Famine and FeastLife on the margins: the inequality of food and nutrition security

MALNUTRITION

PowerPoint presentation by Médecins Sans Frontières / Doctors Without

Borders (MSF) UKSchools Team: Mary Doherty and Severa von Wentzel

March 2014

Malnutrition:Undernutrition

Awareness ribbon for malnutritionImage: Wikipedia

“With diseases related to malnutrition on the rise, the challenge is not only to ensure food security, but also to address the nutritional quality of the food being consumed and its impact on health.” - Dr Frenck G20 2012, http://www.who.int/pmnch/media/press_materials/pr/2012/201205_g20_watch/en/index4.html

Malnutrition termsAdequate food is at the basis of an active and healthy life. Yet, in spite of significant improvements, millions of people today are malnourished.

Malnutrition: An abnormal physiological condition caused by inadequate, unbalanced or excessive consumption of macronutrients and/or micronutrients. Malnutrition includes undernutrition and overnutrition as well as micronutrient deficiencies.

Minimum dietary energy requirement (MDER): amount of energy needed for light activity and a minimum acceptable weight for attained height.

Body Mass Index (BMI) relates weight to height and is used to evaluate thinness and obesity.Source: ftp://ftp.fao.org/docrep/fao/012/i0876e/i0876e02.pdfWorld bank, Scaling up Nutrition: What will it cost? 2010http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULAION/Resources/Peer-ReviewedPublications/ScalingUpNutrition.pdf

Malnutrition termsProtein-energy malnutrition: BMI and shortness are indicators. A broad (older) term from the 1970s when protein deficiency was felt to be the primary driver behind malnutrition. Replaced by the more general term ‘acute malnutrition’ which includes macronutrient imbalance/insuffiency as well as micronutrient deficiency.

Micronutrient deficiency: “hidden hunger”, a lack of one or more essential vitamins and minerals, such as Vitamin A, iron, iodine or zinc. Indicator iron-deficiency anaemia low haemoglobin in blood. Micronutrient powders (MNP) are used to prevent micronutrient deficiencies; for example, on a large-scale basis in Bangladesh.

UndernutritionPoor health, growth and development outcomes can result from hunger and poor nutrition.

Under nutrition is “the outcome of undernourishment, and/or poor absorption and/or poor biological use of nutrients consumed as a result of repeated infectious disease. It includes being underweight for one’s age, too short for one’s age (stunted), dangerously thin for one’s height (wasted) and deficient in vitamins and minerals (micronutrient malnutrition).(FAO definition http://www.fao.org/hunger/en/)

Under nutrition includes being:• Underweight: a child has low weight for age. Composite measure

includes chronic and acute malnutrition.• Stunting: child short for their age as a result of chronic under nutrition

during the most critical periods of growth and development in early life. • Wasting: child’s weight is too low for their height as a result of acute

under nutrition, can vary with the seasons. Reflects loss of muscle tissue and fat.

• Kwashiorkor: sudden onset swelling of the feet, hands and face. Cause unknown, but occurs typically in children 2-3 years old once they are weaned from breast milk and can be cured by feeding a specially fortified milk. Form of severe malnutrition.

Undernourishment Famine

Undernourishment or chronic hunger: A state, lasting for at least one year, of inability to acquire enough food, defined as a level of food intake insuffiecient to meet dietary energy requirements. For the purposes of this presentation, hunger was defined as being synonymous with chronic undernourishment.

Famine is the state in which significant proportion (at least 20%) of a defined population lacks access to food in sufficient quantity and quality, such that epidemics of infectious disease become more frequent, acute malnutrition rates in children under 5 are above 30% and death rates rise. In famine conditions, the most vulnerable members of the population - the very young, the elderly and those with chronic illness – are at higher risk of death.

StarvationStarvation occurs when the individual’ nutrient intake drops below what is needed to maintain body mass and the body begins to consume muscle and other lean tissues in order to supply nutrients to maintain metabolic function.

In an otherwise well adult who continues to drink water but ceases all nutrient intake, this process of starvation leads to death in about 2 months.

The process of starvation affects all the body’s organ systems, but the most visible signs are weakness, apathy and muscle wasting.

Hunger IQ and FAQsAction for students: 1. With a partner test your Hunger IQ:

http://www.wfp.org/hunger/faqs and read Hunger Frequently asked questions (FAQs) including the overview, record what is hunger, who are the hungry, what causes hunger, what is malnutrition?

2. Extract the salient information from each of the documents and individually record the information so you can readily refer to it.

3. Can you explain why solving hunger is regarded as a ‘best buy’ in today's tough economy?

4. Use the data from Who are the hungry? – Draw a bar chart showing how the 870 million hungry people in the world

are distributed. – Draw a pie chart which shows the proportion of hungry people living in rural

areas. – Draw another pie chart showing the proportion of hungry people from small

holding farming communities, those from landless families dependent on farming and the proportion dependent on herding, fishing or forest resources.

Hungercase studies

Action for students: 1.Look through Hunger in the news

http://www.wfp.org/news/hunger-in-the-news2. Make brief notes on the current hunger crises and debates around the

globe paying particular attention to the case studies used in this unit:- The Sahel (Sub-Saharan Africa )- Bangladesh, India (South Asia)- Kenya- The UK- The USA3.What is in the news about these case studies, malnutrition and life on the

margins? Add helpful information to your notes.

“Every man, woman and child has the inalienable right to be free from hunger.” - First World Food Conference Declaration, Rome, 1974

World economic growth and undernourishment

Source: Fairfood http://www.fairfood.org/wp-content/uploads/2012/12/Fairfood-International-Strategy_Final.pdf http://www.fao.org/publications/sofi/en/

Agriculture plays an essential role in the world economy. Beyond food production, it is as an engine of economic growth key to growth in rural settings and poverty reduction in transition countries. It generally accounts for half of GDP in developing countries; its share in the economy tends to decline with development. Investments in agriculture have a poverty-reduction impact larger than any other sector.

