Nutrition in Global Health

1. Nutrition in Global Health Roadmap to the world’s nutritional health: Causes, mechanisms, solutions Allan J Davison PhD, Professor, Biochemist, Faculty of Sciences, Simon Fraser University Department of Biomedical Sciences & Kinesiology June 2011 Prepared as part of an education project of the Global Health Education Consortium & collaborating partners

2. Objectives for Global Nutrition Module Aftercompletingthis module youshould be abletoconceptualize: The extent & impact of severe malnutrition: global inequities The most serious nutritional problems: prevention & treatment Local &global causes of inequities in nutritional health Malnutrition: risks through the life cycle: major population groups Initiatives toward making hunger history: MDG1 & beyond Toolkit for a field workers where nutritional deficiencies occur Page 2

3. Section break 1 • Malnutrition: prevalence, causes, consequences 4 • Major categories & measures of nutritional status4 • Nutrition & crucial periods in the life-cycle; 4 • Determinants of nutrition, dietary patterns & culture2 • Nutrition and its relationship to disease4 • Making hunger history - breaking the poverty-trap 3 • Trends in nutrition, food security & globalization3 • Nutritional considerations for the field practitioner

4. Malnutrition in global context: Overview Inequities in distribution  global hunger & starvation One billion too hungry to live productive lives - an equal number 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 Overnutrition & inactivity  riskof heart disease, cancer, strokes, osteoporosis, & diabetes everywhere Progress: Globally more are fed every year, meanwhile millions die unnecessarily Page 4 Page 4

5. Misconceptions abound. Check yourself As a reality check, and to create “teachable moments”, we invite you to take a 5-minute pre-quiz You will be offered 10 true-or-false questions to dispel some common misconceptions Some misinformation is spread by those who have something to gain from it After completing the pre-quiz, we hope you will continue this module with greater interest & clarity Page 5

6. Prequiz here!

7. To get the most out of this module If you are….. a nutritionist or student of nutrition a student of one of the health professions planning a project in regions with severe nutritional problems a public health practitioner You may want to … Pay attention to global & public health & policy implications. Pay attention to perspectives & realities in desperate situations Emphasize check-lists to prepare for field work & gather information to recommend/advocate for intervention Use these slides & resources in your information / teaching sessions Page 7

8. Preface: Nutrition is crucial to global health Page 8 Among immediately modifiable factors that affect health … nutrition is of prime importance At every age nutrition is a foundation forwhat follows For all nations, rich & poor, nutrition determines physical health & development throughout the life-cycle, including - success in childbearing, cognition, disease resistance, socio-economic independence, education, employment - health & economic development, too, are contingent on adequate food, nutritional resources & support

9. Essential components of the diet Page 9 • We need food-energy for the tasks of daily life • Food elements can be stored, & interconverted, BUT • We can’t make mineral elements. Some 15 are essential, most in trace amounts • We can’t manufacture about 15 vitamins, 8 amino acids, and 1-3 fatty acids • All are “essential” for growth, repair, & reproduction If any one is missing, stores are used … when stores are exhausted life stutters to an end

10. Universal limitations & health consequences Note B In addition: We lost key metabolic abilities our evolutionary ancestors had. Thus we are vulnerable to 2 dietary risks: • In early life – a period of rapid growth, we are vulnerable to “kwashiorkor” (protein insufficiency) because we can’t synthesize 8 “essential” amino acids missing from our diet 2) In later life: we are vulnerable to obesity & diabetes– in part because we can make fat from carbohydrate, but we can’t easily convert stored fats back to carbohydrates Page 10

11. Categories of nutritional status Note C Page 11 Nutritional status is assessed as one of four categories • Good nutritional status: All nutrients (right quantities, time & place) allow optimal, growth, maintenance, & reproduction • Overnutrition: An excess of a nutrients (usually calories) is being consumed, so that health is negatively impacted • Undernutrition: Insufficient food is consumed to allow for the energy needs of the individual. Inevitably dietary (& then body) protein is burned for energy. A secondary protein deficiency ensues – thus: "protein-energy-malnutrition" • Malnutrition: Energy consumption is adequate, but there is an imbalance among constituents of the diet and health is impacted

12. Optimal health: physical & mental developmentreproduction, survival Good nutritional status Foundations of good nutritional status Absence of disease Precursors Healthy diet ... peri-natalcare ... healthservices ... food& water Access to ... Agriculturalproductivity Economicdevelopment # of mouths to be fed Foundations Education NB women Infrastructurenon-exploitive investment intellectual property Geography, stability, climateabsence of conflict, natural resourcesaccess to markets, etc

