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Hidden HungerA Physician’s Perspective

Health Empowerment Through NutritionSouth Africa - August 2011

Hidden Hunger affects more than two billion people. Even when a person consumes adequate calories and protein, if they lack one single micronutrient - or a combination of vitamins and minerals -their immune system is compromised, and infections take hold.

World Hunger Series 2007 - Hunger and HealthWorld Food Program

There is a global nutrition crisis, with a dual problem of hunger and obesity

Myth #1 - The escalation of food insecurity makes it imperative to maximise agricultural yields

Myth #2 - The escalation of obesity makes it imperative to promote a balanced diet

Nutrients

The human body needs sufficient nutrients for optimum health

On a daily basis, we require 17 minerals 14 vitamins 9 amino acids 2 fatty acids

Over tens of thousands of years, human beings developed sustainable ways to feed themselves: Preservation of topsoil Crop rotation Natural fertilisers Locally grown, seasonal fruit and

vegetables Fresh, free range meat, eggs and milk Freshly cooked, nutritious meals 1889

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1919 California 1950

It was no different in Southern Africa, where people had less money than they have today: Millet, sorghum and – more recently -

maize, grown and milled at home Ground nuts, sweet potato, pumpkin,

cabbage Gathering herbs, roots, shoots, fruits and

wild spinach Moderate intake of fresh, free range meat,

eggs and milk

Kalahari Bushmen

Hidden Hunger

In contrast, the science of nutrition is less than 150 years old, and the ‘best evidence’ keeps shifting.

In the early 1960s, the medical advice was Myth #4 - High protein (animal best) Low carbohydrate (unspecified) Low fat (Myth #5 - Traditional margarine

healthier than butter) No supplements (expensive urine)

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Hidden Hunger

After Burkitt’s work in Uganda, the medical advice (late 1960s) was High unrefined carbohydrate (fibre) Moderate protein (pulses good) Low fat (traditional margarine still healthier

than butter) No supplements

It is interesting that Ugandans were healthier (no appendicitis, diverticulitis, diabetes, gallstones, ischaemic heart disease, hypertension and certain cancers)

Hidden Hunger

Today, the medical advice is Myth #6 - 5 fruit and veg Moderate unrefined carbohydrate Moderate protein Low fat (but omegas essential)

Modern margarine healthier than butter Traditional margarine (trans fats) extremely

bad No supplements

Antioxidant Comparison of Plant and Animal foods

Nutrient: 500 Cal Plant Based Animal Based

Cholesterol mg 0 137Fat mg 4000 36000Protein mg 33000 34000Beta Carotene mg 29.9 0.017Dietary Fibre mg 31000 0Vitamin C mg 293 4Folate mg 1.17 0.004Vitamin E mg 11 0.5Iron mg 20 2Magnesium mg 548 51Calcium mg 545 252

These nutrients are universally acknowledged as vital to protect against cancers of all kinds

Plant Based Foods = Equal parts of tomatoes, spinach, lima beans, potatoes and peas

Animal Based Foods = Equal parts of beef, pork, chicken and whole milk

Modern farming methods have conspired to maximise yields at the expense of nutrient content: Deep ploughing NPK fertilisers Pesticides & Fungicides Monoculture GM crops Hydroponics Early harvesting & Artificial ripening Factory farming Storage & Transport

Today, our food contains a fraction of the essential micronutrients it contained 100 years ago The Food Industry has compounded this problem by: Refining Milling Processing Additives Extensive use of sugar, corn syrup and

hydrogenated oils (trans fats)

Influence of Milling on Vitamin & Mineral Content of Maize

Wholegrain Milled % Loss

(μg/g) (μg/g)

Vitamin A 0 0 0Vitamin B1 - Thiamine 4.7 1.3 72.3Vitamin B2 - Riboflavine 0.9 0.4 55.6Vitamin B3 - Niacin 16.2 9.8 39.5Vitamin B6 - Pyridoxine 5.4 1.9 64.8Vitamin E 0 0 0Folate 0.3 0.1 66.7Biotin 0.073 0.014 80.8

Calcium 30.8 14.5 52.9Phosphorus 3100 800 74.2Zinc 21 4.4 79.0Iron 23.3 10.8 53.6

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Feeding People what Rodents Reject

Sammy eats the maize germ, where the cereal fat and micronutrients are found.Human beings refine out the nutrient rich maize germ and eat the sterile remains.