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Rise in hungry people

Number of hungry people, 1969-2010

Since 1995-97 the number of hungry people has risen.Even at times of economic growth and low food prices, the number of hungry has not fallen below around 800 million over the past 40 years.

Source: FAO; Source: http://www.worldhunger.org/articles/Learn/world%20hunger%20facts%202002.htm;

Factors in rise of hungry people

Factors: 1. Governments and international agencies have neglected

agriculture and the synergy between agriculture and social protection relevant to very poor people; for every five people suffering from hunger, three rely on farming. Women and small holder farmers most affected. Food reserves have also shrunk.

2. Current worldwide economic crisis and financial, trade and policy issues;

3. Energy and climate issues;4. Devastating impact of food price hikes, a large upward

movement in price in a short time, on people existing on only a few dollars a day.

5. Speculation and concentration of agribusiness* and retail among very few players.

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* Agribusiness: the manufacture and distribution of farm supplies,; farm production operations, storage, processing and distribution of farm commodities and products most often by corporations. Source: FAO; Source: http://www.worldhunger.org/articles/Learn/world%20hunger%20facts%202002.htm;

Source: http://www.fao.org/publications/sofi/en/

Source: http://www.fao.org/publications/sofi/en/

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Global Hunger IndexInternational Food Policy Research Institute

Rate “A measure of the intensity of the occurrence of an event. For example, the mortality rate equals the numberwho die in one year divided by the number at risk of dying. Rate—A measure of the intensity of the occurrence ofan event.“(http://www.idph.state.ia.us/hpcdp/common/pdf/10_glossary.pdf

Prevalence: proportion of people in a population with a particular disease at a specified point in time or over a specified period of time – as opposed to new cases which is incidence

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Action for students: Note the three dimensions of which the GHI is composed in your folder along with the main trends per region.

Hunger and Nutrition Commitment Index

Source: http://www.hancindex.org/hanci2012/HANCI%202012%20infographic.pdf

Further info: Community voices from Bangladesh: http://www.hancindex.org/community-voices/#.Uke2HoaThuI

How to measure malnutrition

1. Anthropometrya. Weightb. Length or heightc. Middle upper arm circumference

2. Weight and height must be compared to age or to each other and therefore are turned into indices

a. Weight for age called ‘underweight’. Includes both wasting and stunting

b. Weight for length or body mass index, measure of ‘wasting’ and ‘obesity’

c. Height for age, measure of ‘stunting’

3. Other signs or measuresa. Oedema (water retention) of feet, hands, faceb. Blood test for anemia (iron deficiency in particular)c. Blood test for certain micronutrients: Vitamin A or zinc

Food is not enoughWithout essential nutrients millions of

children will die.

“Eating millet porridge every day is the equivalent of living off bread and water. With luck, toddlers here might have milk once or twice a week. Young children are so susceptible to malnutrition because what they eat lacks essential vitamins and minerals to help them grow, remain strong and fight off infections.” - Dr. Susan Shepherd, MSF

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MarasmusThe commonest form of malnutrition called marasmus results in an affected child being severely wasted, with no fat and very little muscle tissue left on his or her body. The internal organs, including the heart and the blood, are also weakened. The child is left with no reserves to fight infection, and any illness that comes along is likely to be fatal. The commonest causes of death during a famine are in fact infectious diseases, rather than starvation per se. Chief among these are pneumonia, diarrhoea, and measles.

– UNICEF on Marasmus http://www.unicef.org/nutrition/training/2.3/4.html

•Severe Wasting, very thin•Loss of Muscle Bulk,•No subcutaneous Fat

• Loose skin folds, floppy buttocks

• Often reasonable appetite when no med complication•Miserable, restless•Apathy

Clinical signs: Marasmus

KwashiorkorThe other form of malnutrition, called kwashiorkor, in which the child's body is swollen, likewise kills by lowering resistance to infection. However, kwashiorkor can also be fatal in its own right, because of the disturbed levels of salts and minerals (electrolyte imbalances) that accompany it.

In a therapeutic feeding centre, where only severely malnourished children are cared for, many deaths tend to occur at night. This is because these children are especially prone to low blood sugar (hypoglycaemia) and low body temperature (hypothermia). (MSF US website) contents

Clinical signs of Kwashiorkor

• Oedema• Loss of muscle & fat

often masked by the oedema

• Anorexia• Abdominal distention• Hair losing color• Apatic/irritable,

miserable• Skin cracks/fragile,

prone to infections• Acutely sick contents

Determinants of child nutrition and development

Immediate determinants include:• Adequate food and nutrition intake• Parenting, caretaking and feeding practices• Low burden of infectious diseases

Underlying determinants include:• Food and nutrition security• Adequate resources at the community, household and

maternal (mother’s) level• Access to health care provision• Safe and hygienic environmentSource: http://download.thelancet.com/flatcontentassets/pdfs/nutrition_4.pdf

The wrong startOne out of six children -- roughly 100 million -- in developing countries are underweight, but trend is down. Source: Global health Observatory, WHO, 2011

Source: Unicef Nutrition Report 2013 and World bank http://passthrough.fw-notify.net/download/589313/http://data.worldbank.org/sites/default/files/wdi-2013-ch1.pdf

Wasting and stunting

Image:http://www.bing.com/images/search?q=Forms+Of+Malnutrition&Form=IQFRDR#view=detail&id=8D2A19491AEE9E080EF2302D4FD4004D2EA0FB5&selectedIndex=2; http://download.thelancet.com/flatcontentassets/pdfs/nutrition_2.pdf

When a population is short this points to nutritional deprivation or disease in childhood.

