Nutrition in Global Health Context

Nutrition in Global Health Context Allan Davison (Simon Fraser University) and @@ helpers April, 2011 Prepared as part of an education project of the Global Health Education Consortium and collaborating partners

Module overview (Delete this slide when no longer necessary) • Author note: This file provides a PowerPoint template for your module. Duplicate each of the below template forms as necessary and replace the illustrative text and figures with your own content. The template forms are: • Title page • Module goals • List of module sections • Learning objectives • Section content • Case study • Supplementary note • Thought or discussion questions • Special features (voiceovers, video clips, etc.) • Quiz (including several quiz options) • Section or Module summary • Further readings and other resources • Acknowledgements • Credits

Module overview (Delete this slide when no longer necessary) • Formatting. Template defaults are Tahoma 32 font for slide titles and Arial 28, 24, and 20 fonts for lower levels of text. Please use these defaults wherever possible but you may deviate from them in individual slides as appropriate. • Components. If your topic can be logically divided into several major subtopics we suggest that each subtopic have its own learning objectives, content, and if useful, case study, quiz, and/or summary. Some of these components may not be appropriate or would unduly complicate or clutter your module and hence may be omitted or modified to meet you needs.

Module overview (Delete this slide when no longer necessary) • Module submission. Send draft module to Tom Hall (thall@epi.ucsf.edu) and to Glenn Nordehn (gnordehn@gmail.com) for review. Use placeholder slides, inserted immediately before the slides to which they refer, to provide instructions for the use of special eLearning features. Examples of such features are given later in this file. GHEC will initiate the review process and arrange for clarification of any questions that arise. • Processing and posting. On completion of the initial review and revision the module will be sent to an IT specialist for processing your module into the appropriate application platform and then posting on GHEC’s website.

Module features (Delete this slide when no longer necessary) • Your module can accommodate these features: • PowerPoint-like slides with text, graphics and buttons that will take viewers to supplementary notes & resources • Ability to highlight by arrows, circles, colors or other means selected features of any slide • Voiceovers, in which you give audio explanations or commentary of selected slides. Voiceovers allow you to expand on a slide without using a lot of text. • Video and YouTube clips. We can provide you with help in how to add these features • Pop quizzes and end-of-module quizzes that provide answers, feedback and tabulation of correct answers • Links to any URLs on the internet

Module goals(Replaceillustrativetextwithyourowntext) @@. Note toauthors. Thisslide describes theoverallgoalforthe module. Itis more general thanthelearningobjectivesthatfollowfor individual sections. Page 6

List of module sections (Replace template text) • Section 1, • Section 2, • Section 3, • Section 4, • Section 5,

Learning objectives: Section 1 Oncompletingthissectionyouwill be ableto: • Listthe principal causes and riskfactorsaffecting • Describe howthemajorriskfactorsaffectthesefactors • Etc. • Etc. • Note to authors: Prefer active verbs (e.g., list, make, describe, able to…) over passive verbs (understand, know, appreciate…) whenever possible. Keep objectives short and specific. Be sure that these objectives are fully covered in the section and are addressed in the quiz. Page 8

Section content • Note to authors: This and additional inserted slides can be used to provide the content for Section 1

[Add topic title] • [Add content for this topic] • [Present details] • [Give an example] • […] Page 10

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

Nutrition in global health - Overview • Inequities in food distribution  global hunger & starvation • One billion are too hungry to live productive lives - an equal number are adversely affected by overweight! • 6 major deficiencies impact health through the life cycle: water, protein, iron, vitamin A, iodine, folic acid • Childbearing women & their children are hardest hit Meanwhile, overnutrition & inactivity risk of heart disease, osteoporosis, cancer, diabetes, strokes, etc. Page 12

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 will emphasize:Immediate causes - scarcity of specific nutrients Primary and secondary prevention Public health approaches to solutions Page 13 Page 13

