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1 Médecins Sans Frontières / Doctors Without Borders (MSF) UK
Life on the margins: the inequality of food and nutrition security MALNUTRITION PowerPoint presentation by Médecins Sans Frontières / Doctors Without Borders (MSF) UK Schools Team: Mary Doherty and Severa von Wentzel January 2014

2 Malnutrition: Undernutrition
Awareness ribbon for malnutrition Image: Wikipedia Malnutrition: Undernutrition

3 “With diseases related to malnutrition on the rise, the challenge is not only to ensure food security, but also to address the nutritional quality of the food being consumed and its impact on health.” - Dr Frenck G ,

4 Malnutrition terms Adequate food is at the basis of an active and healthy life. Yet, in spite of significant improvements, millions of people today are malnourished. Malnutrition: An abnormal physiological condition caused by inadequate, unbalanced or excessive consumption of macronutrients and/or micronutrients. Malnutrition includes undernutrition and overnutrition as well as micronutrient deficiencies. Minimum dietary energy requirement (MDER): amount of energy needed for light activity and a minimum acceptable weight for attained height. Body Mass Index (BMI) relates weight to height and is used to evaluate thinness and obesity. Teacher resource slide: How to measure Malnutrition Source: World bank, Scaling up Nutrition: What will it cost? 2010

5 Malnutrition terms Protein-energy malnutrition: BMI and shortness are indicators. A broad (older) term from the 1970s when protein deficiency was felt to be the primary driver behind malnutrition. Replaced by the more general term ‘acute malnutrition’ which includes macronutrient imbalance/insuffiency as well as micronutrient deficiency. Micronutrient deficiency: “hidden hunger”, a lack of one or more essential vitamins and minerals, such as Vitamin A, iron, iodine or zinc. Indicator iron-deficiency anaemia low haemoglobin in blood. Micronutrient powders (MNP) are used to prevent micronutrient deficiencies; for example, on a large-scale basis in Bangladesh.

6 Undernutrition Poor health, growth and development outcomes can result from hunger and poor nutrition. Under nutrition is “the outcome of undernourishment, and/or poor absorption and/or poor biological use of nutrients consumed as a result of repeated infectious disease. It includes being underweight for one’s age, too short for one’s age (stunted), dangerously thin for one’s height (wasted) and deficient in vitamins and minerals (micronutrient malnutrition).(FAO definition Under nutrition includes being: Underweight: a child has low weight for age. Composite measure includes chronic and acute malnutrition. Stunting: child short for their age as a result of chronic under nutrition during the most critical periods of growth and development in early life. Wasting: child’s weight is too low for their height as a result of acute under nutrition, can vary with the seasons. Reflects loss of muscle tissue and fat. Kwashiorkor: sudden onset swelling of the feet, hands and face. Cause unknown, but occurs typically in children 2-3 years old once they are weaned from breast milk and can be cured by feeding a specially fortified milk. Form of severe malnutrition.

7 Undernourishment Famine
Undernourishment or chronic hunger: A state, lasting for at least one year, of inability to acquire enough food, defined as a level of food intake insuffiecient to meet dietary energy requirements. For the purposes of this presentation, hunger was defined as being synonymous with chronic undernourishment. Famine is the state in which significant proportion (at least 20%) of a defined population lacks access to food in sufficient quantity and quality, such that epidemics of infectious disease become more frequent, acute malnutrition rates in children under 5 are above 30% and death rates rise. In famine conditions, the most vulnerable members of the population - the very young, the elderly and those with chronic illness – are at higher risk of death. Note to teachers: It may be worth stressing that famines can be man-made. An example of a man-made famine of catastrophic proportions was the famine in China between 1958 – 1961.

8 Starvation Starvation occurs when the individual’ nutrient intake drops below what is needed to maintain body mass and the body begins to consume muscle and other lean tissues in order to supply nutrients to maintain metabolic function. In an otherwise well adult who continues to drink water but ceases all nutrient intake, this process of starvation leads to death in about 2 months. The process of starvation affects all the body’s organ systems, but the most visible signs are weakness, apathy and muscle wasting. Teacher resource slide: How Malnutrition kills

9 Hunger IQ and FAQs Action for students:
With a partner test your Hunger IQ: and read Hunger Frequently asked questions (FAQs) including the overview, record what is hunger, who are the hungry, what causes hunger, what is malnutrition? Extract the salient information from each of the documents and individually record the information so you can readily refer to it. Can you explain why solving hunger is regarded as a ‘best buy’ in today's tough economy? 4. Use the data from Who are the hungry? Draw a bar chart showing how the 870 million hungry people in the world are distributed. Draw a pie chart which shows the proportion of hungry people living in rural areas. Draw another pie chart showing the proportion of hungry people from small holding farming communities, those from landless families dependent on farming and the proportion dependent on herding, fishing or forest resources. Note to teachers: The students response to the Action for students on this and the previous and the previous slide will yield very helpful assessment for learning information to the teacher which will inform your future planning of teaching and learning

10 Hunger case studies Action for students: Look through Hunger in the news 2. Make brief notes on the current hunger crises and debates around the globe paying particular attention to the case studies used in this unit: The Sahel (Sub-Saharan Africa ) Bangladesh, India (South Asia) Kenya The UK The USA What is in the news about these case studies, malnutrition and life on the margins? Add helpful information to your notes. “Every man, woman and child has the inalienable right to be free from hunger.” - First World Food Conference Declaration, Rome, 1974 Note for teachers: You may want to start this Unit with a scene setting video- the MSF website will lead you to relevant videos and the slide The SAHEL: Starved for attention has two very good videos to set the scene. The information sheets from the WFP merit careful reading and discussion, you may want to print the sheets for your own reference and ideally for each of the students to have a copy to highlight and annotate or to save in an electronic file suitably annotated and highlighted. Encourage students to think about how best to record the pertinent information and data as a foundation for their study of this topic and to be easily accessible during the pre release preparatory stage. The Sahel is a case study for desertification and climate change impact on food supply, food security at the margins.

