1.TF In the poor nations almost everyone is hungry; in the remainder almost everyone gets an adequate diet

2.TF Worldwide, more people have their lives shortened by overeating than by starvation

3.TF When poor nations now find a place on the ladder of development, they develop slower than rich nations did when they enjoyed their phase of development?

4.TF Most Canadian specialists in global health understand how the distribution of poverty & hunger are changing?

5.TF Health & nutrition benefits are possible only after economic development occurs

6.TF People in regions of extreme hunger & poverty desperately need money

7.TF 50% of children in the US are currently so poor that they must rely on charity for their meals?

Quick quiz – two of the following are T

Quick answers1. F In some nations hunger is the norm; in the remainder,

an adequate diet is the norm2. T Worldwide, more people have their lives shortened by

overeating than by starvation 3. F In the present era, when poor nations find a place on

the ladder of development, they develop slowly compared with the rich nations in their phase of development?

4. F Most Canadian specialists in global health understand the how the distribution of poverty and hunger are changing?

5. F Health & nutrition benefits inevitably occurs after economic development rather than before

6. F People in regions of extreme hunger & poverty desperately need money

7. T 50% of children in the US are currently so poor that they must rely on charity for their meals?

Slides & practice questions (see web)1. The 50% (actually 49.2%) is US children that

will require food-aid some time during childhood2. Pct % of people hungry is declining over years3. Plan to spend 2-3 hours reviewing web info

What works & what doesn’t?toward evidence-based solutions

http://www.sfu.ca/global-nutrition “This is a problem we can solve at a fraction the cost of ignoring it”

(Senator Geo McGovern: US Ambassador to UN Food & Ag Org)

1 billion hungry (800m); 1 billion overweightMinefield Experts are living in the pastNothing in texts

Page 5Page 5

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.

Wor

ld G

DP

$PPP

per

cap

(e

st)

1500

-210

0

1500 2000$0

$5,000

$10,000

India to 1500

China + Indiato 1850

WesternEuropeto 1945

USA + WestEurope

since 1945

http://ers.usda.gov/Data/Macroeconomics/

Manifest destiny of world - wealth

China +India 2040?

6

Global Nutrition

We have a roadmap to a world without hunger

Where are we headed?

The ugly

We know what works?

It wasn’t an accident

How did we get here?

Where are we now?

Can anything help? Yes

Stuffed & starved

The bad

We keep doing what

we know doesn’t work?

The good

Most of you will see hunger in museums!

We are part of the problem

Overview of Nutrition in Global Health

1. Malnutrition and MDGs: cause, effect & cure3 2. Major categories & measures of nutritional status4 3. Nutrition & crucial periods in the life-cycle; 4 4. Determinants of nutrition, dietary patterns & culture2 5. Nutrition and its relationship to disease4 6. Making hunger history - breaking the poverty-trap 37. Trends in nutrition, food security & globalization3

Page 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 Page 9

Page 10Page 10

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 preventionPublic health approaches to solutions

World% undernourished

111970 1980 1990 2000 201015

33%

17%same data22%

14%

1970 2010 2015 target 2030 FAO est

0

2000

4000

6000

8000 FedMalnourished

Number fed & under-nourished worldwide

12

14%

Prediction

6%11%

Target

33%

1212

millions

A vicious cycle for malnutritionpoverty, health, economic deprivation

Page 13

Development:Marginalization

inability to provide for self or family

Access to the ladder of development

Poverty: Diminished access to agricultural & food

resources malnutritionhigh birth rate

Health: Physical & cognitive impairment,

susceptibility to disease, early death inability to

earn an incomenutrition

Routes to famineDiscovering resources

Externally initiated armed conflict …Uncertain rainfall & drought ...

Being landlocked ...

Bad governance ...Israel, Afghanistan

So.AfricaNigeria, Iraq

Lesotho

Being on a trade or pipeline route ...

Zimbabwe [USA]

Sudan, Afghanistan

Sahel, Palestine

Blaming the bonsai tree...

