Nutrition & the Politics of Famine
International Development & Health
Hilary Term 2009
Proochista Ariana
Overview
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•
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Nutritional transitions with economic growth
Anthropometry
Famine Theories
Famine Response
Points for Reflection
• What does anthropometry tell us about
health?
• How can political, economic, or social factors
help explain the dynamic changes in
nutrition?
• To what extent are famines today a
consequences of natural phenomena?
Epidemiological Transition?
Double Burden of Disease
• Concurrence of both communicable and noncommunicable diseases
• Infection is responsible for 25% of cancers in
the developing world compared with 10% in
the developed world
Triple Burden of Disease
• Communicable, non-communicable, and
socio-behavioural
• Increasing recognition of burden of mental
illnesses
• Aging population and chronic diseases of
lifestyle
• Tobacco: “By 2020, tobacco is expected to kill
more people than any single disease, even
HIV/AIDS”
Source: Global Burden of Disease 2004
Cause of Death by Income Level 2004
100%
90%
% of total deaths
80%
70%
60%
Injries
50%
Non-communicable
Communicable
40%
30%
20%
10%
0%
High
Upper Middle
Lower Middle
Income Level
Low Income
Source: Global Burden of Disease 2004
5 stage model of Epi Transition
Stage
Characteristics
Age of pestilence and famine
Infectious and nutritional related
cardiomyopathies; Rheumatic heart disease
Age of receding pandemics
Hypertensive cardiovascular disease
Haemorrhagic strokes
Age of degenerative and man-made
diseases
Haemorrhagic and ischemic stoke, ischemic
heart disease, diabetes and obesity
Onset at younger age
Atherosclerotic cardiovascular disease; Onset of
chronic disease at older ages – delay occurs due
to improved prevention and treatment
Social upheaval causes an increase in the
prevalence of chronic disease at younger ages;
Re-emergence of mortality due to infectious
disease and rheumatic heart disease
Age of delayed degenerative diseases
Age of health regression and social
upheaval
Source: Yusuf et al., (2001)
Delayed Degenerative Diseases
• The age of delayed degenerative disease is
characterised by an increase in the average life
expectancy and an increase in the age of
onset for chronic disease. This stage includes
regions with relatively advanced health care
systems such as North America, Australia and
Western Europe illustrate this stage
Health Regression
& Social Upheaval
• re-emergence of mortality due to
communicable disease in addition to noncommunicable disease
• Average life expectancy decreases and an
increase in the prevalence of noncommunicable diseases is seen at younger
ages
Social Determinants
• conditions in which people are born, grow,
live, work, and age
• access to health care, schools and education,
their conditions of work and leisure, their
homes, communities, towns, or cities
• unequal living conditions are the consequence
of poor social policies and programmes, unfair
economic arrangements, and bad politics
Conditions of Life
• Different Exposures to disease-causing
influences in early life
• Different Vulnerabilities
• Differences in ability to cope (material,
psychosocial, behavioural)
Nutrition Transition
Nutrition Measures
• Anthropometric
– Weight-for-height (wasting)
– Height-for-age (stunting)
– Body mass index
– Adult height
• Dietary consumption
• Micronutrient levels
Under-Nutrition
• Physical and mental lethargy
• Compromised immune system and increased
susceptibility to infections
• Increased frequency and/or severity of
morbidities and enhanced risk of mortality
• Compromised cognitive development
Over-Nutrition
• Blood pressure, cholesterol, triglycerides, and
insulin
• Type 2 Diabetes
• Cardiovascular diseases and fatalities
• Cancer of the breast, colon, prostrate,
endometroium, kidney and gallbladder
• Contributes to osteoarthritis, respiratory
difficulties, musculoskeletal problems,
infertility
Nutrition Transition
Source: Mike Rayner (WHO, SDE/NHD, 2000)
Nutrition Transition
1. Hunting & gathering: Plants, low-fat wild
animals; varied diet
2. Famine: Cereals predominant; diet less varied
3. Receding famine: Fewer starchy staples; more
fruits, vegetables, animal protein; low variety
4. Degenerative disease: More fat, sugar &
