Nutrition and Global Health Micheline Beaudry is professor of Community Nutrition and International Nutrition at Université Laval in Québec city, Canada (since 1989). From January 1995 to December 1996, she was on leave from the University and Chief of the Nutrition Section in UNICEF Headquarters (New York). Previous positions include professor at Université de Moncton (1980-1989) and Regional Advisor in Nutrition Education at the Pan American Health Organization, in Washington (1975-79). She holds a Ph.D. in International Nutrition from Cornell University. Her international experience started in Latin America and the Caribbean at the end of the ‘60s. Between 1980-1991 she developed and directed a cooperation program between the University in Canada and several institutions in Nicaragua. She has since been involved with nutrition issues in most major regions and has seen the ravages of poor nutrition as well as the opportunities it provides for improving people’s lives. She has been active in several professional societies, frequently around the relevance of research, training and programs, to the nutrition problems of vulnerable groups. Her recent research has focused mainly on the area of breastfeeding and on food security. She has a number of scientific publications and communications and has done frequent consultations for national and international organizations Micheline Beaudry, Ph.D. Université Laval

Learning Objectives At the end of this lecture you will Be aware of the key role played by undernutrition in the lives of people & societies around the world Realize that food, though essential, is not equivalent to nutrition Know that there are affordable solutions & wish to find out more about them Malnutrition includes problems of deficiency, of excess and of imbalance in the intake or use of the over 50 nutrients that are recognized as necessary for health and development. It results from the interaction between poor diet and disease and should not be equated exclusively with hunger or inadequate dietary intake. While in industrialized societies, problems of excess or of imbalance are generally dominant, problems of undernutrition in various forms remain the most prevalent in the world & are also rising in countries of the North. Malnutrition is not only associated with poverty, it also contributes to it, seriously impairing not only the health but also the social &economic development of entire societies. This lecture provides an overview of the major problems of undernutrition in the world and some key directions towards their solution. Recent epidemiological data strengthens the relevance and urgency of addressing these problems. Solutions do exist and they are affordable. Everyone concerned with health and development should be aware of these opportunities.

At the end of this lecture you will be able to (performance objectives) List the 4 major nutrition problems in the world, their major manifestations, consequences & global distribution List the major causes of these problems and solutions proposed Convince a friend of the opportunities provided to improve people’s lives

The major nutrition problems in the world are: Protein-energy malnutrition (PEM) Iron deficiency Vitamin A deficiency or hypovitaminosis A (VAD) Iodine deficiency disorders (IDD) Nutrition-related chronic diseases Though these problems frequently co-exist to various degrees in populations, some groups exhibit one or more of these problems more seriously. It is therefore useful to examine each in turn. In industrialized countries, nutrition related chronic diseases are among the major causes of morbidity and mortality. Undernutrition in early childhood as indicated by low birthweight and weight at 1 year, increasingly appears as a risk factor for abdominal fat, obesity, hypertension and increased mortality from cardiovascular disease. The prevalence of such nutrition-related chronic diseases has in fact been rising rapidly in many countries of the South and is a new area of preoccupation. The current lecture will however only address the problems other than nutrition-related chronic diseases listed above. The just released ‘<a href=“http://www.unicef.org/sowc98 “>State of the World’s Children ‘98</a>’ by UNICEF underlines the opportunities provided by increased knowledge and experience in nutrition to better the lives of most of the world’s population.