Yunus:

1 Malnutrition & MDGs: cause, effect, cure3 slides: 1. Trends in nutrition, food security & globalization2. Agricultural trends3. Nutritional inequities - Cause & consequence4. Food security; Prospects for having enough food

Page 15

16

Paying for total strangers to eat?

Not us, not if it goes to corrupt

dictators” }

16

17

http://www.globalissues.org/article/35/foreign-aid-development-assistance#GovernmentsCuttingBackonPromisedResponsibilities

“Development aid”, not spent on poverty or development

Clawed back by unfair tradeEmergency aid Debt relief Refugee, Tied to benefit rich

“Phantom aid”, the wasted 47%Refers toODA, not

MDGs

The Millennium Development Goals

Page 18

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 stateThe 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

Nutrition & Millennium Development Goals

Page 19

Primary goal is to eradicate extreme poverty & hunger

Nutrition – direct prerequisite to goals1, 3, 4, 5 & 6; indirectly to 7 & 8

see next 2 slides

1

maternalhealth

Child mortality

Gender equity Empower ♀ Achieve universal

primary education

HIV, malaria, other diseases

Environmentalsustainability

Global partnershipfor development

Page 20

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. Women’s malnutrition impairs the whole family’s health & nutrition

Centrality of nutrition to MDGs 1, 2, & 3

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, tuberculosisAdapted from Gillespie and Haddad (2003) http://web.worldbank.org/

Page 21

2 Categories & measures of nutritional status

4 slides: • Malnutrition, undernutrition, • Overnutrition / Overweight, Obesity• Energy requirements: calories, carboh, proteins, fats • macronutrients, micronutrients

Page 22

Categories of nutritional statusNutritional status is assessed as one of four

categories 1. Good nutritional status: All nutrients (right quantities, time &

place) allow optimal, growth, maintenance, & reproduction

2. Overnutrition: An excess of a nutrients (usually calories) is being consumed, so that health is negatively impacted

3. 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"

4. Malnutrition: Energy consumption is adequate, but there is an imbalance among constituents of the diet and health is impacted

Page 23

Note C

Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO.

Page 24

Scientific American, Sept 2007

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

Page 25

Note D

“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 what‘s needed for normal, growth, maintenance & reproduction

• It goes without saying that they are unable to provide the necessities for those who depend on them

Page 26

“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 27

28

http://www.who.int/mediacentre/factsheets/fs290/en/index.html

http://www.fao.org/mdg/en/http://www.un.org/millenniumgoals/reports.shtml#mdgs

29

http://www.who.int/mediacentre/factsheets/fs290/en/index.html

http://www.fao.org/mdg/en/http://www.un.org/millenniumgoals/reports.shtml#mdgs

30

http://www.unicef.org/media/files/Tracking_Progress_on_Child_and_Maternal_Nutrition_EN_110309.pdf

http://ije.oxfordjournals.org/content/32/4/518.full.pdf

Percentage stunted

60%

40%

20%

AfricaAsia

Latin Am

Last 2 or 3 points are projections

1980 & every 5 years

3 Critical periods: nutrition in the life-cycle4 slides: 1. Perinatal nutrition: 0-6 mo: Breast vs. formula

1st 5 y Weaning & infancy –intellectual develop2. School years; ability to learn3. Work performance4. Elderly

Page 31

Maternal mortality (Demonstration index slide for a note)

• Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death.

• The major direct causes of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor.

Page 32

Note button

A click on the note button takes viewer

to the note

Nutrition through the life-cycle

Page 33

Stage Risks associated with malnutrition Prenatal & (pregnancy)

birth defects, birth weight, infant and peri-natal mortality, high maternal death rate

Infancy & early life

cognitive & physical development, bone malformation blindness, impaired immune response, risk of infections, faster progress of HIV, in protein-energy malnutrition, early death from causes the well-nourished would survive

Adolescence & adult life

risk of infection, anemia, diabetes, problems with heart, lungs, vision, risk of all cancers, anemia, blindness, beriberi, pellagra This stage of life lays a foundation for later good or ill health, osteoporosis, greatly diminished life-expectancy

Old age few chronically malnourished persons survive to old age. Those who do survive poor lifestyle and nutrition, often endure a very low quality of life

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!