11 World economic growth and undernourishment
Agriculture plays an essential role in the world economy. Beyond food production, it is as an engine of economic growth key to growth in rural settings and poverty reduction in transition countries. It generally accounts for half of GDP in developing countries; its share in the economy tends to decline with development. Investments in agriculture have a poverty-reduction impact larger than any other sector. K Source: Fairfood

12 Rise in hungry people Number of hungry people, Since the number of hungry people has risen. Even at times of economic growth and low food prices, the number of hungry has not fallen below around 800 million over the past 40 years. Note for teachers: Teacher resource title: Hunger by place You may want to ask students to predict how the number of hungry people has changed since 2010 and to ask students to research data on hungry people for 2011 and 2012 and add it to the graph. The examiners report for June 2010 noted that many students referred to the world wide increase in food prices since 2008 which led to the riots in the Philippines and Egypt. Source: FAO; Source:

13 Factors in rise of hungry people
1. Governments and international agencies have neglected agriculture and the synergy between agriculture and social protection relevant to very poor people; for every five people suffering from hunger, three rely on farming. Women and small holder farmers most affected. Food reserves have also shrunk. Current worldwide economic crisis and financial, trade and policy issues; Energy and climate issues; 4. Devastating impact of food price hikes, a large upward movement in price in a short time, on people existing on only a few dollars a day. 5. Speculation and concentration of agribusiness* and retail among very few players. * Agribusiness: the manufacture and distribution of farm supplies,; farm production operations, storage, processing and distribution of farm commodities and products most often by corporations. Source: FAO; Source:

14 Source:

15 Note to teachers: You may want to look at how trends are affected by factors such as growing populations and climate. K Source:

16 Global Hunger Index K International Food Policy Research Institute
Action for students: Note the three dimensions of which the GHI is composed in your folder along with the main trends per region. K Prevalence: proportion of people in a population with a particular disease at a specified point in time or over a specified period of time – as opposed to new cases which is incidence Rate “A measure of the intensity of the occurrence of an event. For example, the mortality rate equals the number who die in one year divided by the number at risk of dying. Rate—A measure of the intensity of the occurrence of an event.“( Note for teachers: This slide could provide the basis for a rich discussion about trends in the world and region by region Action for students: What is the index composed of and used for? Identify the region which in 2012 had the highest under five mortality rate and the lowest. Which region had the highest prevalence of underweight children in 2012? And the lowest? Which region had the greatest proportion of undernourished in 2012? And the least? Teacher resource title: GHI winners and losers AND HANCI commitment

17 Hunger and Nutrition Commitment Index
Further info: Community voices from Bangladesh: Source:

18 How to measure malnutrition
Anthropometry Weight Length or height Middle upper arm circumference Weight and height must be compared to age or to each other and therefore are turned into indices Weight for age called ‘underweight’. Includes both wasting and stunting Weight for length or body mass index, measure of ‘wasting’ and ‘obesity’ Height for age, measure of ‘stunting’ Other signs or measures a. Oedema (water retention) of feet, hands, face b. Blood test for anemia (iron deficiency in particular) c. Blood test for certain micronutrients: Vitamin A or zinc

19 How malnutrition kills
The commonest form of malnutrition called marasmus results in an affected child being severely wasted, with no fat and very little muscle tissue left on his or her body. The internal organs, including the heart and the blood, are also weakened. The child is left with no reserves to fight infection, and any illness that comes along is likely to be fatal. The commonest causes of death during a famine are in fact infectious diseases, rather than starvation per se. Chief among these are pneumonia, diarrhoea, and measles. UNICEF on Marasmus The other form of malnutrition, called kwashiorkor, in which the child's body is swollen, likewise kills by lowering resistance to infection. However, kwashiorkor can also be fatal in its own right, because of the disturbed levels of salts and minerals (electrolyte imbalances) that accompany it. In a therapeutic feeding centre, where only severely malnourished children are cared for, many deaths tend to occur at night. This is because these children are especially prone to low blood sugar (hypoglycaemia) and low body temperature (hypothermia). (MSF US website) Clip on Kwashiorkor

20 Determinants of child nutrition and development
Immediate determinants include: Adequate food and nutrition intake Parenting, caretaking and feeding practices Low burden of infectious diseases Underlying determinants include: Food and nutrition security Adequate resources at the community, household and maternal (mother’s) level Access to health care provision Safe and hygienic environment Source:

21 The wrong start One out of six children -- roughly 100 million -- in developing countries are underweight, but trend is down. Source: Global health Observatory, WHO, 2011 Note for teachers: This is a good opportunity for students, informed by the guidance from the Examiners' Report and the Awarding Body mark scheme to prepare a practise report. Discuss with students the process used for the practise report and using that approach to form a study group with three other students to research, use the information on the preceding slides and develop a written plan for a report with the title: Malnutrition in children under five can be eradicated –discuss. Study groups to exchange report plans and provide written feedback on the plan. Individual students to modify the plan from their own study group and then to work in pairs to write the report. Teacher resource title: Cartogram – proportion of underweight children by country Source: Unicef Nutrition Report 2013 and World bank

22 Wasting and stunting When a population is short this points to nutritional deprivation or disease in childhood. *Acute malnutrition is defined as the percentage of children 0 to 59 months whose weight for height falls below minus two standard deviations (moderate and severe wasting) and minus three standard deviations (severe wasting) from the median of the WHO Child Growth standards. Severe acute malnutrition: percentage of children aged 6 to 59 months whose weight for height is below minus three standard deviations from the median of the WHO Child Growth Standards or by a mid-upper-arm circumference less than 115 mm, with or without nutritional oedema. Notes: Severe acute malnutrition: percentage of children aged 6 to 59 months whose weight for height is below minus three standard deviations from the median of the WHO Child Growth Standards or by a mid-upper-arm circumference less than 115 mm, with or without nutritional oedema. Overweight: percentage of children aged 0 to 59 months whose weight for height is above two standard deviations (overweight and obese) or above three standards (obese) from the median of the WHO Child Growth standards. Standard deviation: Image:;

23 A STUNTED IN CHILD has lower chances of survival and less optimal health and growth. has greater propensity for developing obesity and chronic diseases as an adult, fuelling obesity epidemic in low and medium income countries. is more likely to have been born to a mother with poor nutrition and health status, which perpetuates vicious cycle of under nutrition and poverty. Note for teachers: This slide will be useful to prompt students to consider why the focus has shifted to stunting and also to appreciate the potential lifelong impact of stunting in children. International health organisations are starting to shift their focus from underweight prevalence (inadequate weight for age) to prevention of stunting (inadequate length / height for age). Source: Image: Image:

24 Stunting prevalence by region
Globally, about 1 in 5 (26% in 2011) children are stunted of whom 80% live in 40 countries. Undernutrition affects poor children most, but rates are high enough to deserve attention even among the better-off children in developing countries. South Asia Sub-Saharan Africa Middle-East / North Africa East Asia / Pacific Latin America / Caribbean CEE / CIS Developing countries Note for teachers: The data on this slide, particularly for South Asia and Sub-Saharan Africa can be incorporated into students case studies. South Asia stands out. The bias against women has a negative impact on men and women, because both can have unduly undernourished and small women as mothers. This can compromise their physical and cognitive development. * Prevalence is the proportion of the population that has a condition of interest at a specific point in time. Source: A Ergo et al “What difference do the new WHO child growth standards make for the prevalence and socioeconomic distribution of undernutrition?” Food Nutrition Bulletin

25 Stunting in children and income growth
Improvements in nutritional status lag behind economic growth, but are boosted by income growth. Source:

26 Silent emergency of stunting
Action for students: With a partner use the resources below and others to research the trends of malnutrition prevalence since 1980. 2. Explain the reasons why some have shifted their focus from underweight to stunting . 3. From your research explain the title-The silent emergency of stunting 4. Find out about and write a brief paragraph on the Scaling Up Nutrition (SUN) Movement. Malnutrition prevalence, weight for age (% of children under 5) Map from 1980 in 4 year segments up to “Improving Child Nutrition - The achievable goal for Global Progress” “Break the cycle of stunting": “The Life cycle of malnutrition” Clip on Cycle in South Asia Trendalyzer video / presentation on 1000-day window, cycle and initiatives: and “A Life Free from Hunger” on the life-long consequences of stunting Note for teachers: This research provides an opportunity to focus students attention on how to research and record the fruits of their research. Their response to this task will provide you with helpful evidence on how developed their research skills are currently. In some cases, you may need to do a more intensive session on developing students approaches to research.

27 Note for teachers: This slide should prompt a rich discussion
Source: 1000 infographic What causes maternal and child malnutrition

28 What is at the root of the problem?
Note to teachers: It will be helpful to discuss with students the importance and significance of the 1000 day window Further info on where the poor live and are going to live? Free exchange: The geography of poverty”, The Economist September 1st 2012, Image: 1000 infographic What causes maternal and child malnutrition

29 Childhood malnutrition: causes, campaign and Sahel (1)
The mother’s status (is she disadvantaged?) is likely to affect the child’s food intake and health status – both proximate determinants of the child’s nutritional status. Causes of malnutrition include: poverty, quality of environmental conditions (poor housing conditions, inadequate water, hygiene practices and sanitation), illiteracy, unemployment, social problems poor awareness about mal/nutrition poor access or quality of health services. Source: World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, Switzerland: WHO,1999: Accessed November 2012.

30 Childhood malnutrition: causes, campaign and Sahel (2)
Action for students: Make notes in your folder from the nutrition glossary: Watch the “Rewrite the Story” clip on MSF’s campaign to make childhood malnutrition more visible on the global agenda and in people’s minds. What are the main arguments? Time to prevent malnutrition in the Sahel (on Malaria and Malnutrition) 4. Report Malnutrition in the Sahel: One Million Children Treated – What’s Next? 5. Sahel: Treating malnutrition.