Undernutrition hotspot

What is an undernutrition hotspot?

High mortality + High prevalence stunting,Wasting is variable and fluctuates rapidly

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Source: http://www.unicef.org/media/files/nutrition_report_2013.pdfImage:http://ble.lshtm.ac.uk/pluginfile.php/20037/mod_resource/content/47/OER/PNO101/sessions/S1S17/PNO101_S1S17_030_010.htmlImage: http://challengedkidsinternational.files.wordpress.com/2013/03/stunting-in-children_50291a07a181b.jpg

International health organisations are starting to shift their focus from underweight prevalence (inadequate weight for age) to prevention of stunting (inadequate length / height for age).

• is more likely to have been born to a mother with poor nutrition and health status, which perpetuates vicious cycle of under nutrition and poverty.

• has greater propensity for developing obesity and chronic diseases as an adult, fuelling obesity

epidemic in low and medium income countries.

A STUNTED IN CHILD • has lower chances of survival and less optimal health and growth.

* Prevalence is the proportion of the population that has a condition of interest at a specific point in time.

Source: http://www.unicef.org/progressforchildren/2007n6/images/pfc6_prevalence_stunting_children_under_five.gif; A Ergo et al “What difference do the new WHO child growth standards make for the prevalence and socioeconomic distribution of undernutrition?” Food Nutrition Bulletin http://www.ncbi.nlm.nih.gov/pubmed/19445255

South Asia Sub-Saharan Africa

Middle-East / North Africa

Latin America / CaribbeanEast Asia / Pacific

CEE / CISDeveloping countries

Stunting prevalence by regionGlobally, about 1 in 5 (26% in 2011) children are stunted of whom 80% live in 40 countries. Undernutrition affects poor children most, but rates are high enough to deserve attention even among the better-off children in developing countries.

Stunting in children and income growth

Improvements in nutritional status lag behind economic growth, but are boosted by income growth.

Source: http://download.thelancet.com/flatcontentassets/pdfs/nutrition_4.pdf

Silent emergencyof stunting

Action for students: 1. With a partner use the resources

below and others to research the trends of malnutrition prevalence since 1980.

2. Explain the reasons why some have shifted their focus from underweight to stunting .

3. From your research explain the title-The silent emergency of stunting

4. Find out about and write a brief paragraph on the Scaling Up Nutrition (SUN) Movement.

• Malnutrition prevalence, weight for age (% of children under 5) Map from 1980 in 4 year segments up to 2012. http://data.worldbank.org/indicator/SH.STA.MALN.ZS/countries?display=map

• “Improving Child Nutrition - The achievable goal for Global Progress” www.unicef.org/media/files/nutrition_report_2013.pdf

• “Break the cycle of stunting": http://www.impatientoptimists.org/Posts/2013/04/Hunger-and-Poverty-Still-Core-to-the-MDG-Agenda

• “The Life cycle of malnutrition” http://www.ifpri.org/publication/life-cycle-malnutritionClip on Cycle in South Asia http://www.thp.org/node/575

• Trendalyzer video / presentation on 1000-day window, cycle and initiatives: http://scalingupnutrition.org/resources-archive/videosmultimedia and

• “A Life Free from Hunger” on the life-long consequences of stunting http://www.savethechildren.org.uk/sites/default/files/docs/A-Life-Free-From-Hunger-UK-low-res.pdf

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Source: 1000 days.org infographic What causes maternal and child malnutrition http://www.thousanddays.org/resource/infographic-what-causes-maternal-and-child-malnutrition/

What is at the root of the problem?

Image: 1000 days.org infographic What causes maternal and child malnutrition http://www.thousanddays.org/resource/infographic-what-causes-maternal-and-child-malnutrition/

Further info on where the poor live and are going to live? Free exchange: The geography of poverty”, The Economist September 1st 2012, http://www.economist.com/node/21561878

Childhood malnutrition:causes, campaign and Sahel (1)

The mother’s status (is she disadvantaged?) is likely to affect the child’s food intake and health status – both proximate

determinants of the child’s nutritional status.

Causes of malnutrition include:• poverty, • quality of environmental conditions (poor housing

conditions, inadequate water, hygiene practices and sanitation),

• illiteracy,• unemployment, • social problems • poor awareness about mal/nutrition• poor access or quality of health services. Source: World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, Switzerland: WHO,1999:http://whqlibdoc.who.int/hq/1999/a57361.pdf Accessed November2012. contents

Childhood malnutrition:causes, campaign and Sahel (2)

Action for students:

1. Make notes in your folder from the nutrition glossary: http://www.unicef.org/lac/Nutrition_Glossary_(3).pdf

2. Watch the “Rewrite the Story” clip on MSF’s campaign to make childhood malnutrition more visible on the global agenda and in people’s minds. What are the main arguments?http://www.starvedforattention.org/

3. Time to prevent malnutrition in the Sahel (on Malaria and Malnutrition) http://reliefweb.int/report/mali/time-prevent-child-malnutrition-sahelMSF

4. Report Malnutrition in the Sahel: One Million Children Treated – What’s Next? http://www.doctorswithoutborders.org/publications/reports/2012/Sahel_Briefing_Document.pdf

5. Sahel: Treating malnutrition. http://www.youtube.com/watch?v=nKQkp1qGFp0

Girls and women• The distribution of malnutrition is highly gendered, girls

and women make up more than 70% of the world’s hungry (UN).

• Girls and women produce more than 55% of the world’s food supply (UN). They endure lower salaries, fewer promotions, less secure employment, unreasonably long hours whilst continuing with traditional household responsibilities.

