 1.6), and FAO 1992 est of
malunourished (table 1.10),
Number of Countries Population, millions ()
SS Africa 32 459 (57)
Near East and North Africa 1 13 (2)
Asia 4 262 (33)
Latin America 7 67 (8)
N Am, Aus, Europe, CIS 0 0 (0)
Small Islands 4 1 (0)
Total 48 802

People malnourished total
128 16
15 2
653 (w/China) 77
47 6

1
843 100