Thiamine – Vitamin B1

1884 – Takaki rejects the germ theory for beriberi and attributes the disease to insufficient diet

1897 – Eijkman discovers that fowl fed on polished rice develop paralysis, which can be reversed by discontinuing rice polishing

1901 – Grijns correctly interprets the connection between consumption of polished rice and beriberi

Sugar – A Natural Food – Myth #7

Every human cell can use glucose, but only the liver can metabolise fructose

It turns it into fat. Fructose increases: Blood lipid levels – triglyceride, total and LDL

cholesterol The prevalence of type 2 diabetes, hypertension,

abnormal blood clotting and heart disease Teenage males in the US consume 34 teaspoons

per day - 25% of total calorie intake Chromium?

Positive energy balance

DoH ’98, USDA ’02, NIH ’03, NCHS ‘04

1940 50 60 70 80

The result is a global pandemic ofHidden Hunger (Type B

Malnutrition) which afflicts

the hungry and the obese

This is manifest in an explosion in the prevalence of chronic degenerative disease: Obesity & Diabetes Hypertension & Heart disease Mental Illness & Dementia Impaired immunity

Cancer TB Asthma Arthritis

Myth #8 - We are living longer. Few of us are living healthier.

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Sheffield 1887

Hardee’s ‘Monster Thickburger’

1420 calories, 107g fat: $5.49

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Sheffield 2007

2001

Body Mass Index (BMI)

BMI is not a sensible measure of nutritional status: An improvement in BMI can be achieved by eating

just carbohydrate and fat – which does not equate to good nutrition

Having a BMI within the normal range does not mean you are healthy or nutrient replete

We see confirmation of this, not only in Africa, but also in the USA and UK, where there is a high prevalence of obesity in people eating refined, nutritionally sterile food

We are bombarded with nutrition guidelines that promote a balanced diet: MyPlate 5-a-Day (fruit & veg) Traffic light labelling (fat, sugar & salt)

Some believe that Organic and Free Range are best

All these guidelines assume that our food contains the nutrients we need for health

But 5-a-Day won’t cut it. Nor will 10!

Hidden Hunger

In SA, today, the staples are Refined maize meal (empty calories) Bread (mostly refined) White sugar (empty calories)

Soft drinks SweetsMost processed foods

Traditional margarine (trans fats) Cooking oil

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Hidden Hunger

Iron Deficiency - Children < 5 years: Mozambique - 95% Tanzania - 65% South Africa - 37% Worldwide - 1.2 billion (1988)

- 3.5 billion (2000) Zinc Deficiency

Worldwide - 2 Billion (2001)

Hidden Hunger

The National Food Consumption Survey (1999) showed that South Africans were deficient in iron, zinc, vitamin A and most of the B vitamins

Is it any wonder that immunity is impaired?

In the Third World, fortification of depleted staple foods has become commonplace: Myth #9 - We can get essential

micronutrients from chemicals added to our food They are often toxic They are poorly absorbed They rarely act in the body in the way intended

With the exceptions of iodine and folic acid, this has not been achieved

Why it has Failed

The electrolytic iron used has a bioavailability of less than 2%

Phytates in maize block the absorption of iron, zinc, calcium and magnesium

Electrolytic iron oxidizes the vitamin A The vitamins are denatured and destroyed by

cooking The RDAs are based on adult, not child food

portions – which reduces the intake of the most vulnerable

In 1999, Nobel Prize winner, Günter Blobel, demonstrated that for vitamins and minerals to be effectively absorbed into cells, they needed to be associated with their plant carrier proteins.

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Abundant Scientific EvidenceThe Lancet (2008) One third of child deaths are due to

under nutrition The international nutrition system is

fragmented, dysfunctional and in desperate need of reform

The China study (2005) Isolating nutrients and trying to get

benefits equal to those of whole foods reveals an ignorance of how nutrition works in the body

Wartime Rationing

Wartime Rationing 1940-1954

Very little meat, fat, eggs or sugar 2 ounces (50g) of butter per week One egg per fortnight

The ‘National Loaf’ – wholegrain Home-grown vegetables - 'Dig For Victory' An apple a day keeps the doctor away

Children were allocated milk, cod-liver oil and orange juice Schoolchildren had a weekly dose of malt extract

Most people were better fed during wartime food rationing than before the war years Infant mortality rates declined Average age at which people died from natural causes

increased

Nutrient Form

Myth #10 - Many health professionals believe that different forms of vitamins and minerals are the same, but isolates and food nutrients have different structures use different metabolic pathways function differently in the body

With supplements or fortification, the crucial consideration is bio-availability and bio-efficacy