• They represent 41% of farmers around the world; own only 2% of the land (Rural Poverty Portal)

• Women in Africa receive less than 10% of all credit going to small farmers, and only 1% of the total credit going to the agricultural sector (Rural Poverty Portal)Source: http://www.un.org/ecosocdev/geninfo/women/women96.htm;;

http://www.ruralpovertyportal.org/web/guest/topic/home/tags/gender;; http://download.thelancet.com/flatcontentassets/pdfs/nutrition_2.pdf

Women’s empowerment (1)

Women’s health and nutrition, equality and empowerment are worthwhile ends in themselves.

In addition they have many benefits, including:• Intergenerational benefits• Poverty reduction• Economic efficiencyIn many settings, greater access to agricultural lands and economic rights are needed for women to exploit the synergy between agriculture and social protection.Source:http://elibrary.worldbank.org/content/book/978082132917 Image:http://stuartbramhall.aegauthorblogs.com/2012/3/08/thefemaleface-of-poverty/

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Women’s empowerment (2)

“Gender-based inequalities at every point in the value-chain have traditionally impeded the realization of food and nutritional security.....In most developing countries women play a key role in the cultivation of food and cash crops as well as the nutritional care of their children and are therefore critical to food and nutritional security. Investment in women can lead to tremendous dividends.”

According to the Lancet, evidence supports that women and men allocate food differently. There are:• Positive associations between women’s empowerment and improved

maternal and child nutrition.• Negative associations between disempowerment such as domestic

violence and child nutrition outcomes• Positive impacts on women’s empowerment of agricultural

programmes and cash transfers

Source: http://www.interaction.org/sites/default/files/5649/G8%20Background%20policy%20brief%20FINAL%20FS-AG-N%203-19-12%20(updated).pdf; The lancet “Nutrition-sensitive Interventions and Programmes: How Can They Help Accelerate Progress in Improving Maternal and Child Nutrition?” http://download.thelancet.com/flatcontentassets/pdfs/nutrition_4.pdf

Women’s inequalitydrives the cycle

• Gender “refers to the socially constructed roles behaviour, activities and attributes that a particular society considers appropriate for men and women.” Not inherently given by biology, these vary across cultures.

• “The distinct roles and behaviour may give rise to gender inequalities, i.e. differences between men and women that systematically favour one group. In turn, such inequalities can lead to inequities between men and women in both health status and access to health care.” (http://www.who.int/topics/gender/en/)

• Gender equality “implies a society in which women and men enjoy the same opportunities, outcomes, rights and obligations in all spheres of life.” (http://www.unfpa.org/gender/empowerment.htm)

• Gender equity Process of being fair to men and women alike that leads to equality.

• Gender empowerment: “A critical aspect of promoting gender equality is the empowerment of women, with a focus on identifying and redressing power imbalances and giving women more autonomy to manage their own lives. Women's empowerment is vital to sustainable development and the realization of human rights for all.”

Women’s inequalityand food and nutritional security

Image gender cycle: http://www.srfood.org/images/stories/pdf/officialreports/20130304_gender_en.pdf;

Feast or FamineAction for students: 1.Watch the interactive slideshow on nutrition

emergencies and classification: http://www.unicef.org/nutrition/training/2.2/17.html

2.Discuss in pairs: what is the difference betweenhunger, malnutrition, starvation and famine. Make sure you have a clear definition of each of these words recorded in your folder.

3.Explain why there is malnutrition in LEDCs. 4.What do you believe the phrase ‘Feast or

Famine’ means?

MALNUTRITION IN BANGLADESH AND INDIA

Bangladesh and India

Action for students: 1. Label the map with

countries, main cities, bodies of water.

2. Watch “Terrifying Normalcy” of

malnutrition in Bangladesh –http://www.starvedforattention.org/ 3. Record key data and

information for your case study on Bangladesh and India

4. What do you understand is meant by the title of the video.?Why is it terrifying?

Source: http://www.bing.com/images/search?q=blank+Geography+Map+India+Bangladesh&id=BCE5584B708006B5BF07A0FE628648876E137988&FORM=IQFRBA#view=detail&id=79839EF8E449104CDCA5A1006380F42383FB8E27&selectedIndex=1

Malnutrition in South Asia

“Among all regions, South Asia has the worst record on malnutrition... In developing countries, on average, 29 per cent of children are underweight; In South Asia it is 49 per cent. Thirty-three [of] children in developing countries are stunted; but 48 per cent in south Asia are. Ten per cent of children in the developing world are wasted; the share is 17 per cent in south Asia ... [but] child survival rates in south Asia [are] so much better than in SSA....the south Asian child usually has better access to modern medical care, especially antibiotics”– Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political, Weekly March 11, 2006

Image: http://www.msf.org.uk/country-region/bangladesh

Bangladesh profile (1)

• In South Asia, Bangladesh urbanisation (highest rate in South Asia) is largely driven by rural-urban migration, which gained in momentum after the country’s independence in 1971. The capital Dhaka has most dominant role.

• Half of its population of 163,654,860 (July 2013 est., CIA World Factbook) live in poverty and about one third in extreme poverty, so third largest number after China and India. Poor access to food due to poverty.

• Between 1990 and 2010 poverty rates declined substantially with per capita GDP doubling and economic growth appearing to have reached the poor; agricultural growth averaged 3.3% a year thanks to great gains in rice yields (FAO 2012).

Source:* Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political Weekly March 11, 2006http://hdr.undp.org/en/reports/global/hdr2013/download; http://www.thehungerproject.co.uk/wherewework/bangladesh/CIA World factbook https://www.cia.gov/library/publications/the-world-factbook/geos/bg.html; http://www.fao.org/publications/sofi/en/

Bangladesh profile (2)

• Most densely populated country in the world, 28.4% of total population is urban (2011). Overcrowding, especially intense in urban areas, makes environmental hygienic conditions worse, which leads to greater disease affecting absorption of nutrients. The socio-economic status of rural-urban migrants is moderately lower than their urban native counterparts.