13. The “poverty trap” Note H Page 13 • Even in the richest countries there are some individuals so marginalized that they lack the necessities of live • The trap is that they have no surplus to improve their lot, and without outside help their lot remains unchangeable • Globally there are communities/nations in the poverty trap. No access to the “ladder of development”. Causes: geography, climate, invasion, or “the resource trap” (misappropriation of natural resources by colonialism) In 2001, in the Millennium Development Goals, the world community undertook to provide self-sufficiency to all

14. Making hunger history: hope & impatience Note G Page 14 With help from the outside, people in the poverty trap are finding a place on the development ladder & moving up The MDG promise of 0.7% GDP can eliminate extreme poverty & hunger in < 3 decades However a number of nations are not meeting this goal, including both the US (@@%) and Canada (@@%) Thanks to the nations keeping promises, steady progress is being made on all the MDGs, but behind schedule. The continued toll on human life is cause for frustration

15. A vicious cycle: economics, hunger, health Poverty  diminished access to agricultural & food resources  malnutrition Physical & cognitive impairment, susceptibility to disease, early death  inability to earn an income nutrition Economic marginalization  inability to provide for self or family Page 15

16. When the only tool you have is a hammer … every problem becomes a nail Malnutrition: “spatial & temporal myopia” sees proximate, not ultimate causes It’s natural to focus on our immediate space-time: rash, diarrhea., edema. Then etiology: infection, nutrition, endocrine Meanwhile, causes further back are invisible: poverty, invasion, drought, economic Are you bored yet? You’d better not be! This module will reiterate the more enduring global causes, poverty & lack of will to change the net flow of wealth from the dispossessed to the powerful. Also the ways in which this imbalance is being overcome. Reference: Ban-Ki Moon, Noam Chomsky, The Nation

17. Being landlocked Lesotho Routes to famine Having resources So.Africa Nigeria, Iraq or being on a trade or pipeline route Israel, Afghanistan To learn about the “Resource Trap” read or google Paul Collier Bad governance Zimbabwe, Italy, USA Dafur, Afghanistan Externally initiated armed conflict Sometimes to overthrow a populist government (Allende, Aristide) and install a puppet, or bribable government Uncertain rainfall & drought Sahel, Palestine Blaming the bonsai tree... Yunus:

18. The astonishing background to hunger – a world growing spectacularly rich Next slide shows century by century growth in GDP per capita For half a century we’ve had enough food to nourish everyone Almost a billion are overweight while an equal number cannot get enough food to sustain life. Yet … Why? Because the flow of wealth is overwhelmingly from the poor to the rich, & the rich are able to keep it that way BanKi Moon

19. “Manifest destiny” of world - wealth China + India 2040? World GDP $PPP per cap (est) 1500-2100 http://ers.usda.gov/Data/Macroeconomics/

20. Eliminating hunger may be the main requirement for a world at peace Food is a primary human drive. Lack → social instability GW Bush Health & economic development depend on nutrition In the following vicious circle, note how malnutrition, ill health, & poverty exacerbate each other MDG 1 is elimination of extreme poverty and hunger, most if not all the others depend on this, the primary, one

21. We know in detail the causes of hunger & how to eliminate it We will assume you know the mechanisms in the “poverty trap” the “resource trap” Unfettered free trade favours the powerful Trickledown is overpowered by a torrent of wealth in the other direction The cures are laid out in detail in the MDGs, MVs, Grameen Foundation The chain of cause and effect, and influences are not rooted in the availability offood, nor are they an accident. You must see “starve” as a transitive verb to understand the link between extreme wealth and extreme poverty

22. Section break 2 Malnutrition: prevalence, causes, consequences 4 Categories & measures of nutritional status4 Nutrition & crucial periods in the life-cycle; 4 Determinants of nutrition, dietary patterns & culture2 Nutrition and its relationship to disease4 Making hunger history - breaking the poverty-trap 3 Trends in nutrition, food security & globalization3 Page 22

23. Human Nutrition Fundamentals in Global Context The next 4 sections coversthe critical skill set needed for understanding nutritional issues in the context of global health They are not a substitute for nutritional training, but rather a catalog of nutritional tools applicable to problems a health practitioner might encounter in the field From this you can learn when to call in a nutritional expert, what kind, & what to you might reasonably ask for & receive If you have learned nutrition in a developed country, this may help you to expand your knowledge of nutrition and public health in the context of 3rd world health problems Page 23