31 Girls and women The distribution of malnutrition is highly gendered, girls and women make up more than 70% of the world’s hungry (UN). Girls and women produce more than 55% of the world’s food supply (UN). They endure lower salaries, fewer promotions, less secure employment, unreasonably long hours whilst continuing with traditional household responsibilities. They represent 41% of farmers around the world; own only 2% of the land (Rural Poverty Portal) Women in Africa receive less than 10% of all credit going to small farmers, and only 1% of the total credit going to the agricultural sector (Rural Poverty Portal) Note to teachers: The malnutrition of women and girls and the role of women as small holders is an underpinning theme. Source:

32 Women’s empowerment (1)
Women’s health and nutrition, equality and empowerment are worthwhile ends in themselves. In addition they have many benefits, including: Intergenerational benefits Poverty reduction Economic efficiency In many settings, greater access to agricultural lands and economic rights are needed for women to exploit the synergy between agriculture and social protection. Source: 17 Image: 3/08/thefemaleface-of-poverty/

33 Women’s empowerment (2)
“Gender-based inequalities at every point in the value-chain have traditionally impeded the realization of food and nutritional security.....In most developing countries women play a key role in the cultivation of food and cash crops as well as the nutritional care of their children and are therefore critical to food and nutritional security. Investment in women can lead to tremendous dividends.” According to the Lancet, evidence supports that women and men allocate food differently. There are: Positive associations between women’s empowerment and improved maternal and child nutrition. Negative associations between disempowerment such as domestic violence and child nutrition outcomes Positive impacts on women’s empowerment of agricultural programmes and cash transfers Source: The lancet “Nutrition-sensitive Interventions and Programmes: How Can They Help Accelerate Progress in Improving Maternal and Child Nutrition?”

34 Women’s inequality drives the cycle
Gender “refers to the socially constructed roles behaviour, activities and attributes that a particular society considers appropriate for men and women.” Not inherently given by biology, these vary across cultures. “The distinct roles and behaviour may give rise to gender inequalities, i.e. differences between men and women that systematically favour one group. In turn, such inequalities can lead to inequities between men and women in both health status and access to health care.” ( Gender equality “implies a society in which women and men enjoy the same opportunities, outcomes, rights and obligations in all spheres of life.” ( Gender equity Process of being fair to men and women alike that leads to equality. Gender empowerment: “A critical aspect of promoting gender equality is the empowerment of women, with a focus on identifying and redressing power imbalances and giving women more autonomy to manage their own lives. Women's empowerment is vital to sustainable development and the realization of human rights for all.” Note for teachers: You make want to discuss this slide thoroughly with your students and encourage students to understand the terms and the difference between them.

35 Women’s inequality and food and nutritional security
Note to teachers: This is a vicious cycle, discuss with students how it could become a virtuous one. Image gender cycle:

36 Feast or Famine Action for students: 1. Watch the interactive slideshow on nutrition emergencies and classification: 2. Discuss in pairs: what is the difference between hunger, malnutrition, starvation and famine. Make sure you have a clear definition of each of these words recorded in your folder. 3. Explain why there is malnutrition in LEDCs. 4. What do you believe the phrase ‘Feast or Famine’ means?

37 Malnutrition in Bangladesh And India

38 Bangladesh and India Action for students:
Label the map with countries, main cities, bodies of water. 2. Watch “Terrifying Normalcy” of malnutrition in Bangladesh – 3. Record key data and information for your case study on Bangladesh and India 4. What do you understand is meant by the title of the video.? Why is it terrifying? Note to teachers: You may want to discuss with students why Bangladesh and India are helpful case studies and you may also want to prompt a discussion about how students could structure their case studies to prepare for the exams Source:

39 Malnutrition in South Asia
“Among all regions, South Asia has the worst record on malnutrition... In developing countries, on average, 29 per cent of children are underweight; In South Asia it is 49 per cent. Thirty-three [of] children in developing countries are stunted; but 48 per cent in south Asia are. Ten per cent of children in the developing world are wasted; the share is 17 per cent in south Asia ... [but] child survival rates in south Asia [are] so much better than in SSA....the south Asian child usually has better access to modern medical care, especially antibiotics” – Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political, Weekly March 11, 2006 Image: Note for teachers: It is worth emphasising these statistics and asking students to record for their research

40 Bangladesh profile (1) In South Asia, Bangladesh urbanisation (highest rate in South Asia) is largely driven by rural-urban migration, which gained in momentum after the country’s independence in The capital Dhaka has most dominant role. Half of its population of 163,654,860 (July 2013 est., CIA World Factbook) live in poverty and about one third in extreme poverty, so third largest number after China and India. Poor access to food due to poverty. Between 1990 and 2010 poverty rates declined substantially with per capita GDP doubling and economic growth appearing to have reached the poor; agricultural growth averaged 3.3% a year thanks to great gains in rice yields (FAO 2012). Source:* Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political Weekly March 11, 2006 CIA World factbook; Note to teachers: This is a template slide which can guide the one for India.