Page 34

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_childbirth/childbirth/3rd_stage/jccom/en/index.html

• Ideally, babies should receive vitamins E & K injections at birth

• A baby who’s 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 yearhttp://www2.unicef.org/nutrition/index_22657.html

• Page 35

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

Page 36

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 planet’s 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

Page 37

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 can’t 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 nation’s mind to peace. What will it take to open our eyes to children dying of hunger?

Page 38

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.

Page 39

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

Page 40

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

Page 41

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 world’s 7.6 million cancer-related deaths now occur in developing nations.

Page 42

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.

Page 43

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.

Page 44

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

Page 45

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

Page 46

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”.

Page 47

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 we’ll 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 48

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

Page 49

Prevention of heart attacks and strokes

• There is no easy solution to obesity. In a typical study: <10% of people dieting, <10% of those exercising, and <15% 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

Page 50

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%

Page 51

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 52

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

Page 53

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 54

4 Determinants of nutrition, diet & culture2 slides: 1.

Page 55

Determinants of population nutrition

Page 56

Any broken link can nutritional inequities.

(think about how …)

The mechanisms of hunger – many paths

Page 57

“Repositioning Nutrition as Central to Development:  A Strategy for Large-Scale Action

”

Notice how one path can feed-back to affect others

As diagrammed by WHO

in

Sub-determinants of nutritional sufficiency

Page 58

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

Sub-determinants of nutritional sufficiency

Page 59

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

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

death)

Page 60

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

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

Page 61

• 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

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

Page 62

Note I

Dietary patterns across cultures2. Peasant agriculturalists – successful small scale

farmers (currently the largest group)• Benefits: close to food sources; if no punitive taxes or rents;

usually 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 63

Dietary patterns across cultures3. Indigent, landless crop plantersBenefits: 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

Page 64

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

Page 65

Dietary patterns across cultures5. 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)

Page 66

Note J

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

Page 67

Note D

Healthy diet

Optimal health: physical & mental development

reproduction, survival

Absence of disease

... food& water

... healthservicesAccess to ... ... peri-

natalcare

Good nutritional status

Precursors

FoundationsAgriculturalproductivity

Economicdevelopment

Infrastructurenon-exploitive investment

intellectual property

Geography, stability, climateabsence of conflict, natural resources

access to markets, etc

Education NB women

# of mouths to be fed

5 Nutrition & disease cause vs effect4 slides: • Acute and chronic malnutrition; • Socio-cultural determinants of malnutrition • Undernutrition as contributor to much childhood mortality /

morbidity• Micronutrient deficiencies: Iron, Vitamin A, iodine, calcium, etc.

• Nutrition &major diseases: CV, strokes, diabetes• Over-nutrition, obesity

Page 69

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

Page 70

Note H

Top 6 global manifestations of malnutrition

1) 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 growthPage 71

We begin with a perspective, then we take each of the 6 in turn

The material in this section is well reviewed at: http://www.pitt.edu/~super1/lecture/lec0141/index.htmIron, vitamin A, iodine – check the latest information at: http://www.micronutrient.org/English/view.asp?x=1

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

Page 72

4) Vitamin A deficiencyOver 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

5) Don’t underestimate iodine deficiency disorders• WHO 2003: “1.6 billion people don’t 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/status/en/index.html

In addition nutrition determines chronic disease risk • Heart disease, osteoporosis, cancer, diabetes, strokes, etc.

We’ll go through these one at a time in the following slides

Page 73

Top 6 global manifestations of malnutrition (cont.)

For categories of at risk people across countries, see Note K

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 74

Top 6 global manifestations of malnutrition (cont.)

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

Page 75

http://www.who.int/water_sanitation_health/mdg1/en/index.html

The special importance of proteins

Page 76

• 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

Dietary deficiency of proteins is deadly

Page 77

• When any essential amino acid is missing, all the rest are burned & no protein synthesis can occur – zero!

• All essential aa’s 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

Humans adapt to low protein intakes ...

Page 78

... 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.