Protein-energy malnutrition (PEM) Stunting insufficient height gain relative to age; implies long-term malnutrition and poor health Wasting insufficient weight gain relative to height/losing weight implies recent/acute malnutrition Underweight insufficient weight gain relative to age or losing weight implies various combinations of stunting and wasting Protein-energy malnutrition (PEM) generally refers to undernutrition in young children (though older children and adults can also suffer from it). The term is generally used to designate both increasingly rare forms of severe clinical malnutrition (such as kwashiorkor and marasmus) and the more common forms of growth faltering or growth impairment (often termed mild or moderate malnutrition). Yet, the term PEM fails to take account of the many nutrient deficiencies such as iron, zinc, and vitamin A that are involved in bringing about these conditions, in addition to deficits in protein and energy. Such general undernutrition also involves nondietary causes as infections and deficiencies in child care. Anthropometric indices are used as the main criteria for assessing the adequacy of diet and growth in infancy. The more commonly used indices are derived by comparing height and weight measurements with reference curves: height-for-age, weight-for-age and weight-for-height to identify stunting, wasting and underweight.

Proportion (%) of underweight children by region, 1985-1995 Underweight (weight for age) is still the most widespread indicator used. The proportion of underweight children in each region was estimated by the UN SubCommittee on Nutrition (ACC/SCN) in preparation for the Third Report of the World Nutrition Situation. In 1995, 86 million children were underweight in South Asia, 36 million in South East Asia & the Pacific, 32 million in SubSaharan Africa, 7 million in North Africa & the Middle East and 4 million in Latin America & the Caribbean. While the situation in SubSaharan Africa has been nearly static over the last decade, its prevalence of underweight is still considerably below that in South Asia which includes more than half the malnourished children in the world. Potential explanations are discussed in the attached paper <a href=“http://www.unicef.org/pon96/nuenigma.htm”>Click here<a/>.<br> Global progress in reducing the prevalence of underweight since 1990, or even progress in most regions, is still less than one fifth of that necessary to reach the goal of halving the prevalence from 1990-2000; this goal was approved at the <a href=“http://www.unicef.org/pon96/nutale.htm “>World Summit for Children and reaffirmed at the International Conference on Nutrition</a>.

PEM and young child mortality Malnutrition potentiates the effect of disease on child mortality The effect is for both mild-to-moderate as well as severe malnutrition; it is not only due to confounding by socioeconomic factors or intercurrent illness The effect of malnutrition and infection on child mortality is multiplicative rather than additive as was implicitly assumed PEM has important consequences for the survival, health and development of young children. The results of recent research by David Pelletier of Cornell University clearly show that malnutrition contributes to 56% of all child deaths and this because of its potentiating effects on infectious diseases. This is roughly 8-10 times higher than conventional estimates that ignore the potentiating effects of malnutrition on disease and the effects of mild and moderate malnutrition (MMM). In addition, 83% of the malnutrition-related deaths, are due to MMM as opposed to severe malnutrition; <a href=“http://www.unicef.org/pon95/nutr0007.html”> this is more significant than was commonly recognized</a>.<br> It also has important policy implications regarding the balance of various intervention strategies needed, interventions that combine health care, nutritional improvement, and reductions in disease exposure. (see Pelletier,DL. Nutrition Reviews 52:409-415,1994 or Bull World Health Organ 73(4): 443-448, 1995)

Other consequences of PEM Impaired cognitive & behavioral development Low educability Reduced productivity & income Poor reproductive health PEM also has important consequences for cognitive and behavioral development of young children, and for their educability <br> Because small children become small adults, their work capacity is also reduced physically, in addition to that due to cognitive and behavioral development. Small women have more complications from pregnancy; they also give birth to smaller babies, perpetuating the cycle of poor growth and development. <br> It should be pointed out that growth impairment really happens during foetal development and the first 2-3 years of life. After 3 years, most children seem to grow at fairly normal rates, though from the level attained by then. It is thus critical to facilitate adequate foetal growth and good growth during the first 2-3 years of life. <a href=“ http://www.paho.org/english/hpnfeb97.htm#Undernutrition”>Click here</a>