• Women in South Asia have the worst educational indicators relative to men with lowest adult literacy rates for women as a percentage of men (63%)*

• Bangladesh has seen dramatic advances in child survival thanks to – economic, economic and political empowerment of women;

and – higher participation of girls in formal education with literacy

rates 38% in 1991 increasing to 77% in 2009Source:* Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political Weekly March 11, 2006http://hdr.undp.org/en/reports/global/hdr2013/download; http://www.thehungerproject.co.uk/wherewework/bangladesh/CIA World factbook https://www.cia.gov/library/publications/the-world-factbook/geos/bg.html; http://www.fao.org/publications/sofi/en/

Bangladesh health profile

“During pregnancy, they eat the same food. Whatever they are having now, they have the same then. Who will give them extra food? That’s why their children are weak and suffer from malnutrition; for which they do not do well in education like the children of the rich class. Who will get this fact?” Female, Nilphamari District, Bangladesh, HANCI report http://www.hancindex.org/about/#.UkfUl4aThuK

• Share of government spending on health about double that of India and Pakistan, its large neighbours.

• Twenty-five million face hunger. Hunger distribution is highly gendered with nearly one third of women undernourished (Ahmed, Mahfuz, Ireen et al 2012)

• Second highest child malnutrition rates in the world with 48%, which is linked to low status of women in Bangladeshi society (circumscribed autonomy/agency). Husband and boys can be prioritised in food allocation. Mothers and daughters can have inadequate or low quality food and work requirements, leading to low health status.

• Malnutrition, it is estimated, costs US$ 1 billion a year in lost economic productivity.

• An estimated 50% reduction in undernourishment has been achieved (SUN 2011) Consumption of nutritious food appears to be on the increase.Source: http://www.fao.org/publications/sofi/en/

Bangladesh indicators

Source: http://www.fao.org/publications/sofi/en/; http://opendocs.ids.ac.uk/opendocs/bitstream/handle/123456789/2955/ER25%20Final%20Online.pdf?sequence=1_source=hanci

Significant public health concern:

Wasting16% prevalence beyond 15% emergency threshold.

Levels of stunting 41% and underweight 36%(2011 figures, according to UN definition)

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India case study: country profile sources

Action for students: Using the previous slide on Bangladesh

as a template for a country profile, distil relevant facts pertaining to the population’s well-being in general andmalnutrition in particular. Why do studies look at the

level of themother’s education?• CIA World Factbook, Measure DHS (demographic and health surveys),

World Bank and BBC Country Profiles are good starting points– https://www.cia.gov/library/publications/the-world-factbook/geos/

ha.html– http://www.measuredhs.com/– http://www.worldbank.org/– http://news.bbc.co.uk/2/hi/country_profiles/

Nutritional status:Bangladesh and India

• Percentage of children under 5 underweight (this is a nutritional indicator for the whole community) among highest in the world 2nd for India and 4th for Bangladesh (World Factbook); stunting prevalence 41.3% in Bangladesh in 2011 (Measure DHS)

• Among lowest adult obesity prevalence rate in the world 184th for India and 190th for Bangladesh in the world, but alarming rise in BMI over 25 for women in Bangladesh from 12% in 2007 to 17% in 2011

Bangladesh• Childhood under nutrition has declined, but

maternal nutrition has not improved significantly in Bangladesh (http://www.measuredhs.com/pubs/pdf/PB6/PB6.pdf)

• Anaemia continues to be a major nutritional problem in children and women in Bangladesh

IndiaAction for students: 1. Note some of the issues arising from the fact

that the latest data for India dates back to a 2005-2006 national family health survey http://www.measuredhs.com/pubs/pdf/OD56/OD56.pdf

2. Record the relevant points for your folder from “UNICEF Nutrition in India”http://www.unicef.org/india/nutrition.htmlFAO Country India Nutrition profile http://www.fao.org/ag/agn/nutrition/ind_en.stm

Source: CIA World factbook https://www.cia.gov/library/publications/the-world-factbook/rankorder/2228rank.html?countryname=Bangladesh&countrycode=bg&regionCode=sas&rank=190#bg)(http://articles.timesofindia.indiatimes.com/2013-06-29/india/40271375_1_nutritional-status-addressing-malnutrition-lancet-series

THE DOUBLE BURDEN OF MALNUTRITION AND

NUTRITION TRANSITION

“Malnutrition, both under and over, can no longer be

addressed without considering global food insecurity, socioeconomic disparity, both

globally and nationally, and global cultural, social andepidemiological transitions.” - Darnton-Hill and ET Coyne “Feast and famine: socioeconomic disparities in global nutrition

and health”http://journals.cambridge.org/download.php?file=%2FPHN%2FPHN1_01%2FS1368980098000068a.pdf&code=cac6fec0a6e8779ed4063bbf512011e1

Double burden ofmalnutrition (1)

Double burden of malnutrition: Persistence of under nutrition, especially among children, along with rapidly increasing overweight, obesity and diet- and life-style related chronic diseases especially among the poor. In China, for example, there has been a significant rural-urban difference in obesity prevalence which offset marked reductions in underweight prevalence.

These forms of malnutrition usually result from uneven access to food and unbalanced diets. Both under- and over-nutrition are problems of poverty and are bound to become even more closely interwoven. Immediate and root causes of malnutrition are multidimensional and complex.

Double burden of malnutrition (2)

In countries where famine and under nutrition were traditionally the main issue, the reverse now is the case: over nutrition is increasing, especially in India and China, countries recently more affluent.

