1.tfin the poor nations almost everyone is hungry; in the remainder almost everyone gets an adequate...

1.TFIn the poor nations almost everyone is hungry; in the remainder almost everyone gets an adequate diet 2.TFWorldwide, more people have their lives shortened by overeating than by starvation 3.TFWhen poor nations now find a place on the ladder of development, they develop slower than rich nations did when they enjoyed their phase of development? 4.TFMost Canadian specialists in global health understand how the distribution of poverty & hunger are changing? 5.TF Health & nutrition benefits are possible only after economic development occurs 6.TFPeople in regions of extreme hunger & poverty desperately need money 7.TF50% of children in the US are currently so poor that they must rely on charity for their meals? Quick quiz two of the following are T

Quick answers 1.FIn some nations hunger is the norm; in the remainder, an adequate diet is the norm 2.T Worldwide, more people have their lives shortened by overeating than by starvation 3.F In the present era, when poor nations find a place on the ladder of development, they develop slowly compared with the rich nations in their phase of development? 4.FMost Canadian specialists in global health understand the how the distribution of poverty and hunger are changing? 5.F Health & nutrition benefits inevitably occurs after economic development rather than before 6.FPeople in regions of extreme hunger & poverty desperately need money 7.T50% of children in the US are currently so poor that they must rely on charity for their meals?

Slides & practice questions (see web) 1. The 50% (actually 49.2%) is US children that will require food-aid some time during childhood 2. Pct % of people hungry is declining over years 3. Plan to spend 2-3 hours reviewing web info What works & what doesnt? toward evidence-based solutions http://www.sfu.ca/global-nutrition This is a problem we can solve at a fraction the cost of ignoring it (Senator Geo McGovern: US Ambassador to UN Food & Ag Org)

1 billion hungry (800m); 1 billion overweight Minefield Experts are living in the past Nothing in texts

Nutrition in global health - Overview Inequities in food distribution global hunger & starvation One billion are too hungry to live productive lives - an equal number are adversely affected by overweight! 6 major deficiencies impact health through the life cycle: water, protein, iron, vitamin A, iodine, folic acid Childbearing women & their children are hardest hit Meanwhile, overnutrition & inactivity risk of heart disease, osteoporosis, cancer, diabetes, strokes, etc.

World GDP $PPP per cap (est) 1500-2100 http:// ers.usda.gov/Data/Macroeconomics / Manifest destiny of world - wealth China + India 2040? 6

Global Nutrition We have a roadmap to a world without hunger Where are we headed? The ugly We know what works? It wasnt an accident How did we get here? Where are we now? Can anything help? Yes Stuffed & starved The bad We keep doing what we know doesnt work? The good Most of you will see hunger in museums! We are part of the problem

Overview of Nutrition in Global Health 1.Malnutrition and MDGs: cause, effect & cure3 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 8

Preface: Nutrition is crucial to global health Among the immediately modifiable factors that affect individual & public health nutrition is of prime importance Nutrition at every stage of life lays a foundation for health in the ensuing stage For all nations, rich & poor, nutrition determines physical health & development through the life- cycle, including: Success in childbearing, cognitive function, socio-economic independence, education, disease resistance & employability Health & economic development are contingent on provision of adequate food, nutritional resources & support Page 9

Fundamentals and emphasis As we consider cause and effect we must ask: How & why have such inequities come to be? Who and what factors impede solutions? What current initiatives will bring the resolution? To help answer these, we must will emphasize: Immediate causes - scarcity of specific nutrients Primary and secondary prevention Public health approaches to solutions

World % undernourished 11 same data 22% 14%

Number fed & under-nourished worldwide 12 14% Prediction 6%11% Target 33% 1212 millions

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

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

1 Malnutrition & MDGs: cause, effect, cure 3 slides: 1.Trends in nutrition, food security & globalization 2.Agricultural trends 3.Nutritional inequities - Cause & consequence 4.Food security; Prospects for having enough food Page 15

16 Paying for total strangers to eat? Not us, not if it goes to corrupt dictators } 16

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

The Millennium Development Goals Page 18 At a UN Millennium (2002) summit, the nations of the world set eight MDGs to be achieved by 2015 The world's main development challenges were identified Specific actions and targets (the MDGs) A commitment to provide the means was made by 189 nations & signed by 147 heads of state The MDGs break down into 21 quantifiable targets Targets are measured by 60 time-lined indicators Some nations have kept their trust. But some of the richest in the world have announced that they will not meet their commitments