Causes of malnutrition Manifestations Growth, survival and development Immediate Causes Diet intake Disease CARE practices for mothers&ch Underlying Causes Access to FOOD HEALTH serv & environ. EDUCATION Ressources & Control Human, Economic & Organizational To look for solutions, and especially to sustainable solutions to the problem of PEM, or to favor good growth, survival and development, it is useful to examine the causes of PEM beyond the immediate causes which are related to the synergy between poor diet and disease.(framework adapted from UNICEF, 1990: Strategy for improved nutrition of children and women in developing countries). Poor diet and disease actually result from underlying causes related to insufficient access to food by families or households, inadequate caring practices provided to vulnerable members of the household, generally mothers and young children, and inadequate access to health services and to a healthy environment (e.g. clean water). It is necessary to identifiy in a specific situation what are the major constraints to providing adequate access to food, to health services and to care. These can be influenced to a certain extent by education but they fundamentally result from how ressources are used in society and who controls them; this in turn results from the political and ideological superstructure that is prevalent. Basic Causes Political, Ideological &Economic structure

To ensure adequate growth & nutrition, it is necessary to facilitate The ability of households to provide CARE for mothers & young children (e.g. breast-feeding, complementary feeding, love...) Access by households to sufficient FOOD to lead an active & healthy life Access to adequate HEALTH services (e.g. immunization) & a healthy environment (e.g. clean water) While access to sufficient food is a problem for many households (FAO estimates that 841 million persons still suffer from food inadequacy), it is less frequently the major constraint to adequate development of young children: they actually need only very small amounts of nutrient dense foods, but need them several times a day. Inadequate caring practices (e.g. sub-optimal breastfeeding, inappropriate or infrequent feeding of complementary foods...) & insufficient access to health services (e.g. lack of immunization) & a healthy environment ,(e.g. no clean water, poor sanitary facilities) are often the major obstacles to adequate nutrition of young children. <br> Actions which facilitate the daily deliberate actions and decisions made by parents for their young children, e.g. alleviating the workload of mothers, growth promotion activities (not just growth monitoring), protection of breastfeeding (which should be exclusive for the first 6 months and continued with appropriate complementary foods for 2 years and beyond) are critical.

Iron deficiency Over 2 billion people suffer from some form of iron deficiency Not all causes of anaemia are nutritional in origin; yet anaemia linked to iron and/or folic acid deficiency is among the world’s major nutritional disorders Africa & South Asia have the highest overall incidence of anaemia, followed by Latin America & East Asia Iron deficiency is the most commmon nutritional disorder in the world with anaemia being the major clinical manifestation. In many countries, 40% or more of women of reproductive age are anaemic & a similar prevalence is estimated to occur among preschool-age children. Among pregnant women, 56% are anaemic in developing countries, compared to 18% in developed countries. The prevalence is lower among schoolchildren, non-pregnant women, adolescents and adult males. However, in the developing world 25% of men are also deficient in iron.<br> If uncorrected, <a href=“http://www.unicef.org/pon95/nutr0014.html”> iron deficiency leads to increasingly severe anaemia, reduced work capacity</a>, diminished learning ability, increased susceptibility to infection & greater risk of death associated with pregnancy and child birth.

Consequences of iron deficiency Reduces work capacity, thus productivity, earnings & ability to care for children Associated with 50% of maternal deaths & wholly blamed for up to 20% Retards fetal growth, causes low birth weight (LBW) & increases infant mortality Impairs ability to resist disease; in childhood, reduces learning Iron deficiency results from consuming diets with insufficient iron, reduced dietary iron availability, increased iron requirements to meet reproductive demands and losses due to parasitic infections; these factors often operate concurrently.<br> Increasing the intake of iron rich foods and that of factors which enhance iron absorption (e.g. simultaneous intake of a source of vitamin C, separate intake of tea, other sources of tannin or other inhibiting factors to between meals) are necessary prevention measures. Fortifying commonly used basic foods can be an important adjunct as well as the use of low-cost iron tablets, especially when combined with measures to control parasitic infections and malaria, which sap human iron reserves. <br> That the problem of anaemia remains so widespread and apparently resilient has been attributed to the low compliance with daily iron tablets in the population affected as well as to the problems associated with maintaining supplies in distribution centers (in addition to insufficient intake of Iron from foods).

