nutrition & the politics of famine international development & health hilary term 2009...

Nutrition & the Politics of Famine

International Development & HealthHilary Term 2009Proochista Ariana

Overview

• 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 non-communicable 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

Source: Global Burden of Disease 2004

5 stage model of Epi TransitionStage Characteristics

Age of pestilence and famine Infectious and nutritional related cardiomyopathies; Rheumatic heart disease

Age of receding pandemics Hypertensive cardiovascular diseaseHaemorrhagic strokes

Age of degenerative and man-made diseases

Haemorrhagic and ischemic stoke, ischemic heart disease, diabetes and obesity Onset at younger age

Age of delayed degenerative diseases Atherosclerotic cardiovascular disease; Onset of chronic disease at older ages – delay occurs due to improved prevention and treatment

Age of health regression and social upheaval

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

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 non-communicable disease

• Average life expectancy decreases and an increase in the prevalence of non-communicable 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 varied3. Receding famine: Fewer starchy staples; more

fruits, vegetables, animal protein; low variety4. Degenerative disease: More fat, sugar &

processed foods; less fibre5. 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

Source: World Health Organisation (2006) Global Health Atlas

* Data for latest year available

Levels of obesity in selected countries*

0

10

20

30

40

50

60

70

80

90

Nauru Samoa USA Chile Germany SouthAfrica

Morocco China

Perc

en

tag

e

Men Women

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 <18.50 Severe thinness <16.00 Moderate thinness 16.00 - 16.99 Mild thinness 17.00 - 18.49Normal range 18.50 - 24.99Overweight ≥25.00 Pre-obese 25.00 - 29.99 Obese ≥30.00 Obese class I 30.00 - 34-99 Obese class II 35.00 - 39.99 Obese class III ≥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, income-earning 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

• 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

• 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

Persico et al, 2004

• In the past 13 US presidential elections, the taller candidate has won 10 times (the most recent exception being George W. Bush)

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)

Vitamin AVitamin A

ThiaminThiamin RiboflavinRiboflavin

NiacinNiacinFolateFolate

ManganeseManganese

MagnesiumMagnesium

IronIron

IodineIodine

CobalaminCobalamin

CobaltCobaltZincZinc

Vitamin CVitamin C

Vitamin EVitamin E

Vitamin DVitamin D

Vitamin KVitamin K

Vitamin BVitamin B66

Vitamin BVitamin B1212

SeleniumSelenium

ChromiumChromium

PhosphorusPhosphorus

….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

• 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 ATable 1: Selected animal sources of vitamin AFood Vitamin A (IU) %DVLiver, beef, cooked, 3 ounces 27,185 545Liver, chicken, cooked, 3 ounces 12,325 245Milk, fortified skim, 1 cup 500 10Cheese, cheddar, 1 ounce 284 6Milk, whole (3.25% fat), 1 cup 249 5

226 5

Table 2: Selected plant sources of vitamin A (from beta-carotene)Food Vitamin A (IU) %DV

22,567 45013,418 27011,458 230

9,558 1908,666 175

Vegetable soup, canned, chunky, ready-to-serve, 1 cup 5,820 115Cantaloupe, 1 cup cubes 5,411 110Spinach, raw, 1 cup 2,813 55

2,063 401,651 35

Papaya, 1 cup cubes 1,532 30Mango, 1 cup sliced 1,262 25Oatmeal, instant, fortified, plain, prepared with water, 1 cup 1,252 25

1,050 20Tomato juice, canned, 6 ounces 819 15

473 10Peach, 1 medium 319 6

313 6

http://ods.od.nih.gov/factsheets

Iodine Deficiency

• 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

• 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

• 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 micro-

nutrient 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 mid-1980s 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 long-term 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

• 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 long-

term 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• 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 under-

develops 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 Wolff-Chaikoff 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: Reported military coup thwarted by Kim Jong Il regime in Northeast

April: North 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 responsible for feeding themselves

February : Kim de Jung inaugurated as President of South Korea and initiates ŅSunshine PolicyÓ seeking North-South reconciliation

Purchases of Chinese maize declines, because of production decline thereby increasing the price of grain in private markets

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Kim Il Sung regime indicates two-meal-a-day campaign to ration diminishing food supplies

Food distributions become intermittent in the Northeast

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

August: Massive flooding in the country

September:

Kim Jong Il reduced grain rations for farm (rural) families

Kim Jong Il regime Moves responsibility for managing the food distribution system from national to country authorities

Selective food distributions continue in capital while genera l population fends for itself in private

Early 1997: Unconfirmed reports of martial law

September 27: Kim Jong Il regime creates 927 retention camps in each county for internally displaced people caught without travel permits

Spring: Food prices in private markets decrease due to influx of international food aid shipment

Summer: Kim Jong Il regime tightens travel permit regulations and impose new fines to re-establish order after period of population movement while

Famine Peaks

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