41 Bangladesh profile (2) Most densely populated country in the world, 28.4% of total population is urban (2011). Overcrowding, especially intense in urban areas, makes environmental hygienic conditions worse, which leads to greater disease affecting absorption of nutrients. The socio-economic status of rural-urban migrants is moderately lower than their urban native counterparts. Women in South Asia have the worst educational indicators relative to men with lowest adult literacy rates for women as a percentage of men (63%)* Bangladesh has seen dramatic advances in child survival thanks to economic, economic and political empowerment of women; and higher participation of girls in formal education with literacy rates 38% in 1991 increasing to 77% in 2009 Source:* Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political Weekly March 11, 2006 CIA World factbook;

42 Bangladesh health profile
“During pregnancy, they eat the same food. Whatever they are having now, they have the same then. Who will give them extra food? That’s why their children are weak and suffer from malnutrition; for which they do not do well in education like the children of the rich class. Who will get this fact?” Female, Nilphamari District, Bangladesh, HANCI report Share of government spending on health about double that of India and Pakistan, its large neighbours. Twenty-five million face hunger. Hunger distribution is highly gendered with nearly one third of women undernourished (Ahmed, Mahfuz, Ireen et al 2012) Second highest child malnutrition rates in the world with 48%, which is linked to low status of women in Bangladeshi society (circumscribed autonomy/agency). Husband and boys can be prioritised in food allocation. Mothers and daughters can have inadequate or low quality food and work requirements, leading to low health status. Malnutrition, it is estimated, costs US$ 1 billion a year in lost economic productivity. An estimated 50% reduction in undernourishment has been achieved (SUN 2011) Consumption of nutritious food appears to be on the increase. Teacher resource slide: Food availability and access do not always mean a good diet Source:

43 Bangladesh indicators
Significant public health concern: Wasting16% prevalence beyond 15% emergency threshold. Levels of stunting 41% and underweight 36% (2011 figures, according to UN definition) K Note for teachers: You will want to discuss trends shown in this slide with students. Source:

44 India case study: country profile sources
Action for students: Using the previous slide on Bangladesh as a template for a country profile, distil relevant facts pertaining to the population’s well-being in general and malnutrition in particular. Why do studies look at the level of the mother’s education? CIA World Factbook, Measure DHS (demographic and health surveys), World Bank and BBC Country Profiles are good starting points Note to teachers: Education, especially mother’s education, has an impact on well-being along with factors such as wealth, access to healthcare and family planning.

45 Nutritional status: Bangladesh and India
Percentage of children under 5 underweight (this is a nutritional indicator for the whole community) among highest in the world 2nd for India and 4th for Bangladesh (World Factbook); stunting prevalence 41.3% in Bangladesh in 2011 (Measure DHS) Among lowest adult obesity prevalence rate in the world 184th for India and 190th for Bangladesh in the world, but alarming rise in BMI over 25 for women in Bangladesh from 12% in 2007 to 17% in 2011 Bangladesh Childhood under nutrition has declined, but maternal nutrition has not improved significantly in Bangladesh ( Anaemia continues to be a major nutritional problem in children and women in Bangladesh India Action for students: Note some of the issues arising from the fact that the latest data for India dates back to a national family health survey Record the relevant points for your folder from “UNICEF Nutrition in India” FAO Country India Nutrition profile Source: CIA World factbook®ionCode=sas&rank=190#bg) ( /india/ _1_nutritional-status-addressing-malnutrition-lancet-series

46 The Double Burden of Malnutrition AND Nutrition Transition

47 “Malnutrition, both under and over, can no longer be
addressed without considering global food insecurity, socioeconomic disparity, both globally and nationally, and global cultural, social and epidemiological transitions.” - Darnton-Hill and ET Coyne “Feast and famine: socioeconomic disparities in global nutrition and health” Note for teachers: It will be worthwhile to unravel this quote as it highlights for students that addressing malnutrition is complex and needs global action.

48 Double burden of malnutrition (1)
Double burden of malnutrition: Persistence of under nutrition, especially among children, along with rapidly increasing overweight, obesity and diet- and life-style related chronic diseases especially among the poor. In China, for example, there has been a significant rural-urban difference in obesity prevalence which offset marked reductions in underweight prevalence. These forms of malnutrition usually result from uneven access to food and unbalanced diets. Both under- and over-nutrition are problems of poverty and are bound to become even more closely interwoven. Immediate and root causes of malnutrition are multidimensional and complex. Note to teachers: Summary slide.

49 Double burden of malnutrition (2)
In countries where famine and under nutrition were traditionally the main issue, the reverse now is the case: over nutrition is increasing, especially in India and China, countries recently more affluent. In developing countries, rapid urbanisation is linked to diets with more fats, animal source foods and processed products and lower activity levels resulting in higher levels of obesity. ( Action for students: Write a few paragraphs for your folder explaining what is meant by the phrase “the double burden of malnutrition.”

50 Nutritional adequacy Energy – provided in the form of protein, carbohydrates and fats. Sometimes referred to as macro-nutrients. Micronutrients – vitamins and minerals essential to all metabolic processes in the body. Fruits and vegetables are rich in micronutrients, as are many animal sourced foods. Liver is an excellent source of iron, B vitamins and Vitamin A. Animal sourced food – meat, fish, eggs, dairy. These foods provide complete protein and many micronutrients in addition. For example, dairy foods provide complete protein, an excellent source of calcium, zinc and essential fats. Tubers and cereal – the least expensive source of energy, predominately carbohydrates. Also provide some protein and often rich in B vitamins. However, protein is usually not complete and these foods must be paired with beans or lentils to provide all the essential amino-acids (protein-building blocks).