processed foods; less fibre
5. Behavioural change: Less fat and processing;
increased carbohydrates, fruits and vegetables
Shifts in Diets
• increases in the consumption of foods sourced
from animals, caloric sweeteners and fat
• Between 1970 and 1995 the world
consumption of calories from starchy roots
and pulses fell by 30% while the proportion of
calories from meat increased by a third and
from vegetable oils by almost half
• Over the same period the consumption of
meat and poultry doubled in Asian countries
while the consumption of vegetables halved
Source: Pomerleau et al 2002
Physical Activity
• shifts away from physically demanding
economic activities (e.g. farming, mining and
forestry) towards more sedentary activities
(e.g. office based, assembly lines)
• Technological innovation leads to decreased
activity in previously physically demanding
jobs
• Leisure activities are increasingly sedentary in
nature
Global Obesity Epidemic
• According to the WHO, over 1 billion adults are
overweight, 300 million of whom are obese
• Obesity ranges from under 5% in China to over
75% in urban Samoa
• 17.6 million children under five are estimated
to be overweight worldwide
• In the US, the number of overweight children
has doubled and the number of overweight
adolescents has trebled since 1980
Global Distribution of Obesity
Source: WHO
Levels of obesity in selected countries*
90
80
Percentage
70
Men
60
Women
50
40
30
20
10
0
Nauru
Samoa
USA
Chile
Germany
* Data for latest year available
Source: World Health Organisation (2006) Global Health Atlas
South
Africa
Morocco
China
Increase in Obesity
• in many developing regions obesity
prevalence is outstripping rates in the
developed world
• The rate of increase in obesity among adults in
Asia, North Africa and Latin America are
between two and five times of the rate of
increase in Northern America
Income and Overweight
Wang et al, 2002
Trends in Childhood Obesity
Source: Anderson 2005
Trends in Overweight Children
Shift from Under to Over-weight
Source: Wang et al 2002
Under- and Over-Weight
Source: Wang et al 2002
China (1991-2004)
Source: Dearth-Wesley et al 2008
Transition to Obesity
• Shift to Western dietary habits and a
proliferation of fast-food chains
• Higher energy-dense foods, larger portion size
and an increase in the consumption of sugar
rich soft drinks
• In combination with increasingly automated
and sedentary lifestyles
Fast Food Chains
• Between 1970 and
1980, the number of
fast-food outlets in
the United States
increased from about
30,000 to 140,000,
and to about 222,000
in 2001
(Source: Paeratakul S, Ferdinand D, Champagne C, Ryan D, Bray G. Fast-food consumption among
US adults and children. J Am Diet Assoc 2003:103:1332-8)
Transition?
Nutrition related non-communicable disease risk
among the well off population appear
concurrent with simultaneous persistence of
under-nutrition and low food security among
the poorer populations of the same country
Double Burden Households
Doak et al, 2005
Anthropometry
Anthropometric Measures
• Weight-for-Height: An indicator of acute
malnutrition or ‘wasting’
• Height-for-Age: An indicator of chronic
malnutrition or ‘stunting’
• Weight-for-Age: one of the first measures of
nutritional status and remains the measure
most closely correlated to fatal health (Gomez
et al 1956)
Cut offs
• States of malnutrition are classified using WHO’s
recommended two standard deviation cut-off
points: “In general, abnormal anthropometry is
statistically defined as an anthropometric value
below -2 standard deviations (SD) or Z-scores
(<2.3rd percentile), or above +2 SD or Z-scores
(>97.7th percentile) relative to the reference
mean or median. These cut-offs define the
central 95% of the reference distribution as the
“normality” range” (WHO, 1995 p.181).
International Standard
• 1978 National Center for Health Statistics
(NCHS) reference curves for height-for-age,
weight-for-age, and weight-for-height
• Sample of American formula-fed infants
• Restricted socio-economic and genetic
background
• Intervals of measurement preclude precise
curve fitting
• Positively skewed weight distribution
NCHS versus WHO Standards
Source: de Onis 2006
Categories of Undernutrition
• Stunting: “the process of failure to reach
linear growth potential as a result of
inadequate nutrition and/or public health”;