Selenium, for example, is an important antioxidant. Where there is deficiency, it has become commonplace to fortify bread or salt with sodium selenate or selenite

Forms of Selenium

Form IC50

Selenium Yeast 3.0 μM

Selenomethionine 52.8 μM

Blank Yeast > 100 μM (Not an Antioxidant)

Sodium Selenite > 1000 μM (Not an Antioxidant)

Inhibition Of LDL+VLDL OxidationBy Different Forms of Selenium

Vitamin C

In the 1930s, Szent-Györgyi was awarded the Nobel Prize for the discovery of Vitamin C He demonstrated that the active material in

paprika was ascorbic acid When, with repeated distillation, he extracted

crystalline ascorbic acid, he expected a strong reaction

But it did nothing - the concentrated whole foods he had used in his research were far more effective

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Calcium

Elephants - their skeletons are maintained with the Calcium they get each day from leaves and grass

Pettifor showed that 30mg of Calcium in Ca-rich yeast is better absorbed that 300mg of Calcium Carbonate

The former went to bone; the latter to kidney

Apparently, we are not designed to eat chalk!

Tuberculosis

Tuberculosis is caused by a mycobacterium

One third of the world’s population is infected

Infected people don't usually get sick It is only sick people who can infect others

TB – The Global Situation

Of all infectious diseases, TB is the leading killer of adults - c.2 million people per year

Someone in the world is newly infected with TB every second

Between 2002 and 2020 over 150 million people will become ill and 36 million will die if there is not better control

The evolution of drug resistant strains of TB have had an even greater impact on morbidity and mortality in the face of the global HIV pandemic

An Impending SA Crisis

It is generally accepted that over 60% of the South African population has TB infection in its latent state

As HIV infection weakens immunity, the latent TB is likely to become active over the next few years, giving a potential TB prevalence of 12 million

The potential impact on society and the economy do not bear consideration

Tuberculosis - History

Throughout the nineteenth and early twentieth centuries, TB was common in the cities of Europe and North America

London was one of the worst affected areas TB once caused one in eight of all deaths in the UK The decline was achieved through a combination of

Better housing and nutrition Isolation of infectious patients Pasteurisation of milk

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Methods of Control

1854 - Sanatorium treatment began 3 months resting

Initial confinement to bed Periods of increased activity slowly introduced

Fresh air at all times and in all weathers Enormous amounts of food

1935 – Pasteurisation of milk introduced in UK 1944 – First use of Streptomycin 1952 – First use of Isoniazid 1953 – BCG vaccination introduced in UK

Deaths from Tuberculosis – New York

Year Deaths per 100,000

1910 10029 382

1920 7084 244

1930 5043 178

1940 3569 119

1950 2287 57

A Lesson from History

This dramatic shift in TB mortality was not achieved with: Antibiotics Early detection through mass chest x-ray

programmes Or BCG immunisation

All of which came into widespread general use after 1950

TB & Nutrition

The association between TB and malnutrition has long been known

Malnutrition weakens immunity, increasing the chance that latent TB will develop into active disease

Malnutrition increases drug side effects, making treatment interruption more likely

Treatment interruption results in relapse and drug resistance

Good nutrition enhances the efficacy of TB drugs

HIV/AIDS & Nutrition

More than 50 peer reviewed journal articles show that: Micro-nutrients, including the vitamins A, B6, B12 and E,

and the minerals selenium and zinc, play a critical role in the maintenance of immune function and overall metabolism.

The HIV virus encodes the seleno-enzyme glutathione peroxidase, thereby robbing the host of selenium and the amino acids, cysteine, glutamine, and tryptophan.

Persons living with AIDS suffer from extreme deficiencies of all of these nutrients, which are responsible for depressed CD4 counts, vulnerability to infections and cancers, dementia, depression, diarrhoea, muscle wasting, neuropathy and skin diseases.

SeleniumHETN does not support single issue environmentalism, nor single fixes, but by way of illustration: In Kupka’s study of 949 HIV+ pregnant

Tanzanian women, low plasma selenium was significantly associated with increased mortality.

Each 0.1µmol/l increase in plasma selenium was related to a 5% decreased mortality over 5.7 years of follow up.

In PLWHA, the plasma selenium levels is a better indicator of morbidity and longevity than the CD4 counts.

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Odunukwe studied the impact of selenium yeast in Nigerians with advanced disease (CD4 cell counts < 50) who were on ART. 170 participants received 200µg of Se daily

and 170 received ARV therapy alone. Patients were followed for 72 weeks.