Nutrition & Millennium Development Goals Page 19 Primary goal is to eradicate extreme poverty & hunger Nutrition direct prerequisite to goals 1, 3, 4, 5 & 6; indirectly to 7 & 8 see next 2 slides 1 maternal health Child mortality Gender equity Empower Achieve universal primary education HIV, malaria, other diseases Environmental sustainability Global partnership for development

1. Eradicate extreme poverty & hunger. Poverty is the main determinant of hunger. In turn, malnutrition irreversibly compromises physical & cognitive development & thus transmits poverty & hunger to future generations. 2. Achieve universal primary education. Malnutrition diminishes the chance that a child will go to school, stay in school, or perform well in school 3. Promote gender equality, empower women. Womens malnutrition impairs the whole familys health & nutrition Centrality of nutrition to MDGs 1, 2, & 3

Centrality of nutrition to MDGs 4, 5, & 6 4. Reduce child mortality. Delivery of a live healthy child is dependent, above all, on a well nourished mother. Protein & folic acid are critical here 5. Improve maternal health. Malnutrition accentuates all major risk factors for maternal mortality, e.g., inadequate protein, iron, iodine, vitamin A & calcium 6. Combat serious infectious diseases. Malnutrition aggravates infections, immune competence, transmission & mortality in HIV, malaria, tuberculosis Adapted from Gillespie and Haddad (2003) http://web.worldbank.org/http://web.worldbank.org/ Page 21

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

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 Page 23 Note C

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

Worldwide, nutritional inequities follow poverty (as do health inequities & life expectancy) Globally, there is plenty of food for everyone but those who have more than they need find reasons not to share The result in the time you spend on this module over 1000 children will have died of hunger Each day 1500 children go forever blind from lack of vitamin A The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency). About 2 billion people (56% of pregnant women) have iron deficiency. Their babies have low birth- weight, & mortality Page 25 Note D

The bottom billion (title of a book by Paul Collier ) The poorest of the poor, Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day We define this subclass as people who don't get enough to meet the ordinary demands of life They lack the resources to earn a living, or obtain whats needed for normal, growth, maintenance & reproduction It goes without saying that they are unable to provide the necessities for those who depend on them Page 26

The bottom billion (title of a book by Paul Collier ) Their lack of access to resources is such that a significant fraction will be unable to stay alive They live mostly in isolated rural areas and most are subsistence farmers This means that what they eat this month is what they can take out of the ground from last month's planting Page 27

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

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

30 http://www.unicef.org/media/files/Tracking_Progress_on_ Child_and_Maternal_Nutrition_EN_110309.pdf http://ije.oxfordjournals.org/content/32/4/518.full.pdf Percentage stunted 60% 40% 20% Africa Asia Latin Am Last 2 or 3 points are projections 1980 & every 5 years

3 Critical periods: nutrition in the life-cycle 4 slides: 1.Perinatal nutrition: 0-6 mo: Breast vs. formula 1 st 5 y Weaning & infancy intellectual develop 2.School years; ability to learn 3.Work performance 4.Elderly Page 31

Maternal mortality (Demonstration index slide for a note) Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death. The major direct causes of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor. Page 32 Note button A click on the note button takes viewer to the note

Nutrition through the life-cycle Page 33

Factors in perinatal nutrition ( see also Acute malnutrition module) Nutritional health begins in the womb a healthy outcome to a pregnancy requires that mother be well nourished; good feeding must initiated early The most common birth defects result from a deficiency of folic acid in the diet of the pregnant mother, Best outcomes require folic acid supplementation before conception! Page 34

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 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 whos 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 http://www2.unicef.org/nutrition/index_22657.html Page 35

Perinatal nutrition requires attention 1 Malnutrition in pregnancy birth defects & low birth-weight Failure to thrive is an early danger sign, requiring investigation Nutrition in infancy to early life impacts physical & cognitive development. It determines immediate & future risks of blindness, thyroid function, bone development, & more Under-nutrition or deficiencies of many micronutrients can cause failure to thrive Iron, vitamins K and E are of particular importance. Refer to: 1 http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html Page 36

Malnutrition in early childhood Children are at special need because they are at the fastest-growing stage of life. Problems an adult could survive can be lethal to a child This is the most vulnerable period a child is developing physically & mentally. Damage can be permanent Most importantly, they are unable to fend for themselves & depend on others (parents, others) for health & survival They are the planets future. We owe it to them & to ourselves to ensure that they grow well, with a sense that they have reason to invest in the future, in a caring world Page 37

