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Title: Nutrition%20in%20Global%20Health


1
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
2
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.

Page 2
3
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

Page 3
Page 3
4
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
5
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

Page 5
6
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

Page 6
7
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

Page 7
8
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

9
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
10
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
11
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
12
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
13
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/

14
Slow progress toward the MDGs
At mid-way, most MDGs are partly met. Only
goal 2 is fully within reach!
15
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

Page 15
16
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

17
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
Page 17
18
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
19
Worldwide distribution of malnutrition
  • Over 20 million children suffer from acute
    malnutrition WHO.

Scientific American, Sept 2007
20
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
21
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

22
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

Page 22
23
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
24
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!

25
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
Page 25
26
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
27
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
28
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

Page 28
29
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
30
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
31
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

Page 31
32
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

33
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

34
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
Page 34
35
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

Page 35
36
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
37
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

Page 37
38
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
Page 38
39
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

Page 39
40
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
41
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

42
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

43
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.

44
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

Page 44
45
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
46
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

Page 46
47
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

48
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

49
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

Page 49
50
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
51
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

Page 51
52
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
53
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

Page 53
54
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

55
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

Page 55
56
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
57
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

58
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
59
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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60
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
61
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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64
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..

Page 79
80
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.

Page 83
84
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

Page 85
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

Page 86
87
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
Page 90
91
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

Page 92
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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
94
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

Page 95
96
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 ...
Page 97
98
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.
Page 98
99
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
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