• Wasting: “describes a recent or current severe
process leading to significant weight loss,
usually as a consequence of acute starvation
and/or disease”
• Underweight: is simply defined as “low weight
for age”
Stunting
• WHO contrasts stunting with shortness which
they define as “a descriptive term for low
height-for-age, without implication of cause”
(WHO, 1995 p.422)
• “a high prevalence of low height-for-age
indicates poor nutrition, high morbidity from
infectious disease, or-most often-both”
(WHO)
Wasting
• “A high prevalence of low weight-for-height is
indicative of severe recent or current events,
for example starvation or outbreaks of
infectious diseases such as diarrhoea or
measles” (WHO, 1995 p.181).
Body Mass Index
Underweight
Severe thinness
Moderate thinness
Mild thinness
Normal range
Overweight
Pre-obese
Obese
Obese class I
Obese class II
Obese class III
<18.50
<16.00
16.00 - 16.99
17.00 - 18.49
18.50 - 24.99
≥25.00
25.00 - 29.99
≥30.00
30.00 - 34-99
35.00 - 39.99
≥40.00
Proxy for Malnutrition
• Initially anthropometry was developed and
applied as an easy way to approximate clinical
malnutrition in the field
• Changes in body composition signify one
manifestation of malnutrition which can be
readily measured
• Anthropometry alone is insufficient to define
malnutrition (which requires clinical assessment)
• Rather it identifies individuals at greater risk for
malnutrition (Trowbridge FL, 1979)
Validity
• Relies on evidence linking outward expression
of stature to physiological processes
• Concurrent validity: the ability of the
anthropometric measures to correspond to
clinical assessments of malnutrition
• Predictive validity: the ability of the indicator
to predict future morbidity and mortality
Other Implications
• Even without extra susceptibility to disease,
stunting or wasting or overweight may have
consequences for:
– Energy
– Productivity
– Feelings of well-being
– Shame, humiliation or pride & self-confidence
– Quality of life
Causes versus Consequences
• Causes: Factors that could explain current
nutritional states (nutritional intake, activity,
illness, stress, etc.)
• Consequences: Risks that could emerge from
the nutritional states (illness, cognitive
impairment, educational attainment, incomeearning potential)
Childhood stunting, severe
wasting, and underweight 2005
Black et al, 2008
Prevalence of Childhood Stunting
(Source: de Onis et al 2000)
Trends in Stunting
(Source: de Onis et al 2000)
Consequences of Stunting
• Childhood height-for-age related to adult
height
• Stunting predicts poorer cognitive
performance and/or lower school grades
attained in middle childhood
• Early childhood stunting associated with adult
BMI and central adiposity
• Early childhood stunting associated with risk
of having a LBW infant
Height-for-age and attained height
Victora et al, 2008
Height-for-age and attained
schooling
Victora et al, 2008
Global deaths and disease burden
attributable to undernutrition
Black et al, 2008
Height
Trends in Height
Baten: Working Paper
Heights in Africa
Baten, Working Paper
Contributing Factors
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National income or Political system
Proximity to protein sources
Price of food
Disease environment
Dietary Customs
Genetic (intergenerational transmission of
height)
• Elevation or types of activities
Height and GDP
Baten, Working Paper
Consequences
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Cognitive capacity
Employment opportunities
Income earnings
Morbidity & Mortality (?)
Low birthweight
Height and IQ
• Height at age 9 years a significant predictor of
childhood IQ after adjusting for socioeconomic
status
• Height at age 13 a significant predictor of IQ
after adjusting for socioeconomic status
• Height at age 13 also explained an additional
2.5% of the variation in IQ scores to that already
explained by socioeconomic status and height at
age nine.
Pearce et al, 2005
Height, Ability and Labour Markets
• A large and significant association between
height and test scores for children followed in
the British Cohort Study (BCS) for tests they
took at ages 5 and 10 and for children in the
National Child Development Survey (NCDS) for
tests at ages 7 and 11.
• Economic returns to height are the result of
correlation between height and cognitive ability a correlation that is evident early in life and
