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CONCEPTS OF HUNGER & MALNUTRITION

THE DUAL BURDEN OF MALNUTRITION

Overnutrition Undernutrition

Dr. Veronika Scherbaum

NUTRITIONAL SITUATION

Introduction to the World Nutrition

Situation

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Family in Ecuador

Expenses (per week)Cereals & roots 17$Milkproducts own supply Meat, fish & eggs no supplyFruits, vegetables & nuts 11$Oil & spices 3$Drinks own supply

Total exp. 31$

GEO,2006

Family in Australia

Expenses (per week)Cereals & roots 29$Milkproducts 25$ Meat, fish & eggs 118$Fruits, vegetables & nuts 31$Oil & spices 35$Drinks 38$

Total 276$

Extra expenses/wkSnacks & sweets 5$Instant products 4$Fast food 28$Cigarettes 64$

Total 101$

GEO,2006

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TOO LITTLE FOOD TOO MUCH FOOD

IDA

IDD

VAD

PEM

IUGR

LBW

Vit B def.(Beri-beri)

Vit C def.(Scurvy)

Vit D def.(Rickets)

Obesity

Diabetesmellitus

Stroke

Heart/arterialdisease

Gallstones

Gout

Dental caries

Too many developing countries are spending e.g.

more on debt service than on social service

The Gap between rich and poor is widening

Income of the richest 1/5s

Income of the poorest 1/5s

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~ 20% of the world‘s population lives on the equivalent of < 1 US$ per day~ 50% of the world’s people earn < 2 US$ per day

ABSOLUTE POVERTY

- a condition of life so limited by malnutrition, illiteracy, disease, squalid surroundings, high infant mortality and low life expectancy as to be below any reasonable definition of human decency“(Robert McNamara, 1978)

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60% of the poor are womenWomen earn for the same job up to 60% less than men1/10 of the paid jobs worldwide is performed by women1/100 of the worldwide property is owned by women2/3 of illiterates are women80% of refugees are women and children

WOMEN IN THE WORLD

4.7

1.3 Bill

1.0 Bill Today: > 6 billion people

2025: about 8 billion people

China

India

USA

Indonesia

Brazil

Pakistan

Russia

Japan

Bangladesh

Nigeria

Mexico

Germany

294.0 Mill

219.8 Mill

178.4 Mill

153.5 Mill

146.7 Mill

143.2 Mill

127.6 Mill

124.8 Mill

103.4 Mill82.4 Mill

Asia

AfricaEurope

South-America North-

America Australia/ Oceania

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Pop

ulat

ion

Rate of Population Growth 1995-2000 (in %)

Demographic transition, life expectancyand population growth

critical

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

1950 1975 2000 2015 2030

Year

Developing countries - urbanDeveloping countries - ruralDeveloped Countries - UrbanDeveloped Countries - Rural

United Nations (2002)

Popu

latio

n (in

Bill

ions

)

Rural and Urban Growth in theDeveloping world

Urban population: (2000) 40% → (2030) 60%

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0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

1950 1975 2000 2015 2030

Year

Industr. countries + LA - urbanIndustr. countries + LA - rural

United Nations (2002)

Urban population: (2000) 75% → (2030) 84%

Rural and Urban growth in Industrialised Countries & Latin America

Popu

latio

n (in

Bill

ions

)

About 1.1 billion people withoutadequate water supply

Population withoutadequate

water supply

Asia

Europe

Africa

Latinamerica

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SANITATION• 40% of the world’s population lacks

access to a toilet

City-wide sanitation intervention in Salvador, Brasil

indoor toilet ↑, no open sewage nearby, water in house↑, hygienic behaviour↑

Diarrhoea prevalence fell by 21% from 9.2 days before intervention to 7.3 days per child-year afterwards (< 3 years)

Mauricio LB, et.al. Lancet, 2007, 370: 1622-1628

CLASSIFICATION OF COUNTRIES

• Developing countries (DC)

• Developed/industrialized countries (DC)

• Less developed countries (LDC)

• Low income countries (LIC‘s)GNP - Gross national product < 800 Dollar

• Low income food deficit countries (LIFDC‘s)• Least developed countries (LLDC‘s)

low income, food deficit, lack of infrastructure, lack of economic development

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INDICATORS of HUMAN DEVELOPMENT – Human Development Index (HDI) -

