Nutrition in Global Health
Roadmap to the world’s nutritional health:
Causes, mechanisms, solutions
Allan J Davison PhD, Professor, Biochemist,
Faculty of Sciences, Simon Fraser University
Department of Biomedical Sciences & Kinesiology
June 2011
Prepared as part of an education project of the
Global Health Education Consortium & collaborating partners
Objectives for Global Nutrition Module
After completing this module you should be able to conceptualize:
1.The extent & impact of severe malnutrition: global inequities
2.The most serious nutritional problems: prevention & treatment
3.Local &global causes of inequities in nutritional health
4.Malnutrition: risks through the life cycle: major population groups
5.Initiatives toward making hunger history: MDG1 & beyond
6.Toolkit for a field workers where nutritional deficiencies occur
Page 2
Section break 1
1. Malnutrition: prevalence, causes, consequences 4
2. 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 3
7.Trends in nutrition, food security & globalization3
8. Nutritional considerations for the field practitioner
Page 3
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
Page 4
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 module
If you are…..
• a nutritionist or student
of nutrition
• a student of one of the
health professions
• planning a project in
regions with severe
nutritional problems
• a public health
practitioner
You may want to …
• Pay attention to global & public health
& policy implications.
• Pay attention to perspectives &
realities in desperate situations
• Emphasize check-lists to prepare for
field work & gather information to
recommend/advocate for intervention
• Use these slides & resources in your
information / teaching sessions
Page 7
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
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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
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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
Note B
Page 10
Categories of nutritional status
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
Note C
Page 11
Foundations of good nutritional status
Optimal health:
physical & mental development
reproduction, survival
Good nutritional status
Precursors
Absence of disease
Healthy diet
... food
& water
Access to ...
... perinatalcare
... health
services
# of mouths
to be fed
Foundations
Education
NB women
Geography, stability, climate
absence of conflict, natural resources
access to markets, etc
Agricultural
productivity
Economic
development
Infrastructure
non-exploitive investment
intellectual property
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 allNote H
Page 13
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
Note G
Page 14
A vicious cycle: economics, hunger, health
Poverty  diminished
access to agricultural &
food resources 
malnutrition
nutrition
Physical & cognitive
impairment,
susceptibility to
disease, early death 
inability to earn an
income
Economic
marginalization
 inability to
provide for self or
family
Page 15
When the only tool you have is a hammer
… every problem becomes a nail
Malnutrition: “spatial & temporal myopia” sees proximate, not ultimate causes
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
Page 16
Routes to famine
Being landlocked
Lesotho
Having resources So.Africa Nigeria, Iraq
or being on a trade or pipeline route Israel, Afghanistan
Bad governance
To learn about the “Resource Trap”
read or google Paul Collier
Zimbabwe, Italy, USA
Externally initiated armed conflict
Dafur,
Afghanistan
Sometimes to overthrow a populist government
(Allende, Aristide) and install a puppet, or bribable government
Uncertain rainfall & drought
Sahel, Palestine
Blaming the bonsai tree...
Yunus:
The astonishing background to hunger –
a world growing spectacularly rich
Next slide shows century by century growth in GDP per capita
For half a century we’ve had enough food to nourish everyone
Yet …
Why?
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
BanKi Moon
Page 18
World GDP $PPP per cap
(est) 1500-2100
“Manifest destiny” of world - wealth
1
$10,000
China +
India 2040?
USA + West
Europe
Western
Europe
$5,000
China + India
India to 1500
$0
1500
2000
http://ers.usda.gov/Data/Macroeconomics/
Eliminating hunger may be the main
requirement for a world at peace
Food is a primary human drive. Lack → social instability
GW Bush
Health & economic development depend on nutrition
In the following vicious circle, note how malnutrition, ill health,
& poverty exacerbate each other
MDG 1 is elimination of extreme poverty and hunger,
most if not all the others depend on this, the primary, one
Page 20
We know in detail the causes of
hunger & how to eliminate it
We will assume you know the mechanisms in
the “poverty trap”
the “resource trap”
Unfettered free trade favours the powerful
Trickledown is overpowered by a torrent of wealth in the other direction
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 of
food, nor are they an accident. You must see “starve” as a transitive verb to
understand the link between extreme wealth and extreme poverty
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Section break 2
1.Malnutrition: prevalence, causes, consequences 4
2.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 3
7.Trends in nutrition, food security & globalization3
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Human Nutrition Fundamentals in Global Context
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
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Dietary patterns across cultures
1. Hunter gatherers – the earliest category
Benefits: mixed diet, well nourished in good times
Risks: famine or drought, warfare & plunder,
resourcedepletion through population pressure
Prevalent problems: starvation, thirst,  lifeexpectancy
Note I
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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 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, soilexhaustion, 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 ofPage 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,
Page 27
Dietary patterns across cultures
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 adults
diabetes (carbohydrates), cholesterol, atheroma (lipid),
strokes, heart disease diabetes, gout (uric acid - meat
sources)
Note J
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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
Page 29
countries as in North America and the European
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 underexercising 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
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…..