51 Hunger and obesity - both forms of malnutrition
Action for students: Watch the video Nutrition in 2 minutes - and Unicef slideshow lessons with quiz on nutrition - Childhood Malnutrition: What happens now 3. Discuss and write notes for your folder on ‘under nutrition’ and the malnutrition cycle. 4. Record in your folder the arguments in favour of preventing under nutrition? 5. Discuss in groups of four why hunger and obesity are two sides of the same coin, bearing in mind socio-economic, political and environmental factors. Note to teachers: There is a long-established belief that hunger is about not getting enough food, but it is about getting enough of the right foods at the right time. The Nutrition video introduces the malnutrition cycle and window of opportunity, arguing for prevention on the grounds that it is far more cost-effective than treatment and that treatment cannot reverse life-long damages. The slideshow lessons explains and has pictures about the basic concepts of nutrition in greater detail than the hunger FAQ on the previous slide.

52 Poorest are most vulnerable to malnutrition
Triad: Poverty – Dietary Quality / Adequacy – Health In MEDC, poverty can be associated with poorer health and shortened life expectancy due to obesity because calories are cheap and micronutrients are expensive. In LEDC, it can manifest as wasted/stunted children who do not get enough of the right kinds of foods at crucial moments in their life when assailed by many infections. Adult obesity is one of the risks in populations with many undernourished young children as well as higher mortality rates at all phases of the life cycle.

53 Hunger and obesity The number of hungry people and obese people are both growing, worldwide. Note to teachers: It may be worthwhile to distinguish between absolute numbers and percentage within populations. Source: FAO and WHO study

54 Hunger and obesity afflict poorest populations most (1)
Root cause of chronic hunger: poverty and lack of income generation. These also can limit access to basic health and sanitation services and decent housing. Malnutrition and food insecurity are interrelated with poverty. Social disparities drive both hunger and obesity. Tremendous issues around affordability of food, percentage of income spent on food.

55 Hunger and obesity afflict poorest populations most (2)
Note to teachers: You may want to discuss with students the shape of this curve which shows the percentage of income spent on food by the richest and poorest. This graph could be very helpful for students to be able to sketch and explain in their report writing. Engel’s law: proportion of income spent on food decreases as income increases usually applies for countries that have sustained development. Further info: Gapminder Human development trends, 2005:interactive format Source: Food aid or hidden dumping -

56 Silent killers: hunger, malnutrition and obesity
Action for students: Why should some attention shift from infectious diseases that you can catch from other people (e.g., HIV/AIDS, TB) or mosquitoes (e.g., malaria) to the rising burden of illness related to obesity? Type People affected Hunger 0.9 billion Children underweight 146 million Children overweight 43 million Micro-nutrient deficiency More than 2 billion Overweight to chronic disease 1.5 billion overweight 500 million obese Note for teachers: “The double burden of malnutrition refers to the dual burden of under- and over nutrition occurring simultaneously within a population. Historically, under nutrition has been associated with higher prevalence of infectious diseases; as populations move into epidemiologic and demographic transition, increases in overweight and obesity begin to appear, while under nutrition and infectious disease become past problems. Today, the burden of disease and malnutrition does not fit neatly into the classic stages of transition, but reflects a modified pattern referred to as the protracted-polarized model, where infectious and chronic diseases coexist over long periods of time (Frenk et al., 1989 in Chopra, 2004a). Evidence of this has been documented in countries as diverse as China (Cook and Dummer, 2003) and South Africa (Chopra, 2004a).” Source: Source: Joachim von Braun, IFPRI, September 2007 Source: Women in Agriculture: Closing the Gender Gap for Development, FAO, 2011; Source: Levels and Trends in Child Mortality, UNICEF, 2011

57 Globalisation of hunger and obesity
Globalisation and technical innovation have reduced global inequality, but inequality within countries has widened. The twin forces expose the food system to novel economic and political pressures. Note for teachers: You may want to emphasise the conclusions draw in the Ted talk and discuss with students the evidence base and validity of these conclusions to model for students how to approach developing conclusions in their reports. This is an aspect, which according to the Examiners Reports needs further practise. You may want to remind students of AS work on the factors that accelerate globalisation and now consider how these factors play out in agri-business. Globalisation means individuals can earn and consume more, but also growing inequality. Image: Source: ; Economist October 13th 2012 “True Progressivism”

58 Globalisation of hunger and obesity
Action for students: 1. Define globalisation and take special note of trends and their relevance to obesity and hunger around the world In pairs, watch the Ted Talk video and explain Why “Obesity + Hunger = 1 Global Issue”. What does globalization of obesity and hunger mean? How does obesity in the US relate to Africa? Work with a partner and discuss and record the conclusions that can be drawn from the TED talk.

