Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium & collaborating partners
Allan J Davison PhD, Professor, Biochemist,Faculty of Sciences, Simon Fraser University
Department of Biomedical Sciences & KinesiologyJune 2011
Roadmap to the world’s nutritional health:Causes, mechanisms, solutions
Page 2
Objectives for Global Nutrition Module
1.The extent & impact of severe malnutrition: global inequities2.The most serious nutritional problems: prevention & treatment3.Local &global causes of inequities in nutritional health4.Malnutrition: risks through the life cycle: major population groups5.Initiatives toward making hunger history: MDG1 & beyond6.Toolkit for a field workers where nutritional deficiencies occur
After completing this module you should be able to conceptualize:
Section break 1
1. Malnutrition: prevalence, causes, consequences 42. Major categories & measures of nutritional status4 3. Nutrition & crucial periods in the life-cycle; 4 4. Determinants of nutrition, dietary patterns & culture2 5. Nutrition and its relationship to disease4 6. Making hunger history - breaking the poverty-trap 37.Trends in nutrition, food security & globalization38. Nutritional considerations for the field practitioner
Page 3
Page 4Page 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 risk of heart disease, cancer, strokes, osteoporosis, & diabetes everywhere
Progress: Globally more are fed every year, meanwhile millions die unnecessarily
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
Prequiz here!
To get the most out of this moduleIf 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
• 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
You may want to …
Preface: Nutrition is crucial to global health
• Among immediately modifiable factors that affect health … nutrition is of prime importance
• At every age nutrition is a foundation for what 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
Page 8
Essential components of the diet• 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
Page 9
Universal limitations & health consequences
In addition: We lost key metabolic abilities our evolutionary ancestors had. Thus we are vulnerable to 2 dietary risks:
1) 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
Note B
Nutritional status is assessed as one of four categories 1. Good nutritional status: All nutrients (right quantities, time & place)
allow optimal, growth, maintenance, & reproduction
2. Overnutrition: An excess of a nutrients (usually calories) is being consumed, so that health is negatively impacted
3. 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"
4. Malnutrition: Energy consumption is adequate, but there is an imbalance among constituents of the diet and health is impacted
Page 11
Note C
Categories of nutritional status
Healthy diet
Optimal health: physical & mental development
reproduction, survival
Absence of disease
... food& water
... healthservicesAccess to ... ... peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography, stability, climateabsence of conflict, natural resources
access to markets, etc
Education NB women
# of mouths to be fed
Foundations of good nutritional status
The “poverty trap”• 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
Page 13
Note H
Making hunger history: hope & impatience• 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
Page 14
Note G
A vicious cycle: economics, hunger, health
Page 15
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural &
food resources malnutrition
Physical & cognitive impairment,
susceptibility to disease, early death
inability to earn an income
nutrition
When the only tool you have is a hammer … every problem becomes a
nail
Page 16
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
Malnutrition: “spatial & temporal myopia” sees proximate, not ultimate causes
Routes to famineHaving resources
Externally initiated armed conflict
Uncertain rainfall & drought
Being landlocked
Bad governance
Israel, Afghanistan
Lesotho
or being on a trade or pipeline route
Zimbabwe, Italy, USA
Dafur, Afghanistan
Sahel, Palestine
Blaming the bonsai tree... Yunus:
So.Africa Nigeria, Iraq
To learn about the “Resource Trap” read or google Paul Collier
Sometimes to overthrow a populist government (Allende, Aristide) and install a puppet, or bribable government
The astonishing background to hunger – a world growing spectacularly rich
Page 18
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.
Because the flow of wealth is overwhelmingly from the poor to the rich, & the rich are able to keep it that way
Yet …
Why?
BanKi Moon
Wor
ld G
DP
$PPP
per
cap
(e
st)
1500
-210
0
1500 2000$0
$5,000
$10,000
India to 1500
China + Indiato 1850
WesternEuropeto 1945
USA + WestEurope
since 1945
http://ers.usda.gov/Data/Macroeconomics/
“Manifest destiny” of world - wealth
China +India 2040?