IN THE PAST 30 YEARS:

• Life expectancy rose from 56 to 64 years

• Mortality rates of preschool children fell from 167 per 1,000 live births to 89

• Adult literacy rate rose from < 65% to 73%• School enrolment increased to 77%(f), 84%(m)

• Incomes per capita more than doubled

Trend in life expectancy at birth1955 - 2002

WHO, 2002

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WHO RegionsAfrican Region

South East Asia RegionEuropean RegionEastern Mediterranean RegionWestern Pacific RegionAmerican Region

UNICEF… RegionsEast Asia and PacificSouth AsiaEastern Europe - CEE/CISMiddle East and North AfricaEastern and Southern AfricaWest and Central AfricaLatin America and CaribbeanIndustrialized countries

WHR 2002, Database

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A: Australia, Germany, Italy, Japan, Singapore, Cuba, CanadaB: China, Philippines, Sri Lanka, Poland, Turkey, Iran, Brazil, MexicoC: Belarus, Hungary, Russia, UkraineD: India, Bangladesh, Egypt, Guatemala, Peru, Ghana, CameroonE: Rwanda, South Africa, Uganda, Kenya, Ethiopia, Congo, Zimbabwe

Examples of countriesgrouped bymortality strata

WHO 2002

Deaths attributable to 16 leading risk factors

World Health Report, 2003

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NCD: Nutrition-related chronic disease World Health Report, 2002

THE DALY COSTS OF HUNGERDisability-adjusted life years (DALYs)

DALY = YLL + YLDYLL: years of lost life due to premature mortalityYLD: years lived with disability for incident cases of non-

fatal health conditionYLD = No. Incident cases x Average duration (years) x Disability weight

DALY: Population measure of incident lost years of healthylife due to diseases, injuries and selected risk factors

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Rural und urban burdens of disease(example: Mexico)

131.9113.0Alcohol dependence83.0113.0Brain vascular disease55.7104.1Diabetes mellitus151.794.7Disease of digestive system65.385.1Ischaemic heart disease36.875.5Road traffic accidents112.466.8Anaemia + Malnutrition46.357.5Liver cirrhosis18.347.9Motor-vehicle related deaths27.439.2Homicide und violence73.929.3Pneumonias92.8112.0Diarrheal diseases

Urban rank

Urban(DALYs)

Ruralrank

Rural(DALYs)

Source: Lozano et al. 1999

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Uauy, SCN, 2006

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Low coststreet foods

15-50% of household food expensesin Africa and Asia

Ineffective and arbitraryinspection

Licensing and inspectionupgrading of quality

Inexpensive, accessible serviceNon-existent licensing systemsVaried and nutritious foodLack of social statusAdequate earnings for vendorsNot a recognized industryEmployment opportunitiesContamination, poor hygieneUse of local resources

ProblemsBenefits

Urban agriculture (UA)contributes to

- food security, poverty alleviation- environment (green belt)

Examples of UA Practices:• Horticultures (incl. soil quality

management, irrigation)• Aquaculture• Livestock raising• Urban forestry

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Compositionof foodconsumptionin developingcountries(percentage)

FAO 2006

PHYSICAL ACTIVITY CHANGES

• Reduction of the level of activity within many occupations

• Changes in types of transportation

• Leisure time (reduced energy expenditure)

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Uauy, SCN Geneva 2006

GEO,2006

MAJOR SHIFTS IN DIET

• Increased energy density

• Added caloric sweeteners

• Increases in animal food intake

• Reductions in cereals, roots and pulses

• Similar intake in fruits & vegetables

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Factors Influencing Obesity

ObesityObesity

Biological

BehaviouralInfluences

• Age

• Gender

• Ethnicity

• Hormonal

• Genetic

Environmental

• Habits

• Emotions

• Attitudes

• Beliefs

• Cognition

Modified from Eggen & Swinburn. BMJ 1997;315:477-480

• Climate

• Changes in living conditions

• Urbanization

• Labor-saving devices

• Changes in transportation

• Changes in working conditions

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BURDEN OF UNDERNUTRITION

• ~ 850 mill of people →inadequate food intake

• 1/3 of children <5 year suffer from growth failure

• ~ 30 - 40% of women are anemic and/or underweight

> 2 billion people suffer from micronutrient deficiencies

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„Hidden“ form of malnutrition: Micronutrient deficiencies