59 Prevalence of obesity K
Action for students: Label the ‘obese’ countries. Discuss: What are the factors which have contributed to the burden being so high in the various countries? Looking at the following slide, what are the trends around the world? Record your agreed answers in your folder Note for teachers: It may also be helpful if students prepare a list of countries with the most obesity and least obesity. Encourage students to memorise the top and bottom three countries. K Source: Map not dated in source, but website up to date (2013)

60 Public health issue Obesity is an issue that is as complicated as undernutrition and it is far more complex than personal lifestyle choices. Double burden countries. India is the best example. High prevalence of low-birth weight and childhood undernutrition and rapidly increasing prevalence of adult obesity Mexico: now the most obese country in the world. Excessive consumption of sugar-sweetened beverages, in large part driven by a long history of water-borne illness in the water supply (e.g., poor sanitation, contaminated drinking water) Food policies: the US government with a forty-year history of subsidising corn and soy bean farmers – resulting in a large source of cheap calories , but lead to high calorie, cheap food that coerce the poorer quintiles of the population into consuming less nutritious food that promotes obesity. Note to teachers: You may need to explain or remind students what quintiles are. Image fact food:

61 Obesity: Physical factors
Apart from social disparities and being at the bottom of the income distribution, physical factors cause obesity. These are influenced by the food and physical activity environment in which people live. Further info on obesity causes and source: Image: Shifting consumption Genes (a little) Too much TV Prenatal and early life development Poor diet Note for teachers: This is a useful summary slide of the physical factors contributing to obesity. Too little sleep, too little exercise

62 Health consequences of obesity
In many countries around the world, being obese is now the biggest driver of sickness, because it raises the risk of, for example, diabetes, heart disease, stroke and some cancers. It is also linked to the increased incidence of osteo-athritis of the hip and knee (major cause of hip and knee replacements) Source: The Economist December 15th 2012;

63 Impact of obesity Individuals bear the bulk of the burden, but in many countries the state covers some or most of the associated and growing healthcare costs. The prognosis of those who do fall ill depends on where they live and whether they have access to health care. This can be a major issue for the poor living in the US and India, for example, where there is very high quality health care for those who can afford it. The social consequences go beyond increased health costs and include: National security concerns. In the United States, where health care is privatised for approximately half of the population, obesity is seen as a national security issue because so many military recruits are unfit (overweight). Similarly in China, childhood obesity is becoming a major concern, resulting from increased wealth (better and higher caloric diets) at the intersection of the one-child policy. Economic concerns: lost work days due to illness ultimately impacts productivity.

64 Obesity and social inequality in the UK
Obesity prevalence for adult women increases overall with greater levels of deprivation regardless of indicator used, whereas only occupation-based and qualification-based measures show differences in obesity rates by levels of deprivation for adult men. Highest level of educational attainment can be used as a measure of socioeconomic status. Obesity prevalence goes down as levels of educational attainment go up for both women and men. Adult obesity prevalence by highest level of education Health Survey for England Action for students: In pairs, explain why malnutrition and disease work in a deadly cycle and are driven by inequality and note down your agreed answers in your folder. Adult (aged 16+) obesity: BMI ≥ 30kg/m2 Further info and source: Health Survey for England; and Factsheet

65 Globesity epidemic (1) Since 1980: significant increases in global obesity** rates, the rate has nearly doubled Rises in obesity-related chronic diseases poses threat to individuals, health care systems and economies (e.g., cardiovascular disease diabetes type 2, musculoskeletal disorders — especially osteoarthritis, some cancers (endometrial, breast, and colon). Since 1990: rise in childhood obesity. Obesity has now reached epidemic*** proportions globally. Most prevalent in high-income countries, the obesity epidemic is also spreading to low- and middle-income countries as countries move up the income scale. Sixty-five per cent of the world's population live in countries where overweight and obesity kills more people than underweight. * Obesity: Body mass index (BMI) of 30 or higher. Body mass index is defined as the individual's body mass divided by the square of their height Overweight: 25 BMI or higher. ** Rate “A measure of the intensity of the occurrence of an event. For example, the mortality rate equals the number who die in one year divided by the number at risk of dying. Rate—A measure of the intensity of the occurrence of an event.“( *** Definition of epidemic and pandemic:

66 Globesity epidemic (2) Action for students:
Based on the article below, research and discuss in a group of four: 1. What are the trends by regions? 2. What are the differences by gender? 3. What social disparities drive the globesity epidemic? Globalisation of obesity OECD 2012 Update: Articles on obesity trends by region: Image:

67 Obese children 43 million overweight and obese pre-schoolers worldwide 35 million of whom live in developing countries. K Source: Note for teachers: It is important that students appreciate the rate of increase of overweight children in England and understand some of the factors which have led to this increase. Teacher resource slide: Child obesity on the rise Action for students: Research latest data for obese children for the countries on the graphs and add to the graph and chart on this and the following slide. What conclusions can you draw about obesity in children in England compared to the other countries on the graph?

68 Transition paradox That’s a cupcake! That’s a cupcake! Developmental transition: better food and nutritional status; urbanisation and globalisation as countries become more developed. Urbanisation and meat consumption rising hand in hand Nutrition transition: shift to food with high energy density especially fat “stone age appetites meeting capitalist abundance” Life style changes especially less physical activity Social disparities in obesity are unabated. Obesity shifting disproportionately to poor. Paradox: persisting underweight along with rising obesity within the same country, sometimes household. Source: images: The Economist September 1st 2012 “More or less” Note for teachers: You may want to discuss this paradox with students and the implications of obesity shifting disproportionately to the poor. The demographic transition is significant as richer societies have lower reproduction – so economic development and innovations increasing food supply – go against Thomas Malthus’ prediction of disaster of human populations outstripping food supply.