The rate of CD4 cell recovery was significantly higher and the median CD4 count increment was over twofold higher in patients on Se supplementation (+120 cells/mm3 v. +50 cells/mm3).

The incidence of opportunistic infections was lower resulting in fewer hospital visits.

Weight gain was significantly higher (p = 0.004).

Haemoglobin increment from baseline to 64 weeks was 3-fold higher (+30 g/l v. +10g/l).

Hurwitz followed 174 HIV+ patients over 9 months. 91 of them received 200µg/day of selenium yeast Serum Se increased significantly in the Se-

treated group but not in the placebo-treated group (+32.2μg/l v. +0.5μg/l) (P<0.001)

Greater levels of Se (in the ‘responders’) were significantly associated with decreased HIV viral load (P<0.02) compared with controls

This correlated with a significantly increased CD4 count (P<0.04)

Selenium ‘non-responders’ did not differ from the placebo group in HIV levels and CD4 counts

Parallel Evidence

The HIV/AIDS pandemic is only one of several, involving viruses that encode the seleno-enzyme glutathione peroxidase.

Hepatitis B and C viruses, the Coxsackie B virus and HIV do likewise.

The Chinese are winning a battle against the Coxsackie B virus which causes Keshan disease, a fatal cardiomyopathy that has been common for many years in inhabitants of the great selenium-deficiency belt that crosses China.

Finland has shown that selenium supplementation can have a major beneficial impact on the incidence of HIV/AIDS.

Despite widespread, unprotected, promiscuous sexual activity in Senegal, where soil selenium levels are naturally high, HIV is diffusing very slowly, if at all, amongst the population.

In the UK there is an epidemic of TB among badgers, which is infecting cattle. It has been shown that organic herds fed on clover, which is rich in selenium, are not susceptible. When badgers and traditional herds are given maize supplemented with selenium, they are no longer susceptible.

The Scientific Position Systematic reviews conclude that there is no

evidence that micronutrient supplementation reduces morbidity and mortality in people living with HIV/TB. But: Trials concentrate on single supplement

intervention, or supplementation with a small group of micronutrients

Neither can be expected to correct the type of nutrient deficiency seen in HIV/TB

The dose of supplement is often not physiological

The form of supplement is often not considered

Much of the research is done in the West where baseline nutrition is higher

Academy of Science of SA

The pre-antibiotic phase of dealing with TB was characterised by strengthening the immune defences with diet, improved environmental conditions and every other conceivably helpful measure

After the discovery of effective drugs, this aspect of TB therapy quickly became secondary

The Panel is appalled by the dearth of reliable and informative studies of the nutritional influences / interventions on the course and outcomes of the pandemic chronic diseases (HIV & TB) addressed in this report

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TB / HIV Management

Drugs such as antibiotics and ARVs are essential elements in controlling and hopefully, in the case of TB, curing disease

But without the basics of good nutrition to sustain or rebuild natural health and immunity, we are fighting a losing battle

Something has to change and be done differently to avoid yet more failure in fighting TB and HIV, as well as most other health / wellness problems

It is time to give proper nutrition a full spin

John HeinrichSouth African National Tuberculosis Association

The Challenge If it is the consensus that the maintenance of

health is conditional on eating a balanced diet. -this should be the first priority in any health initiative It is the responsibility of health workers to ensure

that their patients are nutrient replete Advising patients to eat a balanced diet where they

have no access , or no understanding , is unethical Where people have multiple micronutrient

deficiencies, any scientific research that attempts to determine the benefit of this or that micronutrient is unethical and bound to fail, because it runs counter to the prevailing truth that we need balanced nutrition

Beware Dualism

Science v. Religion Copernicus (1530) and Galileo (1610) - The

Heliocentric View Dawkins (2006) - The God Delusion

Germ Theory v. Milieu Interieur Louis Pasteur v. Claude Bernard Robert Koch - Anthrax (1877), Tuberculosis

(1882), Cholera (1883) 1884 – Takaki (1884) & Eijkman (1897) -

Thiamine

Beware Dualism

Drugs v. Nutrition Only Drugs can claim to cure, mitigate

or treat a disease Food and food supplements cannot

claim thisThey may make health claims but only if substantiated by RCTs

FDA & EU Food Supplements Directive

Politics In South Africa there has been a damaging

public media debate, polarising the proponents of drug treatment and the proponents of nutrition Some politicians have argued that HIV & TB are

diseases of poverty, overcrowding and poor nutrition. They are.

The medical profession continues to argue that micro-nutrition is in the research domain, while promoting a balanced diet that is supported by even less scientific evidence.