In developing countries, rapid urbanisation is linked to diets with more fats, animal source foods and processed products and lower activity levels resulting in higher levels of obesity.(ftp://ftp.fao.org/docrep/fao/009/a0442e/a0442e00.pdf)

Action for students: Write a few paragraphs for your folder explaining what is meant by the phrase “the double burden of malnutrition.”

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Nutritional adequacy • Energy – provided in the form of protein, carbohydrates and

fats. Sometimes referred to as macro-nutrients.• Micronutrients – vitamins and minerals essential to all

metabolic processes in the body. Fruits and vegetables are rich in micronutrients, as are many animal sourced foods. Liver is an excellent source of iron, B vitamins and Vitamin A.

• Animal sourced food – meat, fish, eggs, dairy. These foods provide complete protein and many micronutrients in addition. For example, dairy foods provide complete protein, an excellent source of calcium, zinc and essential fats.

• Tubers and cereal – the least expensive source of energy, predominately carbohydrates. Also provide some protein and often rich in B vitamins. However, protein is usually not complete and these foods must be paired with beans or lentils to provide all the essential amino-acids (protein-building blocks).

Hunger and obesity -both forms of malnutrition

Action for students:

1. Watch the video Nutrition in 2 minutes - http://www.wfp.org/videos/nutrition-2-minutes-0 and Unicef slideshow lessons with quiz on nutrition - http://www.unicef.org/nutrition/training/2.1/1.html

2. Childhood Malnutrition: What happens now http://www.doctorswithoutborders.org/publications/reports/2011/childmlntrtn.whathappensnow.pdf

3. Discuss and write notes for your folder on ‘under nutrition’ and the malnutrition cycle.

4. Record in your folder the arguments in favour

of preventing under nutrition?

5. Discuss in groups of four why hunger and obesity are two sides of the same coin, bearing in mind socio-economic, political and environmental factors.

Poorest aremost vulnerable to malnutrition

Triad: Poverty – Dietary Quality / Adequacy – Health

In MEDC, poverty can be associated with poorer health and shortened life expectancy due to obesity because calories are cheap and micronutrients are expensive.

In LEDC, it can manifest as wasted/stunted children who do not get enough of the right kinds of foods at crucial moments in their life when assailed by many infections. Adult obesity is one of the risks in populations with many undernourished young children as well as higher mortality rates at all phases of the life cycle.

Hunger and obesity

Source: FAO and WHO study http://www.farmingfirst.org/green-economy/

The number of hungry people and obese people are both growing, worldwide.

• Root cause of chronic hunger: poverty and lack of income generation. These also can limit access to basic health and sanitation services and decent housing.

• Malnutrition and food insecurity are interrelated with poverty. •Social disparities drive both hunger and

obesity. • Tremendous issues around affordability of

food, percentage of income spent on food.

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Hunger and obesity afflict poorest populations most (1)

Hunger and obesity afflict poorest populations most (2)

Further info: Gapminder Human development trends, 2005:interactive format http://www.gapminder.org/downloads/human-development-trends-2005/Source: Food aid or hidden dumping - http://www.oxfam.org/sites/www.oxfam.org/files/bp71_food_aid.pdf

Action for students: Why should some attention shift from infectious diseases that you can catch from other people (e.g., HIV/AIDS, TB) or mosquitoes (e.g., malaria) to the rising burden of illness related to obesity?

Silent killers: hunger, malnutrition and obesity

Source: Joachim von Braun, IFPRI, September 2007http://www.cces.ethz.ch/latsis2007/Presentations/Latsis_Presentation_von_Braun.pdf; http://www.hsph.harvard.edu/obesity-prevention-source/obesity-trends/obesity-rates-worldwide/#References; Source: Women in Agriculture: Closing the Gender Gap for Development, FAO, 2011; Source: Levels and Trends in Child Mortality, UNICEF, 2011

Type People affected

Hunger 0.9 billion

Children underweight 146 million

Children overweight 43 million

Micro-nutrient deficiency More than 2 billion

Overweight to chronic disease

1.5 billion overweight500 million obese

Globalisation ofhunger and obesity

Image: http://wiki.ubc.ca/images/2/22/Globalisationmap.gif; Source: http://www.bis.gov.uk/foresight/our-work/projects/published-projects/global-food-and-farming-futures/reports-and-publications ; Economist October 13th 2012 “True Progressivism”

Globalisation and technical innovation have reduced global inequality, but inequality within countries has widened. The twin forces expose the food system to novel economic and political pressures.

Globalisation ofhunger and obesity

Action for students:

1. Define globalisation and take special note of trends and their relevance to obesity and hunger around the world http://www.newworldencyclopedia.org/entryGlobalization

2. In pairs, watch the Ted Talk video and explain Why “Obesity + Hunger = 1 Global Issue”. What does globalization of obesity and hunger mean? How does obesity in the US relate to Africa?

3. Work with a partner and discuss and record the conclusions that can be drawn from the TED talk.•http://www.ellengustafson.com/post/3404478440/ted-com-ellen-gustafson-obesity-hunger-1

Prevalence of obesity

Source: http://www.hsph.harvard.edu/obesity-prevention-source/obesity-trends/obesity-rates-worldwide/#adult-trends. Map not dated in source, but website up to date (2013)

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Action for students: Label the ‘obese’ countries. Discuss: What are the factors which have contributed to the burden being so high in the various countries? Looking at the following slide, what are the trends around the world? Record your agreed answers in your folder

Public health issue

Obesity is an issue that is as complicated as undernutrition and it is far more complex than personal lifestyle choices. • Double burden countries. India is the best example. High

prevalence of low-birth weight and childhood undernutrition and rapidly increasing prevalence of adult obesity

• Mexico: now the most obese country in the world. Excessive consumption of sugar-sweetened beverages, in large part driven by a long history of water-borne illness in the water supply (e.g., poor sanitation, contaminated drinking water)

• Food policies: the US government with a forty-year history of subsidising corn and soy bean farmers – resulting in a large source of cheap calories , but lead to high calorie, cheap food that coerce the poorer quintiles of the population into consuming less nutritious food that promotes obesity.