69 Busy bee or couch potato?
There are worryingly high rates of inactivity. “Since the beginning of the industrial revolution, technology and economic growth have conspired to create a world in which the flexing of muscles is more of an option rather than a necessity” – The Economist, July 21st 2012, p. 78 Note for teachers: Discuss with your students what this map and key shows. Does it support or refute the statement from The Economist K

70 Nutrition transition Convergence of diets and lifestyles globally:
More globalised food tastes such as westernised habits of meat eating, more dairy which takes more energy to produce and drives future grain consumption. Media encourages the food transition from traditional diets of grains and vegetables to often high protein and fats and sugars, westernised dietary habits and lower physical activity levels. Globalisation can mean that there is a switch from associating being obese with being rich to with being poor. With rising income rising middle classes in transition economies such as China are changing their food habits (China more quickly than India for various reasons) More choices and less active life style in urban areas Mechanisation of farm activity, switch from subsistence farming to high yielding cash crop also imports bad eating habits to rural areas. Food transition drives obesity and heart disease health risks and changes in the social and physical environment of production areas. The shift to foods that are far more resource-intensive to produce such as meat puts pressure on scarce resources. . Note to teachers: “Characteristics of the nutrition transition The nutrition transition refers to changes in the composition of the diet, usually accompanied by changes in physical activity levels. Popkin (2003) has characterised the nutrition transition into three stages: receding famine, degenerative disease, and behavioural change. In the first stage, diets are primarily derived from plant-based food sources, tend to be monotonous and are based more on home food production that requires high levels of physical activity related to planting, harvesting and processing. The second stage encompasses dietary changes that generally include more animal source foods, higher intakes of fat – both vegetable oils and saturated fat from animal products – increased use of sugar and other sweeteners, and higher reliance on food produced and processed outside the home or immediate community. Mandatory physical activity to produce food and procure water and fuel wood, including agriculture-based labour and household labour, is often also reduced. The final stage involves a shift to a diet with less saturated fat and decreasing reliance on processed foods. Typically, this stage encompasses increased intakes of whole grains, fruits and vegetables and decreased consumption of saturated fat, with a preference for animal source foods with lower saturated fat content (fish and poultry). Intensive physical labour related to agricultural production is not reintroduced, but non-obligatory physical activity is increased. In which populations is the nutrition transition occurring? The diets of most of the world’s population lie somewhere between the first and second stages of nutrition transition, while subsections of populations in North America and northern and southern Europe may be moving into the third stage. “ Source: Edexcel Student Guide Unit 4, Option 3; Image:

71 Shifting consumption Action for students: The issue is with what we eat – too much meat! Watch the Mark Bittman Ted Talk clip and Michael Pollan Oprah interview and write a paragraph supporting or disagreeing with the statement that we must reduce meat consumption Note for teachers: You may want to unravel and discuss this slide thoroughly with your students. You may want to ask students to write a paragraph on each of these pictures and to also write a conclusion for each picture. Image above Joachim von Braun Popkin, B., The World is Fat Image of McDonalds

72 Consumption culture Many consider obesity a personal decision or weakness, but actually a culture of consumption with much broader forces must be at work given the growing scale of the problem around the world. Many answers to deal with obesity have to do with culture and the food system and are not medical or personal, but the chronic health problems created in part by the food system tend to be medicalised by healthcare systems (hooking us up to machines and onto medicines). Teacher resource slide: Converging diets AND Rising food consumption Source:

73 Double pyramid Environmental impact of food choices

74 Transition Paradox and globesity (1)
Action for students: Looking at the PowerPoint “World Is Fat: New Dynamics Shifts in Patterns of The Nutrition Transition” note in your folder what is meant by transition paradox. 2. Using the information in the slides in this section write a report explaining the Nutrition transition and the consequences it may have for food supply, agriculture and health in non-western countries and regions. OR Write a plan, an introductory paragraph and methodology for a report: The nutrition transition is at the root of the growing global obesity (globesity). Note to teachers: This could be another practise opportunity for students. You may want to draw upon the Examiners Report on the Reports developed in the last four or five years, emphasizing to the students what the Examiner expects to see from very good candidates and providing model plans, introductions and methodology BEFORE the students attempt to produce their own in this practise.

75 Transition Paradox and globesity (2)

76 Teacher resources Slides

77 Cartogram: proportion of underweight children by country
Action for students: Label the countries with the biggest burden such as India, Pakistan, Nigeria, Bangladesh and the Philippines. 2. Relate this worldmapper cartogram to earlier one on human development – is the proportion of underweight children related to development? Equal area cartogram* Source:

78 Food availability and access do not always mean a good diet
Availability and access to good food alone do not suffice for balanced, good nutrition, which is necessary for optimal growth and mental development. In Bangladesh (see Figure 3), for example: 65 % of women live in households with food security, but 1 in 5 food secure women are malnourished Still 26% of children in wealthiest households are stunted! Note for teachers: It may be worthwhile reflecting on the UK access and availability to good food and to consider with students if this does lead to balanced good nutrition. Source:

79 Obesity prevalence over time

80 Child obesity on the rise

81 Converging diets K K K Source:

82 Rising food consumption
Global meat production and consumption is projected to rise by 70% between 2000 and 2030 and by 120% between 2000 and This growth and land degradation drive an increase in fertiliser use (IAASTD 2009) K K Source:

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