Parenthetically a personal perspective How easily we see the moral failings of the past. Slavery, the holocausts & genocides, conquests motivated by greed When future generations look amazed at the moral blindness of this generation, what will stand out? Clearly child hunger Where life expectancy is short, toddlers are orphans. In war or famine a region may lack necessities. You cant blame a child Yet in rich countries, yes, the US & Canada, we turn our empty eyes and hands away from those outside our borders A napalmed child turned a nations mind to peace. What will it take to open our eyes to children dying of hunger? Page 38

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 39

Nutrition through the life cycle - adolescence Adolescence carries risks for both poor & affluent Dieting can lead to deficiencies of vit. C, protein, folic acid in a sedentary person. Even if a good mix of foods is consumed, total food intake may be insufficient. A pattern of healthy eating in adolescence sets a pattern that can promote lifelong health A foundation for healthy bones is set by exercise, calcium, & vitamin D. After early adult life, bones go slowly downhill Page 40

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 41

Adult life - degenerative diseases In late life, risk of breast, prostatic, & most other cancers are predicted by diet, obesity, inactivity or smoking in adult life Also heart disease, strokes, osteoporosis, diabetes Cancers and diabetes are now leading causes of death & disability in low- and middle-income countries (see Lancet August 13, 2009) Nearly two-thirds of the worlds 7.6 million cancer- related deaths now occur in developing nations. Page 42

Differential nutritional vulnerability of females Women are much more prone to nutritional anaemias since they need to replace red cells lost in menstruation Women are the majority of elders, increasingly so in Asia and Africa. Osteoporosis is more common in the elderly Osteoporosis is a major cause of illness, disability and death. The annual number of hip fractures worldwide will rise from 1.7 million in 1990 to around 6.3 million by 2050. Page 43

Differential nutritional vulnerability of females Women suffer 80% of hip fractures; lifetime risk 30 - 40% compared with 13% for men. Osteoporosis prevention (exercise, calcium, & vitamin D) must start well before age 30 when bones still respond. Negative calcium balance in later life is not very responsive to nutritional measures. Page 44

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 45

Also, under-nutrition occurs in many rich nations In rich nations, enormous wealth for some has left others ravaged by health costs, unemployment, foreclosures Developed countries have marginalized cultural groups. Hunger is common in N & S America, China & E Europe For example, ~49% of US children (and over 80% of black children) require food-aid at some time during childhood Scandinavia & few western European countries are almost the only exceptions Page 46

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 47

Overnutrition is no longer limited to rich countries Previously, the poorest were almost immune to diabetes, hypertension, gout, & atherosclerosis & heart disease No longer. These are growing problems, impacting health worldwide. In the next few slides well consider prevention. Diabetes has reached epidemic proportions threatening, vision, kidney function, mobility, heart-health & life itself. A cluster of symptoms, hypertension, hyperlipidemia, and hyperglycemia is sometimes called metabolic syndrome Each of them increases risk of heart disease, and together the risk is greatly amplified. Read on.. Page 48

Prevention of heart attacks and strokes Risk factors : hypertension, hyperlipidemias (LDL / bad cholesterol), inactivity & diabetes. All correlated with obesity Smoking is the most life-shortening risk factor of all These risks can be changed earlier or later, by modification of diet & other life-style changes or medication In the past 5 years research has established that exercise & a lean body are the most powerful predictors of a long healthy life, and also of clear thinking into old age Page 49

Prevention of heart attacks and strokes There is no easy solution to obesity. In a typical study: 1 day walk More immediate than money (1) to SURVIVE We dont need studies to learn whats needed Page 100 The poorest - dont give them money Jeffrey Sachs

What do they need? The greatest nutritional problems are well known: Protein energy malnutrition Vitamin A Iron Iodine

What do they need? Short term Give a man a fish... Emergency rations, safe water, first aid, antibiotics, public health vaccinations, drugs, etc In conflict zones, shelter, safety to live, plant, harvest In drought safe-water straws Page 102 oral rehydration solution ready to use foods Millions saved

Phantom aid: 47% is wasted Evaporating aid - promises broken as soon as cameras turn elsewhere $ flow benefits the rich nations tilted trade Aid with strings attached, contingent on UN votes, WB loans, unfair trade Dumped food surplus local farm economy Money given by corrupt rich people to corrupt dictators 103 UK banks in Nigerian corruption Paul Collier: The bottom billion 103 Emergency aid isnt intended for development http://www.globalissues.org/article/35/foreign-aid-development-assistance#GovernmentsCuttingBackonPromisedResponsibilities