19
Eliminating hunger may be the main requirement for a world at
peace
Page 20
MDG 1 is elimination of extreme poverty and hunger, most if not all the others depend on this, the primary, one
In the following vicious circle, note how malnutrition, ill health, & poverty exacerbate each other
Food is a primary human drive. Lack → social instability
Health & economic development depend on nutrition
GW Bush
We know in detail the causes of hunger & how to eliminate it
Page 21
the “poverty trap” the “resource trap”
Unfettered free trade favours the powerful Trickledown is overpowered by a torrent of wealth in the other direction
We will assume you know the mechanisms in
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
Section break 2
1.Malnutrition: prevalence, causes, consequences 42.Categories & measures of nutritional status4 3.Nutrition & crucial periods in the life-cycle; 4 4.Determinants of nutrition, dietary patterns & culture2 5.Nutrition and its relationship to disease4 6.Making hunger history - breaking the poverty-trap 37.Trends in nutrition, food security & globalization3
Page 22
Human Nutrition Fundamentals in Global Context
Page 23
The next 4 sections 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
Page 24
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 25
Dietary patterns across cultures3. Indigent, landless crop plantersBenefits: 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
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
Dietary patterns across cultures5. 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
Note J
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
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
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
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
Section break 3
1.Malnutrition: prevalence, causes, consequences 42.Major categories & measures of nutritional status4 3.Nutrition & crucial periods in the life-cycle; 4 4.Determinants of nutrition, dietary patterns & culture2 5.Nutrition and its relationship to disease4 6.Making hunger history - breaking the poverty-trap 37.Trends in nutrition, food security & globalization3
Page 33
Critical periods: nutrition in the life-cycle1. Perinatal nutrition: 0-6 mo: Breast vs. formula2. 1st 5 y Weaning & infancy –intellectual develop3. School years; ability to learn4. Work performance5. Elderly
Page 34
Overview of nutrition through the life-cycle
Page 35
Stage Risks associated with malnutrition Prenatal & (pregnancy)
birth defects, birth weight, breast feeding protects against infant mortality, high maternal death rate
Infancy & early life
cognitive & physical delays, bone malformation blindness, impaired immune response, risk of infections, faster progress of HIV, in protein-energy malnutrition, early death from causes the well-nourished would survive
Adolescence & adult life
risk of infection, anemia, diabetes, problems with heart, lungs, vision, risk of all cancers, anemia, blindness, beriberi, pellagra This stage of life lays a foundation for good or ill health in old age, osteoporosis, greatly diminished life-expectancy
Old age few chronically malnourished persons survive to old age. Those who survive poor lifestyle and nutrition, often endure a very low quality of life
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 before conception!
Page 36
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.htm http://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
Perinatal nutrition requires attention•Malnutrition in pregnancybirth 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
Page 38
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
Page 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.
Page 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 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 42
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.
Page 43
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.
Page 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 45
Opportunities in adult life for mitigation of upcoming cardiorespiratory risks
Page 46
Prevention is better than cureThese risks are becoming epidemic in poor as well as rich countries
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
Page 47
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
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%
Page 49
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
Nutrition in later life and old age•Worldwide, the proportion of people > 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 diseases of late life are diagnosed too late for effective treatment. Prevention at an early age is ideal
Page 51
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 52
Section Break 5
1.Malnutrition: prevalence, causes, consequences 42.Major categories & measures of nutritional status4 3.Nutrition & crucial periods in the life-cycle; 4 4.Determinants of nutrition, dietary patterns & culture2 5.Nutrition and its relationship to disease4 6.Making hunger history - breaking the poverty-trap 37.Trends in nutrition, food security & globalization3
Page 53
Page 54
• Slides 60 – 62 seem out of place in this section; this is not directly addressing nutrition and its relationship to disease; section 5 should start with slide 63
5 Nutrition & disease cause vs effect• Causes – poverty is the primary cause of malnutrition• Acute and chronic undernutrition; • 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
Page 55
Top 6 global manifestations of malnutrition
1) 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 growthPage 56
We begin with a perspective, then we take each of the 6 in turn
The material in this section is well reviewed at: http://www.pitt.edu/~super1/lecture/lec0141/index.htmIron, vitamin A, iodine – check the latest information at: http://www.micronutrient.org/English/view.asp?x=1
Top 6 global manifestations of malnutrition (cont.)
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 57
4) Vitamin A deficiencyOver 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
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 58
Top 6 global manifestations of malnutrition (cont.)
Note K
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
Page 59
Top 6 global manifestations of malnutrition (cont.)
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
Page 60
http://www.who.int/water_sanitation_health/mdg1/en/index.html
Water– the importance of sodium
Page 61
In hot working environments, everyone may need salt supplements in order to retain their body water
Too much salt can cause dehydration, and cows milk has too much salt for baby kidneysDilute it and it doesn’t have enough energy
The special importance of proteins
Page 62
• Proteins are the machinery of life. We have no storage form. If we must use protein “stores”, 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 and 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
Dietary deficiency of proteins is deadly
Page 63
• 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
Humans adapt to low protein intakes ...
Page 64
... 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
•Then a 1-week lack of protein (parent loses job, baby is fed glucose-water only, or a gastro-intestinal infection) kwash
• In the So African presentation of kwashiorkor, a child is exposed to a protein deficiency crisis (ages 2 to 5) is treated for kwash, sent back to home to previous diet, catches up on growth charts, reaches adolescence without recurrence.
• Early or prolonged Kwash delays in physical and cognitive development become irreversible
Protein & energy nutrition are inseparable
Page 65
• 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.