Image fact food: http://www.economist.com/news/special-report/21568065-world-getting-wider-says-charlotte-howard-what-can-be-done-about-it-big

Obesity: Physical factorsApart from social disparities and being at the bottom of the income distribution, physical factors cause obesity. These areinfluenced by the food and physical activity environment in which people live.

Further info on obesity causes and source: http://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/Shifting

consumption

Too little sleep, too little exercise

Poor diet

Genes (a little)

Prenatal and early life development

Too much TV

Image: http://factfile.org/wp-content/uploads/2012/02/Obesity-Facts-obesity-epidemic-requires.jpg

Health consequences of obesity

Source: http://andrela107.files.wordpress.com/2011/08/hamburger-qui-tue-2.jpghttp://www.healtheo360.com/blog/729/obesity-a-ticking-time-bomb/; The Economist December 15th 2012;

In many countries around the world, being obese is now the biggest driver of sickness, because it raises the risk of, for example, diabetes, heart disease, stroke and some cancers. It is also linked to the increased incidence of osteo-athritis of the hip and knee (major cause of hip and knee replacements)

Impact of obesity • Individuals bear the bulk of the burden, but in many

countries the state covers some or most of the associated and growing healthcare costs.

• The prognosis of those who do fall ill depends on where they live and whether they have access to health care. This can be a major issue for the poor living in the US and India, for example, where there is very high quality health care for those who can afford it.

• The social consequences go beyond increased health costs and include:– National security concerns. In the United States, where health care is

privatised for approximately half of the population, obesity is seen as a national security issue because so many military recruits are unfit (overweight). Similarly in China, childhood obesity is becoming a major concern, resulting from increased wealth (better and higher caloric diets) at the intersection of the one-child policy.

– Economic concerns: lost work days due to illness ultimately impacts productivity.

Obesity and social inequality in the UK

• Obesity prevalence for adult women increases overall with greater levels of deprivation regardless of indicator used, whereas only occupation-based and qualification-based measures show differences in obesity rates by levels of deprivation for adult men.

• Highest level of educational attainment can be used as a measure of socioeconomic status. Obesity prevalence goes down as levels of educational attainment go up for both women and men.

Adult obesity prevalence by highest level of education Health Survey for England 2006-2010

Adult (aged 16+) obesity: BMI ≥ 30kg/m2Further info and source: Health Survey for England; http://www.noo.org.uk/NOO_about_obesity/inequalities and Factsheet http://www.noo.org.uk/uploads/doc/vid_16966_AdultSocioeconSep2012.pdf

Action for students: In pairs, explain why malnutrition and disease work in a deadly cycle and are driven by inequality and note down your agreed answers in your folder.

Globesity epidemic (1)

• Since 1980: significant increases in global obesity** rates, the rate has nearly doubled

• Rises in obesity-related chronic diseases poses threat to individuals, health care systems and economies (e.g., cardiovascular disease diabetes type 2, musculoskeletal disorders — especially osteoarthritis, some cancers (endometrial, breast, and colon).

• Since 1990: rise in childhood obesity. • Obesity has now reached epidemic*** proportions globally. Most prevalent in

high-income countries, the obesity epidemic is also spreading to low- and middle-income countries as countries move up the income scale.

• Sixty-five per cent of the world's population live in countries where overweight and obesity kills more people than underweight.

* Obesity: Body mass index (BMI) of 30 or higher. Body mass index is defined as the individual's body mass divided by the square of their heightOverweight: 25 BMI or higher.

** Rate “A measure of the intensity of the occurrence of an event. For example, the mortality rate equals the numberwho die in one year divided by the number at risk of dying. Rate—A measure of the intensity of the occurrence ofan event.“(http://www.idph.state.ia.us/hpcdp/common/pdf/10_glossary.pdf)

*** Definition of epidemic and pandemic: http://www.medicalnewstoday.com/articles/148945.php

Globesity epidemic (2)

Action for students: Based on the article below, research and discuss in a group of four: 1. What are the trends by regions?2. What are the differences by gender? 3. What social disparities drive the globesity epidemic?

• Globalisation of obesity http://www.globalization101.org/the-globalization-of-obesity-2/

• OECD 2012 Update: http://www.oecd.org/health/49716427.pdf

• Articles on obesity trends by region: http://www.hsph.harvard.edu/obesity-prevention-source/obesity-trends/obesity-rates-worldwide/#adult-trends

Image: http://www.hsph.harvard.edu/obesity-preventionsource/obesity-causes/globalization-and-obesity/

Obese children

Source: http://www.hsph.harvard.edu/obesity-prevention-source/obesity-trends/global-obesity-trends-in-children/

Action for students: 1. Research latest data for obese children for the countries on the

graphs and add to the graph and chart on this and the following slide.

2. What conclusions can you draw about obesity in children in England compared to the other countries on the graph?

http://news.bbc.co.uk/1/hi/health/7151813.stm

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43 million overweight and obese pre-schoolers worldwide35 million of whom live in developing countries.

Transition paradox

• Developmental transition: better food and nutritional status; urbanisation and globalisation as countries become more developed. Urbanisation and meat consumption rising hand in hand

• Nutrition transition: shift to food with high energy density especially fat “stone age appetites meeting capitalist abundance”

• Life style changes especially less physical activity

• Social disparities in obesity are unabated. Obesity shifting disproportionately to poor.

• Paradox: persisting underweight along with rising obesity within the same country, sometimes household.