This debate is specious. Nutrition is key – but it needs definition. It is not a question of ‘either/or’, but ‘both/and’.

Scientific Arrogance

Justus von Liebig (1803 – 1873) Healthy plant growth depends on the

correct balance of Nitrogen, Phosphorus and Potassium – Death of Sustainable Agriculture

Healthy human growth depends on the correct balance of Protein, Carbohydrate and Fat – Death of Good Nutrition

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Remember the Heretics

Copernicus (1530) and Galileo (1610) - The Heliocentric View

Semmelweis (1847) - Hand Washing

Barry Marshall & Robin Warren (1982) - Helicobacter Pylori

Is the Pharmaceutical Model still relevant?

100 years of research has generated a wide range of potent & specific drugs

Anti-microbials Pathogens allow differential metabolic

targeting – ‘weak link’ Wide therapeutic index, curative But resistance is now widespread

Is the Pharmaceutical Model still relevant?

Almost all drugs for CDDs are designed to suppress symptoms, and do not treat the underlying disease

Narrow therapeutic index, palliative Iatrogenic illness is now a major cause of

morbidity and mortality The CDDs still have no cures …

They are increasing in frequency The age of onset is falling

Is the Pharmaceutical Model still relevant?

CDDs are generally not due to an infectious agent, nor a single gene

No single ‘weak link’ Multiple metabolic / physiological

imbalances Multiple nutritional / lifestyle factors

contribute to risk, therefore … Multiple nutrient regimes are necessary

to modify the course of disease

Pharmaco-Nutrition

No magic bullets Identify as many critical metabolic

errors as possible Cross-reference these against the

known pharmacology of food derivates Initiate a multiple support programme The aim is to make people nutrient

replete

Cumulative Risk Reduction (CVD)

Drugs – the ‘Poly-Pill’ A statin A thiazide, a beta blocker & an ACE inhibitor Aspirin Folic acid

Would reduce IHD events 88%, strokes 80%

Adverse effects in 8 – 15% Cost: €43.91/ month (NHS)*

Wald & Law, BMJ 326:1419, ‘03

* Ashcroft JS, bmjjournals.com

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Cumulative risk reduction (CVD)

Food – the ‘Poly-Meal’ 150ml red wine Oily fish - 4 / week Dark chocolate 100mg Fruit & veg 400g Garlic 2g, almonds 68g

Would reduce IHD events 76% Adverse effects – none Cost: €22.44 / week

Franco, Bonneux et al: BMJ 329:1447-1450, ‘04

Cumulative risk reduction (CVD)

Pharmaco-Nutrition programme 150 ml wine: flavonoids @ 1 – 1.5 g Oily fish 4 / week: omega 3’s @ 1 – 2 g Dark chocolate 100mg: flavonols @ 1 g Fruit & veg 400g: carotenoids 25 mg,

fibre(s) 10g, aa’s, cyanogens etc Garlic 2g, almonds 68g: B vitamins etc

Would reduce IHD events 75% Adverse effects – none Cost: € 2.66 / week

HETN recommends FoodState Products for addressing Hidden Hunger

You can buy products that sound similar at a lower cost, but they will not give the same beneficial results

FoodState nutrients are beneficially combined into a food medium which naturally contains all the phytonutrients and other food factors necessary for absorption and use of each nutrient within the body

Combating Hidden Hunger

It is the contention of HETN that people everywhere - malnourished or not -need a diet that is based on whole grains It should be low in fat and sugar It should contain all the vitamins and

minerals that would ideally be sourced from fruit and vegetables in a form that is bio-available

A Call to Action

Remunerate producers on the nutritional content of the food they produce

Eat fresh, local and seasonal Stop refining grain Ban trans fats Reduce sugar, fat and salt consumption Traffic light label all processed foods

A Call to Action

Stop feeding hungry children in the Third World with CSB (refined cereal) or Plumpy’Nut (high fat, high sugar)

Stop using BMI as a measure of nutritional status

Stop believing that we can correct micronutrient deficiencies by adding these to food in the form of chemical isolates

Question whether the RCT is appropriate in nutritional science

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Lest We Forget

In 1940 the UK could not wait for the science They were at war They had to act on the RDA information they had In the process, they improved the health of all

Today there is no time to waste We are at war Our front line is dying of TB and AIDS while we sit

in ivory towers arguing science The time is now

Thank You for Your Interest

Health Empowerment Through Nutrition is aUK Registered Charity concerned with the

alleviation of Hidden Hungerwww.hetn.org