remains throughout.
Case et al, 2006
Height and Labour Market
Outcomes
• In the past 13 US presidential elections, the
taller candidate has won 10 times (the most
recent exception being George W. Bush)
Persico et al, 2004
Height and Labour Market
Outcomes
• Data from Britain’s National Child Development
Survey(NCDS) showed that among white British men
every additional inch of adult height is associated
with a 2.2 percent increase in wages.
• Data from the US National Longitudinal Survey of
Youth (NLSY) showed that among adult white males
in the US, every additional inch of height as an adult
is associated with a 1.8 percent increase in wages.
• The tallest quarter of the population has a median
wage that is more than 13 percent higher than that
of the shortest quarter.
Persico et al, 2004
Height on Workplace Success and
Income
• For every inch of height increase amounts to a
salary increase of about $789 annually
Judge et al, 2004
Macronutrients and Micronutrients
Total Energy Malnutrition:
Marasmus
• Caused by inadequate
intake of protein and
calories
• Presents as decreased
activity, lethargy,
behavioural changes,
slowed growth and weight
loss
• Subsequent effects on the
body are wasting and a loss
of subcutaneous fat and
muscle, resulting in growth
retardation.
CDC Public Health Image Library
Protein Energy Malnutrition:
Kwashiorkor
• Caused by inadequate
protein intake
• Characterised by failure
to gain weight,
generalised oedema,
protuberant (swollen)
abdomen, diarrhea,
skin desquamation
(peeling) and vitiligo
(white spots on the
skin)
Zinc
Vitamin D
Riboflavin
Thiamin
Vitamin E
Magnesium
Iodine
Vitamin B6
Manganese
Folate
Iron
Vitamin B12
Vitamin A
Vitamin C
Cobalt
Phosphorus
Cobalamin
Selenium
Niacin
Vitamin K
Chromium
….are endemic almost throughout the world including in most
emergency-affected populations….
Iron Deficiency
• Feeling tired and weak
• Decreased work and school performance
• Slow cognitive and social development during
childhood
• Difficulty maintaining body temperature
• Decreased immune function, which increases
susceptibility to infection
Anemia in Pre-schoolers
WHO, 2008
Anemia in Pregnant Women
WHO, 2008
Anemia in Women of
Reproductive Age
WHO, 2008
Sources of Iron
• Dried beans; Dried fruits
• Eggs (especially egg
yolks)
• Liver
• Lean red meat (especially
beef)
• Oysters
• Poultry
• Salmon
• Tuna
• Whole grains
• Iron-fortified cereals
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•
•
Iron from vegetables, fruits,
grains, and supplements is
harder for the body to absorb.
Dried fruits: prunes, raisins,
apricots, Legumes: lima beans,
soybeans, dried beans and
peas, kidney beans, Seeds,
almonds, Brazil nuts;
Vegetables: broccoli, spinach,
kale, collards, asparagus,
dandelion greens; Whole grains:
wheat, millet, oats, brown rice
If you mix some lean meat, fish,
or poultry with beans or dark
leafy greens at a meal, you can
improve absorption of vegetable
sources of iron up to three
times.
Vitamin A Deficiency
• Bitot spots - areas of abnormal
squamous cell proliferation and
keratinization of the conjunctiva
• Night blindness
• Blindness
• Dry skin, dry hair, pruritus, broken
fingernails
Distribution of Vitamin A
Deficiency
WHO, 2004
Prevalence of vitamin A deficiency
in children <5
Black et al, 2008
Sources of Vitamin A
http://ods.od.nih.gov/factsheets
Iodine Deficiency
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Goiter
Hypothyroidism
Cretinism
Mental retardation
Distribution of Iodine Deficiency
WHO, 2004
Sources of Iodine
• Iodized salt
• Seafood is naturally rich
in iodine; Cod, sea bass,
haddock, and perch are
good sources.
• Kelp is the most common
vegetable seafood that is
a rich source of iodine.
• Dairy products also
contain iodine. Other
good sources are plants
grown in iodine-rich soil.
Scurvy - Vitamin C deficiency
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Fatigue
swollen and bleeding gums
Haemorrhage
slow healing of wounds
populations with no access to fruit and
vegetables or entirely reliant on rations as
source of food
Vitamin C Sources
• All fruits and vegetables
contain some amount of
vitamin C.
• Foods that tend to be the
highest sources of vitamin C
include green peppers, citrus
fruits and juices, strawberries,
tomatoes, broccoli, turnip