Protein & energy nutrition are inseparable

Page 79

• 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

Protein-energy malnutrition - in adults

Page 80

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 can’t 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

Hungry kids – difficulties in diagnosis

Page 81

• 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 82

• 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

Protein malnutrition is different

Protein malnutrition: diagnosisWhen there are many sick kids in a community, but

none look undernourished be sure to look for protein deficiency. Why?

• It’s 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

Page 83

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 84

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)

Page 85

Note L

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/made-at-home.htm#recipes

• 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 86

Iron deficiency affects 500 million globally

• 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 … Page 87

Note M

http://www.micronutrient.org/English/view.asp?x=579

Iron deficiency affects 500 million globally

• Iron deficiency is best diagnosed in the preclinical stage, by measurement of transferrin saturation

• Females > 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 88

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 Page 89

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 90

Iron excess - dangerous to some

Page 91

• 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

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?x=577

Page 92

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 Page 93

*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

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.

Page 94

Iodine deficiency disorders

• The world’s 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

Page 95

For latest data, see: http://www.micronutrient.org/english/View.asp?x=578

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

Page 96

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

Page 97

6 Making hunger history - breaking the vicious cycle of the poverty-trap3 slides: • Worldwide distribution of malnutrition

& its relation to poverty• Societal costs of malnutrition

including effects on young children

Page 98

We now know what works!Widespread agreement at conferences! Tool-kits for

elimination of extreme poverty & hunger exist

MDGs, change agents, Grameen, Millennium Village, Agencies & foundations for development. CIGHR, GHEC, Supercourse, Universities, Spokespersons

for the developing nations

We know what we can do to help right now.

We know we can do it better! New knowledge production, dissemination, data

mining, knowledge brokering & application

Resources, personnel, sharing what works, time needed to get on development ladder

Need govt action!

Need info & research

Money? No way to get it & useless!

• No one to employ anyone, no one to sell things to• No shops to spend money in• What they eat this month is what they can take out of

the ground from last month's planting• Hungry & stunted kids tiny unmarked graves• Hospital, dispensary, emergency > 1 day walk

More immediate than money – (1) to SURVIVE We don’t need studies to learn what’s needed

Page 100

The poorest - don’t give them money

Jeffrey Sachs

What do they need?

The greatest nutritional problems are well known:Protein energy malnutritionVitamin AIronIodine

What do they need?Short term – “Give a man a fish ...”

Emergency rations, safe water, first aid, antibiotics,public health – vaccinations, drugs, etc

In conflict zones, shelter, safety to live, plant, harvest

In drought “safe-water straws”

Page 102oral rehydration solution ready to use foods

Millions saved

“Phantom aid”: 47% is “wasted”

• Evaporating aid - promises … broken as soon as cameras turn elsewhere

• $ flow benefits the rich nations – tilted trade• Aid with strings attached, contingent on UN votes,

WB loans, unfair trade• Dumped food surplus local farm economy• Money given by corrupt rich people to

“corrupt dictators”

103

UK banks in Nigerian

corruptionPaul Collier: The bottom billion10

3

Emergency aid isn’t intended for development

http://www.globalissues.org/article/35/foreign-aid-development-assistance#GovernmentsCuttingBackonPromisedResponsibilities

http://blogs.browardpalmbeach.com/cleanplatecharlie/LifeStraw.jpeg

To become self-sufficient - obviously:good seeds, fertilizer, drinkable water, sanitation, low technology agricultural info & resources, drip-irrigation, ARVs mosquito nets, dispensaries, hospitals

Emergency aid – beyond Survival at the same time (2) Sustainablity

Long term – (3) To thriveScaling up production - factories

“... teach a man to fish”

development ladder

To become self-sufficient - obviously:good seeds, fertilizer, drinkable water, sanitation, low technology agricultural info & resources, drip-irrigation, ARVs mosquito nets, dispensaries, hospitals