To become self-sufficient - obviously: good seeds, fertilizer, drinkable water, sanitation, low technology agricultural info & resources, drip-irrigation, ARVs mosquito nets, dispensaries, hospitals Emergency aid beyond Survival at the same time (2) Sustainablity Long term (3) To thrive Scaling up production - factories ... teach a man to fish development ladder

7 Malnutrition & MDGs: cause, effect, cure 3 slides: 1.Trends in nutrition, food security & globalization 2.Agricultural trends 3.Nutritional inequities - Cause & consequence 4.Food security; Prospects for having enough food Page 107

We know what works Transparent & accountable, open bids Partnerships not paternalism Goals, objectives, timed milestones Strategies revised annually by both partners Externally monitored. No political pressure Sustainable emphasis on poverty, agriculture Serves recipient needs, not donor / ideology Firm long-term commitments: MV, Grameen Unrealistic? Lets see... 108

Grameen Family of social enterprises Billionaire philanthropists & foundations The Millennium Village project Passionate & influential voices for change Scientists & students bring energy to future Instant spread of innovations: agric, educ, &c Beyond MDGs: amazing changes109 www.sfu.ca/global-nutrition

Microfinancing successes Donkey carts ($200) repay in 2.5 mos 4 Factories for treadle pumps. 2y later there are 75 Drip irrigation allows winter cukes @ 3x price. 1A farm profit $100 $550 / yr Business Week

Grameen Impact http://www.grameenfoundation.org/our-impact 9.4 million poor have been helped 1,000,000 microloans have been generated http://www.youtube.com/watch?v=kW-4gJmXy5M http://www.youtube.com/watch?v=1UugpcDjjJU Grameen village phone 10M subscribers 300k cell-phone ladies

Innovations that make a difference Barefoot agriculturistsSoil conservation, dont burn contour farming, irrigation, crop rotation Drip irrigation Pump installation Burkina Faso: planting-pits & stone furrows land food for 500,000 Phillipines: Tilapia in protein for 30,000,000 China: Hybrid rice in enough for 60,000,000 Bangladesh: Market liberalization in rice yield 3x Millions fed

Appropriate technology Innovations that make a difference $25 pump irrigates acre $100/y net Watering can irrigation rainwater collection pits valve sub-surface drip irrigation

Zero-tillage wheat-seeder drill - $100? Labour goes further. Earlier planting yield Doubled yield govt subsidy Farmer buys & rents to pay off 2 factories 100 in Haryana & Punjab

Millennium Village Project Farm production Gender equity Nutritional services Energy & environment Health services Water Prevent malaria & TB Environment $3m x 5yrs funded in advance

Initiatives making a difference Grameen Family of social enterprises The Kings of Philanthropy & 100s of foundations The Millennium Village project Influential voices for change Scientists & students are making a difference The Millennium Development Goals for the poorest You!... amplify with others @ SFU &? Vote Speak, write, telephone International internship Donate Live against 99.7% of tax on ourselves Oxfam, IDRF (Can Revenue charities) to leave enough for everyone consider study abroad

Supplementary note to the preceding slide Every day, 1500 women die from pregnancy- or childbirth- related complications. In 2005, there were an estimated 536 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable. (1) Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations Millennium Summit in 2000. In Millennium Development Goal 5 (MDG5), countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. However, between 1990 and 2005 the maternal mortality ratio declined by only 5%. Achieving Millennium Development Goal 5 requires accelerating progress. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www. who.int/reproductive- health/publications/maternal_mortality_2005/index.html, accessed 14 August 2008). Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html Photo credits

Supplementary note to the preceding slide Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html

Supplementary note to a preceding slide Why do mothers die? Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are: severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia and HIV.(2) Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies.

120 Passionate renegades120

Take home message Catastrophic inequities in distribution of foods Kinds of nutritional status & health impact Weve faced causes, know there are cures As we face the future we are... water, protein, iron, vitamin A, iodine Not by accident? Whos responsible? Whats needed perinatal - women and children not just across nations increasingly within Impatient Optimistic http://www.sfu.ca/global-nutrition

1.tfin the poor nations almost everyone is hungry; in the remainder almost everyone gets an adequate...

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