greens and other leafy greens,
sweet and white potatoes, and
cantaloupe.
• Other excellent sources
include papaya, mango,
watermelon, brussels sprouts,
cauliflower, cabbage, winter
squash, red peppers,
raspberries, blueberries,
cranberries, and pineapples.
Zinc deficiency
• Zinc deficiency is characterized by growth
retardation, loss of appetite, and impaired immune
function.
• In more severe cases, zinc deficiency causes hair
loss, diarrhea, delayed sexual maturation,
impotence, hypogonadism in males, and eye and
skin lesions.
• Weight loss, delayed healing of wounds, taste
abnormalities, and mental lethargy can also occur.
National risk of zinc deficiency in
children <5
Black et al, 2008
Zinc Sources
• High-protein foods contain high amounts
of zinc. Beef, pork, and lamb contain more
zinc than fish.
• The dark meat of a chicken has more zinc
than the light meat.
• Other good sources of zinc are peanuts,
peanut butter, and legumes.
Famines
Caloric Needs
• For basal metabolic activities
• For physical or mental exertion
• For growth (children and pregnant women)
• For immune response
(Gender and age differences in requirements)
Food Shortage
• How many days can we go without food?
• How many days can we go without water?
Adaptive Processes
• Metabolic: efficiency with which convert food
to energy
• Physiological: prioritise vital organs
– Blood glucose
– Fat stores
– Break down muscle mass (wasting)
– Compromised linear growth (stunting)
• Socio-behavioural: activities
Infection- Undernutrition Cycle
• Undernutrition compromises immune system
• Infection exacerbates undernutrition by
– Decreasing absorption of nutrients
– Decreasing appetite
– Increasing demand for energy
Starvation
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Long process (not a static state)
Loss of body mass
Weakness and lethargy
Compromised temperature regulation
Irritability, lack of concentration
Immune deficiency
Anaemia and manifestation of other micronutrient deficiencies
Social interpretations
• Deprivation on a mass scale in multiple
spheres:
– Sociability
– Various dimensions of satisfaction
• What are some local words for starvation or
famine?
But what is Famine?
“There is still a major controversy over whether the
Ethiopia crisis of 1999-2000 should be labeled a
“famine” or not, in light of the emotive and political
connotations of the word. In the author’s view - given
the number of people affected, the damage to
livelihoods and human development, and the loss of
human life - there is no question about whether
Ethiopia 1999-2000 was a famine. But the continued
controversy over this issue points to the need for a
broadly accepted operational definition of famine.”
Maxwell, 2005
Theoretical Definitions
• “In statistical terms, [famine] can be defined as a
severe shortage of food accompanied by a
significant increase in the local or regional
death rate.” (Mayer, 1975: 572)
• “Famine is a socio-economic process which
causes the accelerated destitution of the most
vulnerable, marginal and least-powerful groups
in a community, to a point where they can no
longer, as a group, maintain a sustainable
livelihood. Ultimately, the process leads to the
inability of the individual to acquire sufficient
food to sustain life.” (Walker, 1989: 6)
Useful?
“Most definitions merely provide ‘a pithy
description’ of what happens during
famines, rather than ‘helping us to do the
diagnosis - the traditional function of a
definition’.” (Sen 1981: 40)
Indian Famine Codes (1880s)
• Codify administrative responses to food crises
• Three levels of food stress: near scarcity, scarcity and famine
• Scarcity was defined as “prevailing want of food or other
necessaries”, while famine was “the aggravation of conditions
of scarcity into a state of extreme scarcity” (Singh, 1993: 149).
• Scarcity was identified by: three successive years of crop
failure; crop yields of four to six annas (compared to a normal
yield of 12 annas); and large populations in distress.
• The declaration of famine was based on additional criteria,
including: food price rises above the “scarcity rate” (defined
as 40 per cent above the “normal price”), signs of increased
migration and the extent of mortality.
Early Warning Systems
• Historical precedents of Famine Codes using various
food security indicators developed after the mid1980s famines in Sub-saharan Africa.