Other GHEC modules contribute to our understanding of Nutrition in Global Health • This module does not stand alone. “Roadmap to a world without hunger” will follow (see note) • Two other GHEC modules deal with poverty & hunger • Module 48: Acute malnutrition – Clinical aspects (deals with treatment) • Why is the 3rd world the 3rd world? (underlying and diverse causes of poverty & hunger) http://globalhealthedu.org/resources/Pages/default.aspx To see this module in the context of what will follow, see Note A Note A

Pre-quiz (pending completion of “quiz” feature in GHEC’s server) • As a reality check, and to create “teachable moments” for what follows, we now invite you to take a 5-minute pre-quiz • You will be offered 10 true-or-false questions to dispel some common misconceptions • Some of this misinformation is spread by those who have something to gain from it • After completing the pre-quiz, we hope you will continue this module with greater interest and renewed clarity Page 15

Learning objectives After completing this module you should be able to • Describe the extent of malnutrition & its impact on people of the planet, and understand how MDGs depend on nutrition • Analyze the factors that determine nutritional health • Identifynutritional problems among individuals & populations, identify causes & appropriate solutions • Assess risks at various stages of the life cycle & recommend strategies for diminishing risk • Comparecompeting theories accounting for the inequities • Predictoutcomes by projectingcurrent trends into the future & foresee a pathway toward a world without hunger Page 16

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 17

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

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

The Millennium Development Goals • At a UN Millennium (2002) summit, the nations of the world set eight MDGs to be achieved by 2015 • The world's main development challenges were identified • Specific actions and targets (the MDGs) • A commitment to provide the means was made by 189 nations & signed by 147 heads of state • The MDGs break down into • 21 quantifiable targets • Targets are measured by 60 time-lined indicators Some nations have kept their trust. But some of the richest in the world have announced that they will not meet their commitments

Nutrition & Millennium Development Goals Primary goal is to eradicate extreme poverty & hunger 1 see next 2 slides Nutrition – is a direct prerequisite to goals 1, 3, 4, 5 & 6; indirectly to 2, 7 & 8

Centrality of nutrition to MDGs 1, 2, & 3 1. Eradicate extreme poverty & hunger. Poverty is the main determinant of hunger. In turn, malnutrition irreversibly compromises physical & cognitive development & thus transmits poverty & hunger to future generations. 2. Achieve universal primary education. Malnutrition diminishes the chance that a child will go to school, stay in school, or perform well in school 3. Promote gender equality, empower women. Women’s malnutrition impairs the whole family’s health & nutrition

Centrality of nutrition to MDGs 4, 5, & 6 4. Reduce child mortality. Delivery of a live healthy child is dependent, above all, on a well nourished mother. Protein & folic acid are critical here 5. Improve maternal health. Malnutrition accentuates all major risk factors for maternal mortality, e.g., inadequate protein, iron, iodine, vitamin A & calcium 6. Combat serious infectious diseases. Malnutrition aggravates infections, immune competence, transmission & mortality in HIV, malaria, tuberculosis Adapted from Gillespie and Haddad (2003) http://web.worldbank.org/

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

Nutrition in Global HealthCourse overview Overview of nutrition across humankind Nutrition fundamentals in global context Top six nutrition problems, & their solutions Nutrition across the life cycle in rich & poor nations Cause & effect in population nutrition Overview and where we are now Bridge to Part 2, Roadmap to a world without hunger Page 25

Universal limitations & health consequences • We can’t survive without about 15 essential mineral elements, so they are needed in our diets, most in trace amounts • We can’t manufacture about 15 vitamins, so they must be provided in our diets And in addition……

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 27

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

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

“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 32

Unhelpful misconceptions about aid False: “Most aid money goes into the Swiss bank accounts of corrupt African dictators” “Aid creates dependence & impedes self-sufficiency” “Despite all the aid $, the problems are only getting worse” The truth is: Overwhelmingly African leaders are not corrupt. When they are, most bribes come from the West Well planned aid builds capacity & self-sufficiency Overall, hunger worldwide is diminishing. MDGs go forward because of the countries that honour their pledges! Note E

Money? Useless - no nearby shops • It’s hard to imagine a malnourished community and you may want to experience field conditions in advanceNo commerce! Try it at a Medecins sans Frontieres site:http://www.starvedforattention.org/ • No shops to spend money in, no one to employ anyone, no one to sell things to • Hungry children are all too visible, and those who didn’t survive are in tiny unmarked graves Their needs are much more immediate than money We don’t need studies to learn what they need - read on!