Source: http://www.nottingham.ac.uk/globalfoodsecurity/documents/prahash-shetty-presentation.pdf; images: http://www.cpc.unc.edu/projects/nutrans/presentations/worldisfat.ppt/view; The Economist September 1st 2012 “More or less”

http://epianalysis.files.wordpress.com/2012/09/obesity.jpg; That’s a

cupcake!That’s a cupcake!

Busy bee or couch potato?

There are worryingly high rates of inactivity. “Since the beginning of the industrial revolution, technology and economic growth have conspired to create a world in which the flexing of muscles is more of an option rather than a necessity” – The Economist, July 21st 2012, p. 78

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Nutrition transition

Convergence of diets and lifestyles globally:

• More globalised food tastes such as westernised habits of meat eating, more dairy which takes more energy to produce and drives future grain consumption. – Media encourages the food transition from traditional diets of grains and vegetables

to often high protein and fats and sugars, westernised dietary habits and lower physical activity levels. Globalisation can mean that there is a switch from associating being obese with being rich to with being poor.

– With rising income rising middle classes in transition economies such as China are changing their food habits (China more quickly than India for various reasons)

• More choices and less active life style in urban areas

• Mechanisation of farm activity, switch from subsistence farming to high yielding cash crop also imports bad eating habits to rural areas. Food transition drives obesity and heart disease health risks and changes in the social and physical environment of production areas.

• The shift to foods that are far more resource-intensive to produce such as meat puts pressure on scarce resources.

. Source: http://www.fao.org/FOCUS/E/obesity/obes2.htm; Edexcel Student Guide Unit 4, Option 3; http://www.edexcel.com/migrationdocuments/GCE%20New%20GCE/Unit-4-Option-3-Life-on-the-margins-Food-supply-problem-final.ppt.Image: http://transitionbuxton.co.uk/node/431

Shifting consumption

Image above Joachim von Braun Popkin, B., The World is Fat http://www.cpc.unc.edu/projects/nutrans/presentations/worldisfat.ppt/view;Image of McDonaldshttp://upload.wikimedia.org/wikipedia/commons/thumb/2/2f/Mac_Japan.jpg/220px-Mac_Japan.jpg; http://www.economist.com/news/special-report/21568064-food-companies-play-ambivalent-part-fight-against-flab-food-thought

Action for students: The issue is with what we eat – too much meat! 1. Watch the Mark Bittman Ted Talk clip and Michael Pollan Oprah interview

and 2. Read “Increasing homogeneity of world food supplies warns of serious

implications for farming and nutrition” http://www.sciencedaily.com/releases/2014/03/140303154102.htm

3. write a paragraph supporting or disagreeing with the statement that we must reduce meat consumption

• http://www.globalissues.org/article/558/obesity#NumberofPeopleOverweightorWithObesityRivalsWorldsHungry•http://www.oprah.com/oprahshow/Michael-Pollan-on-Eating-Meat-Video

Consumption culture

Many consider obesity a personal decision or weakness, but actually a culture of consumption with much broader forces must be at work given the growing scale of the problem around the world.

Many answers to deal with obesity have to do with culture and the food system and are not medical or personal, but the chronic health problems created in part by the food system tend to be medicalised by healthcare systems (hooking us up to machines and onto medicines).

Source: http://artobserved.com/artimages/2009/01/andy-warhol-hamburger-1985-61.jpg; http://teoteodora.files.wordpress.com/2013/04/andy-warhol-three-coke-bottles.jpg; http://mitusa.files.wordpress.com/2009/12/consumption.jpg

Double pyramidEnvironmental impact of food choices

Image: http://www.thefoodsection.com/foodsection/2010/11/double-pyramid-recommends-foods-for-health-and-environmental-protection.html

Transition Paradoxand globesity (1)

Action for students:

1. Looking at the PowerPoint “World Is Fat: New Dynamics Shifts in Patterns of The Nutrition Transition” http://www.cpc.unc.edu/projects/nutrans/presentations/worldisfat.ppt/view note in your folder what is meant by transition paradox.

2. Using the information in the slides in this section write a report explaining the Nutrition transition and the consequences it may have for food supply, agriculture and health in non-western countries and regions. OR Write a plan, an introductory paragraph and methodology for a report: The nutrition transition is at the root of the growing global obesity (globesity).

Transition Paradoxand globesity (2)

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TEACHER RESOURCESSLIDES

Cartogram: proportion of underweight children by country

Action for students: 1. Label the countries with the biggest burden such as India, Pakistan, Nigeria, Bangladesh

and the Philippines. 2. Relate this worldmapper cartogram to earlier one on human development – is the

proportion of underweight children related to development?

Source: http://sasi.group.shef.ac.uk/worldmapper/posters/worldmapper_map182_ver5.pdf

Equal area cartogram*

Food availability and access do not always mean a good diet

Availability and access to goodfood alone do not suffice forbalanced, good nutrition, which

isnecessary for optimal growth

andmental development.

In Bangladesh (see Figure 3), for example:• 65 % of women live in

households with food security, but 1 in 5 food secure women are malnourished

• Still 26% of children in wealthiest households are stunted!

Source: http://www.measuredhs.com/pubs/pdf/PB6/PB6.pdf

Obesity prevalence over time

Source: http://www.economist.com/news/special-report/21568065-world-getting-wider-says-charlotte-howard-what-can-be-done-about-it-big

Child obesityon the rise

Source: http://download.thelancet.com/flatcontentassets/pdfs/nutrition_2.pdf

Converging diets

Source: http://www.fao.org/publications/sofi/en/; http://geodev.grid.unep.ch/extras/geg_slider.php

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Rising food consumption

Source: http://www.fao.org/publications/sofi/en/

Global meat production and consumption is projected to rise by 70% between 2000 and 2030 and by 120% between 2000 and 2050. This growth and land degradation drive an increase in fertiliser use (IAASTD 2009)

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