• Context-specific food security indicators are
monitored and analysed as to whether current
conditions qualifies as a potential or actual crisis
• “indicators of vulnerability, of imminent crisis, of
famine” (Cuny, 1999) complemented by
anthropometric data, where available, to assess
severity of food situation
Coping Strategies as Indicators
• Generalisable patterns and sequences of behavioural
responses of populations affected by food crises used as
indicators
• Stage a: includes strategies for overcoming ‘normal
seasonal stress’, such as rationing food or diversifying
income.
• Stage b: food stress is prolonged, increasingly
irreversible strategies - such as selling breeding livestock
or mortgaging land which trade short-term gain for longterm problems (discounting)
• Stage c: dependence on external support such as food
aid
• Stage d: starvation and death
Nutrition Surveillance
Famine
•
•
•
•
Highly politicized label
When is a ‘famine’ declared and who decides?
Incentives or disincentives to declare
What are the information needs and how
reliable are information sources?
Famine Theories
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•
•
•
Food Availability Decline (FAD)
Food Entitlement Decline (FED)
Market Failure
Concatenation Process
Food Availability Decline
• Supply theory of famine
• Shortage of food
• Assessed through estimation of
– Food production (+)
– Imports (+)
– Exports (-)
– Wastage (-)
– grain needed for sowing (-)
– residual stocks (+)
Relevance of FAD Equation
• Closed Systems
– Remote regions, environmentally hostile &
isolated regions, islands
– Sanctions, economic blockades, or conflict
• Reliance on local Production
Causes of FAD
•
•
•
•
•
•
•
•
Drought or floods
Diseases of plants or animals
Declines in soil productivity
Conflict
Government policies (e.g. cash cropping)
Regulations on land use
Trade regulations
Alternative use of agricultural production (e.g.
Food as fuel)
Food Entitlement Decline
• Demand theory of famine
• Failure to demand even when supply sufficient
• Types of entitlements (entitlement set):
– Ownership
– Exchange
– Non-market
• Relationship between non-food and food prices
• Famine may result form a change in the price of
key items in the entitlement set
Market Failures
• Imperfect system of distribution
– Infrastructure
– Transport (ownership, repair, alternative uses)
• Physical fragmentation
– Transaction costs & risks (physical isolation,
imperfect information)
• Speculation and hoarding
– Collusion of merchants to artificially limit supply in
order to increase costs and profits
Modern Famines
• Complex combinations of many factors including
FAD and FED and market failures
• Conflicts and/or sanctions
• HIV/AIDS
• FAD may lead to FED by leading to
unemployment and consequent price scissors
– Price of goods sold by poor ↓ (supply ↑ demand↓)
– Price of goods bought by poor ↑ (supply ↓
demand↑)
Food Waste
• Today, over one third of the world's cereals are
being used as animal feed (UNEP, 2009)
• Currently an estimated 30 million tons of fish are
discarded at sea annually
• Losses and food waste in the United States could
be as high as 40-50 per cent, according to some
recent estimates
• Up to one quarter of all fresh fruits and
vegetables in the US is lost between the field and
the table
Food Waste
• Almost one-third of all food purchased in the
United Kingdom every year is not eaten
• in Africa, the total amount of fish lost through
discards, post-harvest loss and spoilage may be
around 30 per cent of landings
• Food losses in the field between planting and
harvesting could be as high as 20-40 per cent of
the potential harvest in developing countries
(source: UNEP 2009)
Policy Response to Famine
•
•
•
•
Reformism (deliberate relief policy)
Mild interventionist (emergency relief)
Non-interventionist
Radical non-intervention
Reformism
• Often integrated with development policies
• Idea that markets insufficient so need longterm policies offering state-welfare
– Institutions
– Employment
– Food distribution
• Hope to decrease vulnerability to such
disasters
Reformism
• Post disaster rehabilitation
– Assets
– Credit
– food
• Institutional Support
– Public/state distribution of subsidised grains
– Food for work
– Employment guarantees
• Medium-term reforms