24. Dietary patterns across cultures Note I 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 24

25. Dietary patterns across cultures 2. Peasant agriculturalists – successful small scale farmers (currently the largest group) • Benefits: close to food sources; if no punitive taxes or 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 25

26. Dietary patterns across cultures 3. Indigent, landless crop planters Benefits: Community, share with family, neighbors, income is typically less than a dollar a day Risks: Crop failure, drought or famine, erosion, soil-exhaustion, pestilence, economic exploitation (by landlords, seed providers, loan-sharks), displacement, forced migration, civil unrest or foreign invasion Problems: multiple vitamin deficiencies, kwashiorkor (protein malnutrition), infectious disease epidemics. Too poor, powerless to help themselves, most of them will never escape their circumstances, nor achieve full health Page 26

27. 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 27

28. Dietary patterns across cultures Note J 5. Affluent urbanites – most recent category Benefits: many food choices (appropriate and inappropriate) Risks: inactivity along with high fat, sugar, alcohol intakes Prevalent problems: overnutrition, obese babies and adultsdiabetes (carbohydrates), cholesterol, atheroma (lipid), strokes, heart disease diabetes, gout (uric acid - meat sources) Page 28

29. 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 29

30. 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 30

31. 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 31

32. Overnutrition is no longer limited to rich countries In the early 1900s, the poorest had almost zero incidence of diabetes, hypertension, gout, atherosclerosis & heart disease No longer. These are growing problems, impacting health everywhere. In @@the next few slides@@ we’ll consider prevention. Diabetes has reached epidemic proportions threatening, vision, kidney function, mobility, heart-health & early death. Obesity, hypertension, hyperlipidemia, & hyperglycemia cluster together as “metabolic syndrome”, now widely prevalent. Each symptom increases risk of heart disease, & together the risk is greatly amplified. Read on….. Page 32

33. Section break 3 Malnutrition: prevalence, causes, consequences 4 Major categories & measures of nutritional status4 Nutrition & crucial periods in the life-cycle; 4 Determinants of nutrition, dietary patterns & culture2 Nutrition and its relationship to disease4 Making hunger history - breaking the poverty-trap 3 Trends in nutrition, food security & globalization3 Page 33

34. Critical periods: nutrition in the life-cycle • Perinatal nutrition: 0-6 mo: Breast vs. formula • 1st 5 y Weaning & infancy –intellectual develop • School years; ability to learn • Work performance • Elderly

35. Overview of nutrition through the life-cycle

36. 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 be 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 beforeconception!

37. 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.htmhttp://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 37

38. Perinatal nutrition requires attention • Malnutrition in pregnancybirth defects, ↓birth-weight • Failure to thrive in infancy (slower than WHO growth charts) is an early danger sign, requiring investigation • Nutrition in infancy to early life impacts physical & cognitive development. Also risk of blindness, thyroid function, bone development, & more • Undernutrition or deficiencies of many micronutrients can cause “failure to thrive” • Iron, vitamins K and E are of particular importance http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html

39. 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 • Physical & mental delay can be permanent • Most importantly, they are unable to fend for themselves & depend on others (parents, others) for health & survival • We owe it to ourselves & the planet to ensure that kids grow well, and have reason to invest in the future

40. 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.

41. 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 41

42. 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 42

43. Adult life – cancer & degenerative diseases • Diet, obesity, inactivity or smoking in adult life predict ↑risk in later years of cancer, breast, prostatic & other, 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.

44. Differential nutritional vulnerability of females • Women are much more prone to nutritional anaemias. They need to replace red cells lost in menstruation • Women are the majority of elderly, increasingly so in Asia & Africa. So they are at ↑risk for diseases of old age, most notably osteoporosis & dementia • 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.

45. 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 45

46. Opportunities in adult life for mitigation of upcoming cardiorespiratory risks Prevention is better than cure These risks are becoming epidemic in poor as well as rich countries

47. 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 • Recent research shows that exercise & a lean body are the most powerful predictors of a long healthy life, & even of clear thinking into old age

48. 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 48

49. Measures to diminish cardiovascular risks Lifestyle measures: 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) inexpensive & effective • Moreover, a 10% reduction in LDL cholesterol reduces the risk of coronary heart disease by 30%

50. 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 50