Visual forms of malnutrition:Kwashiorkor andMarasmus

Measured and calculated forms of malnutrition: based on anthropometric data and/ or energy intake

IRON DEFICIENCY / ANEMIA (IDA)

• ~ 2 billion anemic

• Mild to moderate anemiapregnancy complicationsimpairs child developmentdecreases work capacity

• Severe anemia - high mortality

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IODINE DEFICIENCY DISORDERS (IDD)

Iodine required to produce thyroid hormones

• IDD consequences- abortion, stillbirth- congenital effects- mental retardation- deaf-mutism- cretinism

Most preventable cause of mental retardation in the world

VITAMIN A DEFICIENCY (VAD)

Vitamin A regulates cellular differentiation

VAD consequences:- Growth retardation- Epithelial metaplasia- Impaired immune system- Night blindness- Xerophththalmia- Bitot‘s spots

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ZINC DEFICIENCY

• Difficult to assess• High grain – low meat diet• Increases risk of - diarrhea

- respiratory infection- severe malaria- death

FAO Estimation of Undernourishment“Undernourishment”: % of population whose food intake (daily per capita energy availability) falls below minimum requirementDerived from Food Balance sheets andFAO modeling:– Daily per capita dietary energy supply– Energy intake within a country, based on

representative household food intake surveys– Minimum daily per capita energy requirement based

on body weight and activity level weighted by age-sex population fractions for „typical person“

LC Smith, IFPRI, May 1998

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Average supply of dietary energy(person per day)

Range: 3850 - 1680 kcal/person/day

Kcal/p/d

Per capita food consumption

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FOOD AVAILABILITY

• Rose from 2,100 (1970) to 2,700 (2005)kcal/person/day

enough to meet average needs

• But it remains below minimum requirements in Sub-Saharan Africa

• Rose from 3,100 (1970) to 3,400 (2005) in developed countries

EACH DAY about 850 million people go hungry

• Among them are 170 mill. children < 5 y

• Number of food-insecure people has fallen from 950 million (1970) to 790 (1997) and increased again↑

• The WORLD FOOD SUMMIT GOAL (1996) and the Millenium Development Goals:‚half the number of hungry people by 2015‘

can not be reached

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Undernourishment in Developing countries

FAO 2006

Developing countries with < 2200 kcal (in 1999/01)Highest and lowest 5-year average kcal recorded during 1961-2001

FAO 2006

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FAO 2006

Changes of undernourishedpeoplein subregions

from 1990-1992 to 2001-2003

2004

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2002: Asia 500 millions 16 % of total population

SS-Africa 200 millions 33 % of total population

HOUSEHOLD FOOD SECURITY (since 80‘s)

Adequate access to food needed for a healthy and active life for all household members- in terms of quality, quantity, safety and cultural

acceptance

Nutrition Security (since 90’s)

- requires a healthy individual who is able to optimally utilize the offered nutrients

Agriculture commercialization, economic development and nutrition (since 90’s)

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STAPLE FOOD

50 000 edible plant species• 15 crop plants provide 90% of

the world‘s energy intake• 3 crop plants (rice, maize,

wheat) provide 2/3 of the world‘s energy intake

• Rice feeds almost half of humanity

Dominant part of the diete.g. cereals, roots, legumes

Source of macronutrients in % of total energy intake

Children < 5 years, Harari State, Ethiopia

Back, E. 2000

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Source: Golder A. 1999

The Maldives

Child Malnutrition& death

Inadequate dietary intake

Disease

Insufficientaccessto food

Poor water/sanitation & inadequate

health services

Quantity/quality of actual resources & the waythey are controlled

Potential resources: environment, Technology, people

Outcome

Immediate causes

Underlying causes

Basic causes at societal level

Source: The State of the World’s Children, UNICEF, 1998

Inadequate maternal& child-care

practices

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Each year nearly 10 Million children die before their 5th birthday

Changes in <5 Mortality rates

WHO 2004

Unicef 2000

99% of thesedeaths occur in developingcountries

Where are 10 million children dying every year ?