– Soil and water conservation efforts
– Land reform
– Agricultural technology
Mild Interventionists
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•
•
•
•
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Markets necessary but not sufficient
Relief only at times of acute starvation
Early warning systems
Nutritional surveillance and food balance sheets
Satellite facilitated crop forecasting
Supplementary feeding & rationing (food, water,
fodder)
• Medical relief
• Loans, ↓taxes, public employment
Libertarian Non-Interventionism
• Competitive, integrated markets necessary and
sufficient to deal with famines. Famine relief
interferes with markets and creates inefficiency
• Population is regulated via the market to the
level of the available means of subsistence.
Relief distorts this process
• Relief misused by elites for their own ends and
perpetuates exploitive economic arrangements
• Geo-political motivations
Radical Non-Intervention
• Markets unnecessary and insufficient
• Mechanisms of inequality which underdevelops the poor
• Immiserisation conscientises
(if you let things get really bad, people will make
them right)
Thank You
Accidents and Injuries
Road Traffic Accidents
• Road traffic accidents rank as the 11th leading
cause of death and account for 2.1% of all
deaths globally
– kill 1.2 million people a year or an average
– injure or disable between 20 million and 50
million people a year
• 90% of road traffic deaths occur in low-income
and middle-income countries
Violence
• Each year, more than 1.6 million people
worldwide lose their lives to violence
• Violence is among the leading causes of death
for people aged 15–44 years worldwide,
accounting for about 14% of deaths among
males and 7% of deaths among females
• Of the 1.6 million violence-related deaths
worldwide (including those from conflict and
suicide) that occur each year, 90% happen in
low- and middle-income countries
Source: Deaton 2005
Iodine Toxicity
• Chronic toxicity may develop when intake is > 1.1
mg/day.
• Some people who ingest excess amounts of iodine,
particularly those who were previously deficient, develop
hyperthyroidism (Jod-Basedow phenomenon).
• Paradoxically, excess uptake of iodine by the thyroid
may inhibit thyroid hormone synthesis (called WolffChaikoff effect). Thus, iodine toxicity can eventually
cause iodide goiter, hypothyroidism, or myxedema.
• Very large amounts of iodide may cause a brassy taste
in the mouth, increased salivation, GI irritation, and
acneiform skin lesions.
Vitamin A Toxicity
• Can occur when large amounts of liver are regularly
consumed and from taking excess amounts of the
nutrient in supplements
• Four major adverse effects:
– birth defects,
– liver abnormalities,
– reduced bone mineral density that may result in
osteoporosis, and
– central nervous system disorders
• Signs of acute toxicity include nausea and vomiting,
headache, dizziness, blurred vision, and muscular
uncoordination.
Iron Toxicity
• children can sometimes develop iron
poisoning by swallowing too many iron
supplements.
• Symptoms of iron poisoning include:
Fatigue; Anorexia; Dizziness; Nausea;
Vomiting; Headache; Weight loss;
Shortness of breath; Grayish color to the
skin
Zinc Toxicity
• Zinc supplements in large amounts may
cause diarrhea, abdominal cramps, and
vomiting, usually within 3 - 10 hours of
swallowing the supplements. The
symptoms go away within a short period of
time after stopping the supplements.
Source: De Onis 2000
Dietary Energy Supply, USA
WHO Global Database on
Body Mass Index
Height-for-age and systolic blood
pressure
Victora et al, 2008
Trends in Body Weight
Marques-Vidal et al, 2008
Trends in BMI
Marques-Vidal et al, 2008
Trends in Height
Marques-Vidal et al, 2008
Height-for-age and offspring
birthweight
Victora et al, 2008
Height-for-age and BMI
Victora et al, 2008
Height-for-age and glucose
concentration
Victora et al, 2008
1984-1985 Ethiopian Famine
North Korean Famine 1996
• After the withdrawal of USSR and Chinese
food subsidies in the early 1990s and the
cumulative effect of collective farming,
food availability in North Korea declined
steadily and then plummeted between
1995 and 1997 when flooding followed by
drought struck the country.
• From 1994 to 1998, 2-3 million people
died of starvation and hunger-related
illnesses
North Korean Famine Timeline