Improving Iron status Iron tablets (daily vs. weekly) Iron fortification of basic foods Increased consumption of iron rich foods & factors which enhance absorption Control of parasitic infections Recent research suggests that the efficacy of iron tablets taken once or twice a week may be similar to that when taken daily. Given the above mentioned problems with daily doses, the use of weekly or twice weekly supplements may have greater effectiveness to reduce anaemia. Until a consensus is established on the effectiveness of weekly or twice weekly tablets, it has been recommended that areas that do not already have a well managed program of daily supplements should at least institute a weekly program of supplementation to vulnerable groups. <br> In addition, much greater efforts need to be dedicated to appropriate promotion of the increased consumption of iron rich foods and of enhancing factors; a better understanding of effective promotion and conditions of success is a sorely neglected area.<br> The appropriate fortifiation of selected basic foods with iron also needs to be promoted.

Vitamin A deficiency (VAD) Subclinical, severe & moderate 251 million children 0-4 years old Clinical (xerophtalmia) 2.8 million children 0-4 years old Blindness, total or partial at least half a million children a year about half die within a few months It is only recently that serious attention has been given to documenting the situation of vitamin A status in most countries. Information therefore remains incomplete around the world. Currently, Vitamin A deficiency (VAD) is a moderate to serious public health problem in 76 countries, particularly in Africa, South-East Asia and the Western Pacific. <br> When vitamin A deficiency occurs, the integrity of epithelial barriers and the immune system are compromised before the visual system is impaired. This leads to increased severity of some infections and risk of death, especially among children. When vitamin A depletion is sufficient to affect the visual system, nightblindness occurs first, followed by xerophtalmia which can affect both the conjunctiva and cornea, and may lead to irrreversible partial or total blindness (see: WHO. Global Prevalence of Vitamin A Deficiency. MDIS Working Paper no. 2. 1995 (WHO/NUT/95.3)).<br> Interestingly, in most populations where VAD is now prevalent, a word exists in their language or dialect to depict, for example nightblindness!

Consequences of VAD Onset of childhood diseases increases Partial or total childhood blindness Child mortality increases at least 20-30% May increase maternal mortality May increase HIV transmission While VAD has long been recognized as the leading cause of preventable childhood blindness, more recent research has shown that mild and moderate deficiencies can significantly increase the onset of childhood diseases and can cause death. Improving vitamin <a href=“http://www.unicef.org/pon95/nutr0002.html”>A status could reduce child death by around a third, even in otherwise adequately nourished children</a>.<br> Recent research suggests that improving vitamin A status could also significantly reduce the rate of HIV transmission such as can occur in pregnancy, and can significantly reduce maternal mortality. While these results still need to be confirmed by further research, they appear very promising. <a href=“http://www.unicef.org/sowc98/”>click here for the state of the world’s children, focus on nutrition</a> by <a href=“http://www.unicef.org/”>UNICEF</a>.

Improving vitamin A status Increased intake of vitamin A rich foods e.g. eggs, butter, whole milk, liver, red palm oil, dark green, yellow & red fruits & vegetables Fortification of basic foods with vit. A Supplements e.g. 2 capsules per year to young children These devastating problems could be easily prevented by promoting the production and consumption of foods rich in vitamin A or by supplementing children’s diets with just two vitamin A capsules per year at a production cost of around two US cents per capsule. <br> Availability of vitamin A rich foods should not be confused with consumption. For example, per capita availability is very high in the Sahelian belt and West Africa, as well as in South Asia. Yet VAD is endemic in these regions. Availability clearly masks problems of uneven distribution, generally associated with poverty. Several countries have now begun to take action to improve the intake of Vitamin A. In the <a href=“http://www.unicef.org/pon95/nutr0003.html”>attached table</a>, countries are ranked 1 to 4 according to progress they have made in instituting measures against vitamin A deficiency. Food based measures have again been sorely neglected until now.