• Better said, an amount of milk that provides enough protein in a calorically adequate diet, may be insufficient to meet protein needs in a calorie limited diet
• Do an internet search on “protein-sparing effects of carbohydrates” if you want to understand this further
Protein-energy malnutrition - in adults
Page 66
Tissues are raided, with the following consequences:
• Loss of plasma proteins oedema*
• Loss of liver & kidney function diminished inactivation & excretion of carcinogens and toxins
• Infertility in men and women
• 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
Hungry kids – difficulties in diagnosis
Page 67
• 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 68
• 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
Protein malnutrition is different
Protein malnutrition: diagnosisWhen 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 1st symptom to present is often diarrhoea, or oedema
• The child may be treated for a gastrointestinal infection while the underlying cause, kwashiorkor, goes undiagnosed
• Oedema is an early symptom, and may be mistaken for chubby limbs, so test if nutrition may be compromised
Page 69
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. They 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 70
What saves lives after PEM diagnosis• Treatment is urgent - hospitalization is preferred• Oral rehydration solutes “ORS” have saved
millions with diarrhoea (usually the case) • Ready-to-use foods “RTUF” rebuild wasted tissues• Delayed physical growth is often restored in catch-
up growth when a good diet is provided• Prolonged cognitive disabilities may be irreversible
Page 71
Note L
Early measures required on PEM diagnosis
• Both RTUF and ORS can be given at home in a bottle (Wikipedia). World production of ORS is around 500 million sachets / year. Improvisation of ORS is described at http://rehydrate.org/ors/made-at-home.htm#recipes
• Powdered milk protein in boiled water can be very helpful as an emergency measure
• Acute fatality rate IS 10-25% even with prompt treatment
Page 72
Iron deficiency affects 500 million globally
• Iron deficiency is best diagnosed in the preclinical stage, by measurement of transferrin saturation
•Females > males due to iron loss at menstruation -- >50% of pregnant women are affected in the developing world – 3 times as many as in developed countries
•25% of men also are deficient in iron in the developing world
Page 73
Iron deficiency affects 500 million globally
• Causes: insufficient availability of dietary iron, or increased iron requirements to meet reproductive demands, haemmorhage, parasitic infections (often concurrently).
• The result is an increasingly severe anaemia, reduced work productivity → poverty, diminished learning ability, increased susceptibility to infection
For more on consequences of iron deficiency, see …
Page 74
Note M
http://www.micronutrient.org/English/view.asp?x=579
Treatment of iron deficiency: rebuilding iron reserves
• Iron tablets are effective within weeks, but non-compliance is common. Check compliance!
• Increase iron intake through combining iron-rich foods with agents that iron absorption (vit C)
• Encourage availability & use of iron-fortified foods
Page 75
Treatment of iron deficiency: rebuilding iron reserves
•Weekly / daily supplementation is recommended for vulnerable groups in areas with widespread iron deficiency
•Treat causes of diminished iron reserves: haemorrhage, parasites (including malaria), and hemolytic conditions.
•Be alert! Iron may be lethal in some inherited anaemias (thalassemias, sickle cell, or Hb M) common in Africa & Asia
Page 76
Iron excess - dangerous to some
Page 77
• Those with haemolytic anaemias: (eg thalassaemia – common in people of African or Asian descent). Iron should not be prescribed until the cause of an anaemia is known
• Where iron pots are used for cooking or beer: Siderosis: iron deposition in liver, kidney, heart, pancreas organ failure
• Children: Parents' iron pills are attractive to kids in developed countries. The most common of fatal childhood poisonings
• Those with familial haemochromatosis: This common inherited disease has symptoms similar to siderosis (above)The first sign of this disease is often inoperable liver cancer
Note N
Vitamin A deficiency in public health• Vit. A deficiency is a public health problem in over
70 countries, especially in Africa, SE Asia & the W Pacific where it affects 250 million mostly aged 0-4 years
• Night blindness may predict vitamin A deficiency, with risk of permanent total blindness if it progresses
• There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
• Vitamin A supplements can be beneficial when given as seldom as once a year. Check the latest information at:
http://www.micronutrient.org/english/View.asp?x=577
Page 78
Vitamin A deficiency & perinatal health
• Vit. A is crucial for maternal & child survival, supplements in high-risk areas can dramatically decrease maternal mortality*
• In pregnant women Vit. A deficiency is seen in the last trimester when demands by unborn child & mother are highest
• Partnerships for progress in vitamin A nutritionIn 1998 WHO, UNICEF, CIDA, USAID (ia) launched a global initiative in 40 countries that has to date averted 1.25 million deaths, by giving vitamin A to kids at clinics Page 79
*This issue is under active investigation. For the status at time of writing see Lancet, Volume 376, Issue 9744, p 873 - 874, 11 September 2010
Vitamin A deficiency & perinatal health
• Night blindness in pregnant women - an early danger sign• In children, the cost-effective prevention is breast-feeding• Genetically engineered high Vit. A rice crops could help
Caution: Vit. A supplements as retinol are controversial. It can be toxic & teratogenic ( birth defects). However, given as carotene, vitamin A supplements are safe, leading only to an orange tinge in skin colour.