42% in Sub-Saharian Africa, 35% in South Asia

(Lancet Child Survival I, 2003)1 dot = 5000

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What are the main causes of <5 deaths?

The vast majority of these deaths is preventable

WHO/Unicef 2000-2003

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Half of <5-Mortality: within neonatal period (1st month)

• 75% in the first week of life• 40% within first 24 hours• in 40-70% of these deaths:

low birth weight (<2.5kg)

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In developing countries, children who are not breastfed are

6 to 14 times more likely to die

Exclusive breastfeeding (during the first 6 months)can save the lives of 1.3 million children per year(Labbok M. 2007)

Frequent problem: missed opportunities in health institutions

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We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the fountain of life.Many of the things we need can wait. The childcannot.Right now is the time his bones are beingformed, his blood is being made and his sensesare being developed.To him we cannot answer„Tomorrow“.

His name is „Today“.

Gabriela Mistral

A FOCUS ON CHILDREN IS NEEDED

MALNUTRITION AMONG PRESCHOOL CHILDREN

impairs their mental and physical developmentexcess infections and mortalitydecreased activity, poor school performancecompromises their future health, productivity, and food securityundermines economic growth (malnutrition accounts for 20-25% of the economic impact of childhood diseases in LDC) and social justice

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Causes of Chronic Energy Deficiency(CED)

• energy intake less than the individual requirement, for several months or years

• Heavy workloads

• Parasitic infections(hookworm, malaria..)

Example: health of women

Pre-/Peri-/ Postnatal-problems

Malnutrition, Stunting

NeglectAbuseViolence...

ChildhoodReproductive health-problems↓Information about SexualityEarly marriageViolence, STI Early/frequentpregnanciesComplications duringdelivery Illegalel abortionsExperienced infant deaths

Adolescence& Maternity

AgingEarly aging

Chronicphysical/psych. illnessDisabilities

Social Isolation

Impoverishment

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Intergenerational effects

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The female cycle of malnutrition

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43%

12%

19%

26%

Women´s educationWomen´s statusHealth environmentNational food availability

Contributions to reductions in developing-country child malnutrition (1970-1995)Smith et al. 2000

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THE THEORY OF FETAL PROGRAMMING

Maternal malnutrition can cause adjusting mechanisms in the undersupplied foetus which may lead to chronic diseases like coronary heart diseases, hypertension, elevated cholesterol level, disturbed glucose tolerance and diabetes

later on in life

The shifting of obesity towards the poorest women in Southeast of Brasil

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Obesity in women (20 – 49 yrs) by SES in 37 DC ordered by GNP per capita (1992-2000)

Predicted prevalence (%) of women’s obesity in extreme SES at different countries GNP

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In Mexico: Feeding programmes target children < 2 years in lower income households…as well as pregnant and lactating women…

Does adequate targeting of undernutritioncontrol strategies protect families from

potential adverse effects on obesity?

In Mexico, food supplements for women target lowest income households (who are already largely overweight)

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Ferrari M, Mauritania, SCN Geneva, 2006

The dual burden household phenomenOften in households of middle GNP-countries:

coexisting under- and overnutrition

Causes (frequently existing among marginally poor):- cheap energy dense food- „obesogenic“ environment- changes in metabolic system- stunting in childhood- different age-specific

demands of nutrients

Phenomen must beaddressed in all nutritioninterventions!

0

5

10

15

20

Vietnam

China

Kyrgisistan

Indonesia

Russia

Brazil

USA

%Prevalence of dual burden householdsin selected countries

Doak CM et al., 2005

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WHO 2005

The epidemic of overweight

Malnutrition in all its forms• Low birth weight• Underweight (defined by a low weight-for-age)

• Stunting (defined by a low height-for-age)

• Wasting (defined by a low weight-for-height)

• Multimicronutrient deficiency(iron-, iodine, vitamin A-, zinc deficiency, etc.)

• Overweight/Obesity (high BMI for age)

• Nutrition related chronic diseases(NRCDs)

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INTERNATIONAL NUTRITION

• Lecture notes (pdf files) and references can be downloaded underFNS Modulehttp://ilias.uni-hohenheim.deInstitute 140a, International Nutrition, IN

Exam questions to be discussed