Which THREE of the following are True?

1. Which THREE of the following are True? TF In the poor nations almost everyone is hungry; in the remainder almost everyone gets an adequate diet TF Worldwide, more people have their lives shortened by overeating than by starvation TF When poor nations now find a place on the ladder of development, they develop slower than rich nations did when they developed TF Most NAmspecialists in global health understand how the distribution of poverty & hunger are changing TF Health & nutrition benefits are possible only after economic development occurs TF People in regions of extreme hunger & poverty desperately need money TF 50% of children in US will, at some time, have to rely on charity for foof? TF Over half of the worlds hungry people live in Africa TF Discovery of rich mineral resources is of great help to the development of an economically stressed nation TF The percentage of people who are hungry gets less and less very year TF Population growth has brought us to where the world cannot produce enough food for everyone

2. Quick answers F In some nations hunger is the norm; in the remainder, an adequate diet is the norm T Worldwide, more people have their lives shortened by overeating than by starvation 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? F Most Canadian specialists in global health understand the how the distribution of poverty and hunger are changing? F Health & nutrition benefits inevitably occurs after economic development rather than before F People in regions of extreme hunger & poverty desperately need money T 49.2% of children in the US are currently so poor that they must rely on charity for their meals?

3. What works & what doesn’t?toward evidence-based solutions Plan to spend 2-3 hours reviewing web info “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) http://www.sfu.ca/global-nutrition

4. 1 billion hungry (800m); 1 billion overweight Experts are living in the past Nothing in texts Minefield

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. Page 5

6. Global Nutrition The ugly Where are we now? Stuffed & starved We keep doing whatwe knowdoesn’t work? The bad How did we get here? The good It wasn’t an accident Can anything help? Yes We are part of the problem We know what works Where are we headed? We have a roadmap to a world without hunger Most of you will see hunger in museums!

7. Overview of Nutrition in Global Health • Malnutrition and MDGs: cause, effect & cure3 • 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

8. Preface: Nutrition is crucial to global health • Among the immediately modifiable factors that affect individual & public health … nutrition is of prime importance • Nutrition at every stage of life lays a foundation for health in the ensuing stage • For all nations, rich & poor, nutrition determines physical health & development through the life-cycle, including: • Success in childbearing, cognitive function, socio-economic independence, education, disease resistance & employability • Health & economic development are contingent on provision of adequate food, nutritional resources & support

9. 3 Critical periods: nutrition in the life-cycle 4 slides: • Perinatal nutrition: 0-6 mo: Breast vs. formula1st 5 y Weaning & infancy –intellectual develop • School years; ability to learn • Work performance • Elderly

10. 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. A click on the note button takes viewer to the note Note button

11. Nutrition through the life-cycle

12. 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 beforeconception!

13. 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 13

14. 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

15. 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

16. 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 16

17. 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.

18. 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 18

19. 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 19

20. 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.

21. 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.

22. 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 22

23. 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

24. 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 24

25. 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”.

26. 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 26

27. 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

28. 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 28

29. 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%

30. 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 30

31. 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

32. 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 32

33. 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 33

34. 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

35. 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

36. 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 36

37. 5 Nutrition & disease cause vs effect 4 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

38. 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

39. 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

40. 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 23 % • & 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 40

41. Top 6 global manifestations of malnutrition (cont.) For categories of at risk people across countries, see 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 Page 41

42. Top 6 global manifestations of malnutrition (cont.) Page 42 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

43. Water: one of our most important foods • Adequate safe water is most important dietary component • 9 million worldwide have water-borne diseases • In India, contaminated water kills 300,000 children annually • Problems relating to water supply & safety have simple, relatively inexpensive solutions • Water “ownership” is, however, contentious & usually follows military power (e.g. in Middle East) • In hot humid conditions workers may need over 5 l / day & also need to replace the NaCl lost along with water in sweat http://www.who.int/water_sanitation_health/mdg1/en/index.html

44. The special importance of proteins • Proteins are the machinery of life. We have no storage form. If we must use our protein “stores”, our tissues lose function • Plasma, liver and kidney lose function first. Their proteins are the most “labile”. Then, digestive tract, muscle & heart • Proteins are made up of 20 amino acids. 12 are non-essential – they can be made from other dietary components • 8 amino acids are “essential”. If even one is missing, no protein can be synthesized. A protein lacking any one essential amino acid has zero “biological value

45. Dietary deficiency of proteins is deadly • When any essential amino acid is missing, all the rest are burned & no protein synthesis can occur – zero! • All essential 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

46. Humans adapt to low protein intakes ... • ... otherwise impact of protein deficiency would be even higher • Endocrine changes improve the recycling of proteins. As tissues repair, the released amino acids are reused more efficiently • In the African presentation of kwashiorkor, a child is exposed to a protein deficient diet (age 1 to 5) & adapts successfully • Then a 1-week lack of protein (parent loses job, baby is fed glucose-water only, or a gastro-intestinal infection)  kwash • Child is treated for kwash, sent back to the home to same diet, & reaches adolescence, usually without recurrence.

47. Protein & energy nutrition are inseparable • When the diet lacks carbohydrates, it uses some amino acids to make glucose for brain, muscle, etc. • When a diet lacks total calories, proteins are co-opted, first dietary, then plasma, liver, kidney, etc. • For these reasons, a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed. • Google “protein-sparing effects of carbohydrates” if you want to understand this further Page 47

48. Protein-energy malnutrition - in adults • Tissues are raided, with the following consequences: • Loss of plasma proteins  oedema* • Loss of liver & kidney function diminished inactivation & excretion of carcinogens and toxins • Loss of immune function gastro-intestinal infections • Loss of digestive tract / liver function amino acids 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

49. Hungry kids – difficulties in diagnosis • Marasmic babies may not seem undernourished until a check for “pitting oedema” reveals that what appear to be strong arms and legs, are in reality oedematous • Another diagnostic complication is that most deficiencies are combined, as in protein energy malnutrition “PEM” with multiple vitamin deficiencies • The distinctions are crucial both in determining treatment, and in determining if the underlying problem in the community is scarcity of food, a protein, or many nutrients Page 49

50. Protein malnutrition is different • In uncomplicated kwashiorkor, only protein is lacking - “Malnourished, not undernourished” • The risk of death or permanently retarded development is great, and the risk is increased because its easier to miss the diagnosis • Kwashiorkor babies may have more than adequate calories in their diets. They may be chubby, with substantial subcutaneous fat • Kwashiorkor may go unnoticed even when urgent hospitalization is needed, or when death is imminent