If they don’t need money – what do they need? Note F Short term they likely need emergency rations, safe waterIn conflict zones, shelter & safety to live, plant, harvest Medium term they need to become self-sufficient, with:good seeds, fertilizer, usable water, sanitation, low technology agricultural info & resources, health services, mosquito nets, pharmaceuticals Long term they need the prerequisites of sustainable economic development - tools for development – see Part 2 Kids need particular attention – see note below & later slides Page 35

The goal is to see everyone self-sufficient • People in the poverty trap live from hand to mouth, with no opportunity to put resources aside to build a better future • Such communities cannot access the ladder of economic development without external help. • The MDG promises of 0.7% of rich country GDP for aid was chosen to eliminate extreme poverty & hunger in 3 decades • But there are many nations that failed to meet this goal, including both the US and Canada • Thanks to the nations that keep their promises, widespread hunger may be eliminated, but only after 30-50 years. This not, however, cause for undiluted joy. See Note G. Note G

Some communities subsist in the “poverty trap” • Even among the richest there are some individuals so marginalized that there seems little hope for them The larger culture, if it is compassionate, takes long-term responsibility for ensuring them the necessities of life • Globally there are communities that have been denied the resources to ever become wealthy. Often from geography, climate, invasion, or appropriation of their natural resources Regardless, a world community of compassion can provide the necessities of life, & offer new life to the dispossessed, as North America once opened its doors to the poor Note H

Nutrition in Global HealthCauses, mechanisms, solutionsNutrition is crucial to global health & MDGs Overview of nutrition across humankind Human nutrition fundamentals in global context Top Six nutrition problems, & their solutions Nutrition across the life cycle in rich & poor nations Cause & effect in population nutrition Overview and where we are now Bridge to Part 2, Roadmap to a world without hunger Page 38

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

Dietary patterns across cultures 1. Hunter gatherers – the earliest category Benefits: mixed diet, well nourished in good times Risks: famine or drought, warfare & plunder, resource- depletion through population pressure Prevalent problems: starvation, thirst,  life-expectancy Note I

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 41

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

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

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 44

Nutrition in Global HealthCauses, mechanisms, solutionsNutrition is crucial to global health & MDGs Overview of nutrition across humankind Human nutrition fundamentals in global context Top six nutrition problems & their solutions Nutrition across the life cycle in rich & poor nations Cause & effect in population nutrition Overview and where we are now Bridge to Part 2, Roadmap to a world without hunger Page 45

Top 6 global manifestations of malnutrition We begin with a perspective, then we take each of the 6 in turn • Water is a food (“food” is the material we eat & drink”)In hot climates, we can die in a few hours from a lack of it 2) Protein-energy malnutrition • The machinery of life, sculpted from 20 different amino acids • Deficiency is most serious in children (time of fastest growth): "failure to thrive", stunted growth The material in this section is well reviewed at:http://www.pitt.edu/~super1/lecture/lec0141/index.htm Iron, vitamin A, iodine – check the latest information at:http://www.micronutrient.org/English/view.asp?x=1

Top 6 global manifestations of malnutrition (cont.) • 4) Vitamin A deficiency • Over 100 million children under 5 suffer vitamin A deficiency • In high deficiency areas vit. A tabs child mortality by >20% • & child blindness by 80%. Night-blindness is an early sign 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 47

Top 6 global manifestations of malnutrition (cont.) Note K 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 and Note K lists categories of at risk people across countries Page 48

Top 6 global manifestations of malnutrition (cont.) Page 49 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

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 liters / day & to replace the NaCl lost along with water in sweat http://www.who.int/water_sanitation_health/mdg1/en/index.html

Nutrition in Global Health Context