Emergency aid – beyond Survival at the same time (2) Sustainablity

Long term – (3) To thriveScaling up production - factories

“... teach a man to fish”

development ladder

7 Malnutrition & MDGs: cause, effect, cure3 slides: 1. Trends in nutrition, food security & globalization2. Agricultural trends3. Nutritional inequities - Cause & consequence4. Food security; Prospects for having enough food

Page 107

We know what works•Transparent & accountable , open bids•Partnerships not paternalism•Goals, objectives, timed milestones•Strategies revised annually by both partners•Externally monitored. No political pressure•Sustainable emphasis on poverty, agriculture•Serves recipient needs, not donor / ideology•Firm long-term commitments: MV, Grameen

Unrealistic? Let’s see ...108

• Grameen Family of social enterprises

• Billionaire philanthropists & foundations

• The Millennium Village project

• Passionate & influential voices for change

• Scientists & students bring energy to future

• Instant spread of innovations: agric, educ, &c

Beyond MDGs: amazing changes

109

www.sfu.ca/global-nutrition

Microfinancing successes

Donkey carts ($200) repay in

2.5 mos

4 Factories for treadle pumps. 2y later there are 75

Drip irrigation allows winter cukes @ 3x price. 1A farm profit

$100 $550 / yr

Business Week

Grameen Impacthttp://www.grameenfoundation.org/our-impact

9.4 million poor have been helped1,000,000 microloans have been generated

http://www.youtube.com/watch?v=kW-4gJmXy5M

http://www.youtube.com/watch?v=1UugpcDjjJU

Grameen village phone10M subscribers300k cell-phone ladies

Innovations that make a differenceBarefoot agriculturistsSoil conservation, don’t burn

contour farming, irrigation, crop rotationDrip irrigation

Pump installation

Burkina Faso: planting-pits & stone furrows land food for 500,000

Phillipines: Tilapia in protein for 30,000,000

China: Hybrid rice in – enough for 60,000,000

Bangladesh: Market liberalization in rice yield 3x

Millions fed

Appropriate technologyInnovations that make a difference

$25 pump irrigates ½ acre $100/y net

Watering can irrigation

rainwater collection pitsvalve

sub-surface drip irrigation

Zero-tillage wheat-seeder drill - $100?

Labour goes further. Earlier planting yield

Doubled yield govt subsidy

Farmer buys & rents to pay off

2 factories 100 in Haryana & Punjab

Millennium Village Project

Farm production

Gender equity

Nutritional services

Energy & environment Health services

Water

Prevent malaria & TB

Environment

$3m x 5yrsfunded in advance

Initiatives making a differenceGrameen Family of social enterprisesThe Kings of Philanthropy & 100s of foundations

The Millennium Village project

Influential voices for changeScientists & students are making a difference

The Millennium Development Goals – for the poorest

You! ...amplify with others @ SFU &?

VoteSpeak, write, telephone

International internship

DonateLive

against 99.7% of tax on ourselvesOxfam, IDRF (Can Revenue charities)

to leave enough for everyoneconsider study abroad

Page 117

Supplementary note to the preceding slide

Every day, 1500 women die from pregnancy- or childbirth-related complications. In 2005, there were an estimated 536 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable. (1) Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations Millennium Summit in 2000. In Millennium Development Goal 5 (MDG5), countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. However, between 1990 and 2005 the maternal mortality ratio declined by only 5%. Achieving Millennium Development Goal 5 requires accelerating progress.

Maternal mortality in 2005: estimates developed by WHO, UNICEF,

UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www.

who.int/reproductive-health/publications/maternal_mortality_2005/index.html,

accessed 14 August 2008).

Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html

Photo credits

Page 118

Supplementary note to the preceding slide

Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html

Page 119

Supplementary note to a preceding slide

Why do mothers die?Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are: severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia and HIV.(2) Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies.

120

Passionate renegades

120

Take home message• Catastrophic inequities in distribution of

foods

• Kinds of nutritional status & health impact

• We’ve faced causes, know there are cures

• As we face the future we are ...

water, protein, iron, vitamin A, iodine

Not by accident? Who’s responsible? What’s needed perinatal - women and children

not just across nations – increasingly within

Impatient Optimistic

http://www.sfu.ca/global-nutrition