Early 1990s:
Reduction in
subsidized
food and
crude oil form
USSR and
China
July: Kim Il
Sung dies
and Kim
Jong Il
ascends to
power

Late 1995:
Reporte d
military coup
thwarted by
Kim Jong Il
regime in
Northea st

April: Nort h
Korea
agrees to
join US,
China and
South Korea
in Four Party
Peace Talks

Drough t
across
agricultural
areas


January: Kim
Jong Il regime
announces
that families
now
responsibl e for
feed ing
themselves
February : Kim
de Jung
inaugur ated as
President of
South Korea
and initiates
ŅSunshine
PolicyÓseeking
North-South
reconciliation

Purchases of
Chinese
maize
declines,
because of
production
decline
thereby
increasing the
price of grain
in private
markets
Famine Peaks

September:
Kim Jong Il
reduced
grain rations
for farm
(rural)
families


Kim Jong Il
regime
Moves
responsibil it
y for
managing
the food
distribution
system from
national to
country
authorities
Selective
food
distributions
continue in
capital while
genera l
popul ation
fends for
itself in
privat e


Early 1997:
Unconfi rmed
reports of
martial law
September
27: Kim
Jong Il
regime
creates 927
retention
camps in
each county
for internally
displaced
peopl e
caught
without
travel
permits


Spring: Food
prices in
privat e
markets
decrease du e
to influx of
international
food aid
shipment
Summer: Kim
Jong Il regime
tightens trave l
permit
regula tions
and impose
new fines to
re-establish
order after
period of
popul ation
movement
while
1999
August:
Massive
flooding in
the country
1998

1997

Kim Jong Il
regime shuts
down
distribution
of public
food system
in Northeast
October:
Agreed
framework
signed
eases
tensions and
opens door
for
international
food
assistance
1996

1995
1994

Kim Il Sung
regime
indicates twomeal-a-day
campaign to
ration
diminishing
food supplies
Food
distributions
become
intermittent in
the Nort heast
1993
1992
1991
1990

Relief Foods
• Often cereals (corn, rice, flour)
• Lack nutritional diversity
• Emergency food aid today consists of cereals
(often supplemented with soya for protein
and micronutrients) and accompanied by
pulses
Prediction Efforts
• Identify ‘normal’ then detect deviations from
that normal state
• Famine codes
• Early warning systems
• Coping strategies as prediction tools
• Nutrition surveillance
Coping
• Famines may be slow processes with long tails
• Trigger event then long process of coping
strategies
– Wild foods (non-customary)
– Change in activities
– Migration and risk taking
• Beneficiaries of process (those that get rich
during famines)
Height, Ability and Labour Markets
Case et al, 2006