Iodine deficiency disorders (IDD) In 1990: 1.6 billion people worldwide at risk of IDD At least 655 million with goitre 43 million with some degree of mental impairment 11 million with cretinism An inadequate intake of iodine can cause ill health at any age, but is most serious in pregnant women and young children. In pregnancy, it results in retarded foetal development. Severe deficiency may result in foetal death or severe physical and mental retardation, a disease known as cretinism. <br> Milder deficiencies cause less severe but significant mental & physical retardation. In childhood, it may also result in speech & hearing defects, delayed motor development & impaired physical growth. In adults, chronic deficiency causes goitre, a swelling of the thyroid gland at the base of the neck, which may be disfiguring. Grouped together, goitre, cretinism &delayed physical & mental development due to iodine deficiency are known as Iodine Deficiency Disorders (IDD) (see Hetzel, B.S. and C.S. Pandav, eds.. S.O.S. for a billion: The conquest of Iodine Deficiency Disorders. Oxford University Press, 2nd ed. 1996)<br> The soil in many regions of the world is very poor in iodine and all food produced in this environment will likely be iodine deficient. In these areas, IDD will continue unless a new source of I is provided, either from imported food or from a supplement.

Other consequences of IDD Moderate Iodine deficiency: associated with average reduction of over 13 IQ points Adequate intake of Iodine: can prevent all IDD, make milder forms of goiter disappear & improve development of older children mildly affected Severe forms of IDD such as cretinism, cannot be reversed; can only be prevented by adequate intake of I during pregnancy Iodine Deficiency Disorders are best controled by fortifying table salt with iodine. Capsules or injections of oil containing iodine can be given to people in areas of severe iodine deficiency as an interim control measure until the iodization of salt is well established. <br> In 1990, participants at the World Summit for Children promised to Iodize at least 90 per cent of edible salt by 1995 and to virtually eliminate IDD by the year 2000.<br> Few developing countries had large-scale salt iodization programmes in 1990 and fewer than 20 per cent of people at risk consumed iodized salt. Substantial progress has now been accomplished in a large number of countries and currently it is estimated that 60% of all edible salt in the world is iodized.

Progress in iodizing salt 60% of all edible salt in the world is now iodized in 1997 Before 1990, some 40 million children were born each year at some risk of mental impairment due to I deficiency in their mother’s diets. By 1997 is closer to 28 million The progress achieved in salt iodization is remarquable but is not due to chance. It is the result of policy-makers successfully joining efforts with legislators, salt producers and distributors, as well as consumers, to effect these substantial changes. International groups e.g. the Kiwanis have also provided major support in many different forms. <br> The <a href=“http://www.unicef.org/pon95/nutr0008.html “>attached table</a> shows progress in iodizing salt at the end of 1994, and much further progress has been realized since.<br> IDD will soon be a feature of the past, owing its success larely to the many successful intersectoral and interdisciplinary coalitions which have been developed since the early ‘90s.

Improving nutrition can lead future progress in health and development around the world As is well outlined in the <a href=“http://www.unicef.org/sowc98 “>1998 State of the World’s Children Report</a>, advances in nutrition and in how to best apply our accumulated knowledge, provide many new opportunities for improving the lives of millions of children and their families. Much more needs to be done to reduce the global toll of severe and moderate malnutrition. Governments in poor and rich countries must also show leadership and commitment and must provide funding to mount and support actions to combat malnutrition that can be implemented by communities themselves. The price of inaction is high, the report warns: Countless millions of children who are intellectually disabled, physically stunted and especially vulnerable to illness.<br> I hope this lecture has convinced you that much can be done to improve the lives of so many around the world, and that many among you want to be part of this exciting moment in our history.