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Section break 3
1.Malnutrition: prevalence, causes, consequences 4
2.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 3
7.Trends in nutrition, food security & globalization3
Page 33
Critical periods: nutrition in the life-cycle
1.
2.
3.
4.
5.
Perinatal nutrition: 0-6 mo: Breast vs. formula
1st 5 y Weaning & infancy –intellectual develop
School years; ability to learn
Work performance
Elderly
Page 34
Overview of nutrition through the life-cycle
Stage
Risks associated with malnutrition
birth defects, birth weight, breast feeding protects against infant
mortality, high maternal death rate
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 risk of infection, anemia, diabetes, problems with heart, lungs, vision,
& adult life 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
Prenatal &
(pregnancy)
Infancy &
early life
Page 35
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/jcco
m/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, breastfeeding should be initiated within an hour of birth & maintained exclusively
for 6 months.
• Breastfeeding could prevent 1.3 million deaths each year
http://www2.unicef.org/nutrition/index_22657.html
•
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Perinatal nutrition requires attention
•Malnutrition in pregnancybirth 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 disorders
beriberi, 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 cancerrelated 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
Prevention is better than cure
These risks are becoming epidemic in poor as well as rich countries
Page 46
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 of
diabetes, 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 4
2.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 3
7.Trends in nutrition, food security & globalization3
Page 53
•
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
Page 54
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
We begin with a perspective, then we take each of the 6 in turn
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
The material in this section is well reviewed at:
http://www.pitt.edu/~super1/lecture/lec0141/index.htm
amino acids
Iron, vitamin A, iodine – check the latest information at:
http://www.micronutrient.org/English/view.asp?x=1
• Deficiency
is most serious in children (time of fastest
growth):  "failure to thrive", stunted growth Page 56
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
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
Page 57
Top 6 global manifestations of malnutrition (cont.)
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
Note K
Page 58
Top 6 global manifestations of malnutrition (cont.)
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
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
Page 60
Water– the importance of sodium
In hot working environments, everyone may need salt supplements in order to retain
Too much salt can cause dehydration, and cows milk has too much salt for baby kidneys
Dilute it and it doesn’t have enough energy
Page 61
The special importance of proteins
• 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 nonessential 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
Page 62
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
Page 63
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
•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
Page 64
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.
• 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
Page 65
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
• 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
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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
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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
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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 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
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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
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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 catchup growth when a good diet is provided
• Prolonged cognitive disabilities may be irreversible
Note L
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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
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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
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Iron deficiency affects 500 million globally
http://www.micronutrient.org/English/view.asp?x=579
• 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 …
Note M
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Treatment of iron deficiency:
rebuilding iron reserves
• Iron tablets are effective within weeks, but noncompliance 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
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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
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Iron excess - dangerous to some
• 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
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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
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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 nutrition
In 1998 WHO, UNICEF, CIDA, USAID (ia)
launched
a global initiative in 40 countries that has
*This issue is under active investigation. For the status at time of writing see Lancet, Volume 376,
9744,million
p 873 - 874, 11
September 2010
to date avertedIssue
1.25
deaths,
by giving
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vitamin A to kids at clinics
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.
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Iodine deficiency disorders
• The world’s major cause of preventable brain damage
In 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
For latest data, see: http://www.micronutrient.org/english/View.asp?x=578
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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
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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
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Wrapup elements here. Quite a few
more slides! But little additional
content
Page 84
Proximate and ultimate causes
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?
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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
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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
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If they don’t need money – what do they need?
• Short term they likely need emergency rations, safe water
In 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
Note F
Page 88
Optimistic, and impatient to the point
of indignation
If you’re not convinced of the urgency go to http://www.starvedforattention.org/
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Take home message
• Catastrophic inequities in distribution of
nutrients Especially water, protein, iron, vitamin A, iodine
not just across nations – increasingly within
• Kinds of nutritional status & health impact
perinatal - women and children
Not by accident? Who’s responsible? What’s needed
We’ve faced causes, know there are cures
As we face the future we are ...
Optimistic and impatient
Appendix: Nutrition skill-set for the
practitioner in fragile health regions
For those who can see a need in the future for more specific skill-set
the 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 deaths
Know 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 problem
Know 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 available
The importance of agriculture and agricultural resources
Know where and how to call in help, and what they need to make an informed decision
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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 help
1 Know what to look for in a community that's experiencing obvious health issues –
sudden increase in infant deaths
2 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 for
Know 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 available
4 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.
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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 problem
If 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
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