Module 41A Nutrition in Global Health

1. Module 41A Nutrition in Global Health Part 1: 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 January 2011 Prepared as part of an education project of the Global Health Education Consortium & collaborating partners

2. Nutrition in global health - Overview • Inequities in food distribution  global hunger & starvation • A 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 2

3. 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 3 Page 3

4. Other GHEC modules contribute to our understanding of Nutrition in Global Health • This module Part 1 does not stand alone. Part 2 “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 3rdworld? (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

5. Pre-quiz • 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 • [[LINK TO THE PRE-QUIZ HERE]] Page 5

6. Learning objectives After completing this module you should be able to • Describe the extent of malnutrition & its impact on people of the planet, 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 6

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 will 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 slides & resources in your information / teaching sessions Page 7

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. 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

10. 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 • 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

11. 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 7 & 8

12. 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

13. 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. NB 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/

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

15. 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 15

16. 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……

17. 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 17

18. 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

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

20. 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

21. “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 these 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

22. “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 22

23. 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

24. Money? Useless - no nearby shops • It’s hard to imagine a malnourished community and you may want to experience field conditions in advance No 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!

25. 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 25

26. The goal is to see everyone self-sufficient, • Peoples 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 some nations whose promises mean little. Long before 2008, US & Canada “changed their minds” • Thanks to the nations that keep their promises, widespread hunger will be eliminated, but only after 30-50 years This is not, however, cause for undiluted joy. See Note g

27. 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

28. 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 28

29. 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

30. 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

31. 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 31

32. 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

33. 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

34. 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 34

35. 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 35

36. 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

37. 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 37

38. Top 6 global manifestations of malnutrition (cont) For of 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 ensuing slides Page 38

39. Top 6 global manifestations of malnutrition (cont) Page 39 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

40. Water: one of our most important foods • Adequate safe water is the 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

41. 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 one is missing, no protein can be synthesized. A protein lacking any 1 has “biological value”=0

42. 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 1d later is useless • A diet previously adequate in essential amino acids becomes inadequate if non-essential amino acids are removed. • Although the body can make missing non-essential aa, it has to use essential amino acids to do so • Protein complementarity, de-emphasized in nutrition courses, can be vital where protein intake is compromised

43. 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 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 same diet & reaches adolescence, usually without recurrence.

44. 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” if you want to understand this further Page 44

45. 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

46. 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, also in determining if the underlying problem in the community is scarcity of food, a protein, or many nutrients Page 46

47. 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 • Kwash babies may have more than adequate calories in their diets. They may be chubby, with substantial subcutaneous fat, • Kwash may go unnoticed even when urgent hospitalization is needed, or when death is imminent

48. Protein malnutrition: diagnosis When 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 first symptom noticed by parents or aid workers is often diarrhoea. • The child may be treated for a gastrointestinal infection while the underlying cause, kwash, goes undiagnosed • Oedema is an early symptom, and may be mistaken for chubby limbs, so test where nutrition may be compromised

49. 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. 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 49

50. 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 (ie usually) Note l