Quick quiz – two of the following are T

1. Quick quiz – two of the following are T 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 enjoyed their phase of development? TF Most Canadian specialists 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 the US are currently so poor that they must rely on charity for their meals?

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 50% 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 Slides & practice questions (see web) 1. The 50% (actually 49.2%) is US children that will require food-aid some time during childhood 2. Pct % of people hungry is declining over years 3. Plan to spend 2-3 hours reviewing web info 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)

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

7. 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!

8. 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

9. 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

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 prevention Public health approaches to solutions Page 10 Page 10

11. World% undernourished 22% same data 14%

12. Prediction millions Number fed & under-nourished worldwide Target 33% 14% 11% 6% 12 12

13. A vicious cycle for malnutritionpoverty, health, economic deprivation Poverty: Diminished access to agricultural & food resources  malnutrition high birth rate Health: Physical & cognitive impairment, susceptibility to disease, early death  inability to earn an income nutrition Development: Marginalization  inability to provide for self or family Access to the ladder of development

14. Routes to famine Lesotho Being landlocked ... So.AfricaNigeria, Iraq Discovering resources Being on a trade or pipeline route ... Israel, Afghanistan Bad governance ... Zimbabwe [USA] Externally initiated armed conflict … Sudan, Afghanistan Uncertain rainfall & drought ... Sahel, Palestine Blaming the bonsai tree... Yunus:

15. 1 Malnutrition & MDGs: cause, effect, cure 3 slides: • Trends in nutrition, food security & globalization • Agricultural trends • Nutritional inequities - Cause & consequence • Food security; Prospects for having enough food

16. Paying for total strangers to eat? } Not us, not if it goes to corruptdictators”  16

17. “Development aid”, not spent on poverty or development Clawed back by unfair trade Emergency aid Debt relief Refugee, Tied to benefit rich “Phantom aid”, the wasted 47% Refers to ODA, notMDGs http://www.globalissues.org/article/35/foreign-aid-development-assistance#GovernmentsCuttingBackonPromisedResponsibilities

18. 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

19. Primary goal is to eradicate extreme poverty & hunger Nutrition & Millennium Development Goals  Gender equity Empower ♀ see next 2 slides Achieve universalprimary education 1 HIV, malaria, other diseases  Child mortality  Environmentalsustainability Global partnershipfor development Nutrition – direct prerequisite to goals 1, 3, 4, 5 & 6; indirectly to 7 & 8  maternalhealth

20. 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

21. 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/

22. 2 Categories & measures of nutritional status 4 slides: • Malnutrition, undernutrition, • Overnutrition / Overweight, Obesity • Energy requirements: calories, carboh, proteins, fats • macronutrients, micronutrients

23. 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

24. Worldwide distribution of malnutrition Over 20 million children suffer from acute malnutrition WHO. Scientific American, Sept 2007

25. 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

26. “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

27. “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.htmlhttp://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.htmlhttp://www.who.int/mediacentre/factsheets/fs290/en/index.html http://www.fao.org/mdg/en/ http://www.un.org/millenniumgoals/reports.shtml#mdgs

30. Percentage stunted http://www.unicef.org/media/files/Tracking_Progress_on_Child_and_Maternal_Nutrition_EN_110309.pdf 60% http://ije.oxfordjournals.org/content/32/4/518.full.pdf Africa Asia 40% Latin Am 20% 1980 & every 5 years Last 2 or 3 points are projections

31. 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

32. 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

33. Nutrition through the life-cycle

34. 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!

35. 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 35

36. 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

37. 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

38. 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

39. 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.

40. 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

41. 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

42. 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.

43. 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.

44. 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

45. 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

46. 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

47. 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”.

48. 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

49. 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

50. 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