Page 80
Iodine deficiency disorders
• The world’s major cause of preventable brain damageIn 1990: 1.6 billion people were at risk in >100 countries, mainly in parts of Africa &Asia where soil is iodine-deficient
• 38 Million children have mental impairment from lack of iodine
• As a result of the micronutrient initiative, this number is falling
Page 81
For latest data, see: http://www.micronutrient.org/english/View.asp?x=578
Iodine deficiency disorders • Consequences start before birth and continue afterward
– In utero, spontaneous abortion, congenital abnormalities & retarded foetal development
– In early childhood and progress toward adolescence iodine deficiency causes cretinism, an irreversible retardation. Impacts home, school, & work
– Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox & polio
Page 82
Toward iodine sufficiency – iodized salt• A cost-effective low-tech therapy, iodized salt costs just $0.05
per person per year• UNICEF, ICCIDD (International Council for Control of IDD),
& the salt industry have set up iodization programmes.Globally, 66% of households have access to iodized salt.
• As of 2009 the number of at risk countries has been halved!• However, progress has slowed and we are behind targets set
by the international community. • 54 countries are still affected – efforts continue
Page 83
Wrapup elements here. Quite a few more slides! But little additional content
Page 84
Proximate and ultimate causes
Page 85
One can give a pill with the missing nutrient and see a child recover
Why is this not the long term solution?
What’s the equivalent of teaching someone to fish?
What are the causes outside the control of the person, community?
How do we address these?
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
Page 86
Note H
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!Page 87
If they don’t need money – what do they need?
• 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 88
Note F
Optimistic, and impatient to the point of indignation
Page 89
If you’re not convinced of the urgency go to http://www.starvedforattention.org/
Take home message• Catastrophic inequities in distribution of
nutrients
• Kinds of nutritional status & health impact
We’ve faced causes, know there are curesAs we face the future we are ...
Especially water, protein, iron, vitamin A, iodine
Not by accident? Who’s responsible? What’s neededperinatal - women and children
not just across nations – increasingly within
and impatient Optimistic
Appendix: Nutrition skill-set for the practitioner in fragile health
regions
Page 91
For those who can see a need in the future for more specific skill-setthe module provides enrichment material For those who may find themselves the first line of defense for a community that is experiencing obvious health issues – sudden increase in infant deathsKnow what to look for when there’s a need to call in help (deleted material)Know your limitations. Often the community isn’t asked when experts are doing a needs assessment. We don’t need an expert, ask us, we’ll tell you the problemKnow what information you already have Provide referrals, and core information on nutrition to a community that needs. to make the best of the nutritional, hygiene, and PH resources availableThe importance of agriculture and agricultural resourcesKnow where and how to call in help, and what they need to make an informed decision
Page 92
Enrichment objectives (Skill-set) for those who encounter extreme poverty and hunger and would like to feel less helpless) links to source material that may help1 Know what to look for in a community that's experiencing obvious health issues – sudden increase in infant deaths2 Know when, where, and how to call in help (a checklist on what the public health or emergency aid authorities will need to make an informed decision)3 Know your limitations and strengths. be aware of resources rtuf, ors; know what you’re preparing forKnow what information you already have enough to give referrals, and core information to a malnourished community that needs to make the best of the food, hygiene, agricultural and maternity/PH resources available4 Recognize the need for agricultural measures that the community may find useful. Be able to communicate the importance of agriculture and point the way to practical resources and advice. Be careful not to convey any impression that you know more about seeds, or farming techniques than those who've been farming this soil for decades and have tried everything they can think of. Soil conservation, drought mitigation measures, appropriate agricultural technology, and persons from their own language group who can convey the evidence for what is working worldwide. Pictures (web or paper) of new low tech innovation that demonstrate the consist increase in yield.
Page 93
Have big ears and a tiny mouth. Often the community isn’t asked when experts are doing a needs assessment. We don’t need an expert, ask us, we’ll tell you the problemIf you don't know the pros and cons of DDT, genetically modified seeds, globalization, chemical fertilizers, from the perspective of the poor, don't discredit yourself or get involved in contentious debates which you will lose. Instead, use the wisdom of Muhammad Yunus and say: "To the extent this helps diminish hunger and poverty among your people, I support it". Stick with contour ploughing, drip irrigation, crop rotation, drought resistant crops and seeds. Know what to expect: http://www.starvedforattention.org/
General guidelines for someone who would like to be an agent of change in mitigating inequities (from Vic Neufeld)about 2 pages
