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Nutrition in Global Health. Part 1: Roadmap to the world’s nutritional health: Causes, mechanisms, solutions. Allan J Davison PhD, Professor, Biochemist, Faculty of Sciences, Simon Fraser University Department of Biomedical Sciences & Kinesiology June 2011.

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Nutrition in global health

Nutrition in Global Health

Part 1: Roadmap to the world’s nutritional health:

Causes, mechanisms, solutions

Allan J Davison PhD, Professor, Biochemist,

Faculty of Sciences, Simon Fraser University

Department of Biomedical Sciences & Kinesiology

June 2011

Prepared as part of an education project of the

Global Health Education Consortium & collaborating partners


N utrition in global health overview
Nutrition in global health - Overview

  • Inequities in food distribution  global hunger & starvation

  • One billion are too hungry to live productive lives - an equal number are adversely affected by overweight!

  • 6 major deficiencies impact health through the life cycle: water, protein, iron, vitamin A, iodine, folic acid

  • Childbearing women & their children are hardest hit

    Meanwhile, overnutrition & inactivity risk of heart disease, osteoporosis, cancer, diabetes, strokes, etc.

Page 2


F undamentals and emphasis
Fundamentals and emphasis

As we consider cause and effect we must ask: How & why have such inequities come to be? Who and what factors impede solutions? What current initiatives will bring the resolution?

To help answer these, we must will emphasize:Immediate causes - scarcity of specific nutrients Primary and secondary prevention Public health approaches to solutions

Page 3

Page 3


Other ghec modules contribute to our understanding of nutrition in global health
Other GHEC modules contribute to our understanding of Nutrition in Global Health

  • This module does not stand alone. “Roadmap to a world without hunger” will follow (see note)

  • Two other GHEC modules deal with poverty & hunger

    • Module 48: Acute malnutrition – Clinical aspects (deals with treatment)

    • Why is the 3rd world the 3rd world? (underlying and diverse causes of poverty & hunger) http://globalhealthedu.org/resources/Pages/default.aspx

To see this module in the context of what will follow, see Note A

Note A


Pre quiz pending completion of quiz feature in ghec s server
Pre-quiz Nutrition in Global Health(pending completion of “quiz” feature in GHEC’s server)

  • As a reality check, and to create “teachable moments” for what follows, we now invite you to take a 5-minute pre-quiz

  • You will be offered 10 true-or-false questions to dispel some common misconceptions

  • Some of this misinformation is spread by those who have something to gain from it

  • After completing the pre-quiz, we hope you will continue this module with greater interest and renewed clarity

Page 5


Learning objectives
Learning objectives Nutrition in Global Health

After completing this module you should be able to

  • Describe the extent of malnutrition & its impact on people of the planet, and understand how MDGs depend on nutrition

  • Analyze the factors that determine nutritional health

  • Identifynutritional problems among individuals & populations, identify causes & appropriate solutions

  • Assess risks at various stages of the life cycle & recommend strategies for diminishing risk

  • Comparecompeting theories accounting for the inequities

  • Predictoutcomes by projectingcurrent trends into the future

    & foresee a pathway toward a world without hunger

Page 6


To get the most out of this module
To get the most out of this module Nutrition in Global Health

If you are…..

a nutritionist or student of nutrition

a student of one of the health professions

planning a project in regions with severe nutritional problems

a public health practitioner

You will want to …

Pay attention to global & public health & policy implications.

Pay attention to perspectives & realities in desperate situations

Emphasize check-lists to prepare for field work & gather information to recommend & advocate for intervention.

Use slides & resources in your information / teaching sessions

Page 7


Preface nutrition is crucial to global health
Preface: Nutrition is crucial to global health Nutrition in Global Health

  • Among the immediately modifiable factors that affect individual & public health … nutrition is of prime importance

  • Nutrition at every stage of life lays a foundation for health in the ensuing stage

  • For all nations, rich & poor, nutrition determines physical health & development through the life-cycle, including:

    • Success in childbearing, cognitive function, socio-economic independence, education, disease resistance & employability

    • Health & economic development are contingent on provision of adequate food, nutritional resources & support


A vicious cycle economics hunger health
A vicious cycle: economics, hunger, health Nutrition in Global Health

Poverty  diminished access to agricultural & food resources  malnutrition

Physical & cognitive impairment, susceptibility to disease, early death  inability to earn an income

nutrition

Economic marginalization

 inability to provide for self or family


The millennium development goals
The Nutrition in Global HealthMillennium Development Goals

  • At a UN Millennium (2002) summit, the nations of the world set eight MDGs to be achieved by 2015

  • The world's main development challenges were identified

  • Specific actions and targets (the MDGs)

  • A commitment to provide the means was made by 189 nations & signed by 147 heads of state

  • The MDGs break down into

  • 21 quantifiable targets

  • Targets are measured by 60 time-lined indicators

Some nations have kept their trust. But some of the richest in the world have announced that they will not meet their commitments


Nutrition millennium development goals
Nutrition & Millennium Development Goals Nutrition in Global Health

Primary goal is to eradicate extreme poverty & hunger

1

see next 2 slides

Nutrition – is a direct prerequisite to goals

1, 3, 4, 5 & 6; indirectly to 7 & 8


Centrality of nutrition to mdgs 1 2 3
Centrality of nutrition to MDGs 1, 2, & 3 Nutrition in Global Health

1. Eradicate extreme poverty & hunger. Poverty is the main determinant of hunger. In turn, malnutrition irreversibly compromises physical & cognitive development & thus transmits poverty & hunger to future generations.

2. Achieve universal primary education. Malnutrition diminishes the chance that a child will go to school, stay in school, or perform well in school

3. Promote gender equality, empower women. Women’s malnutrition impairs the whole family’s health & nutrition


Centrality of nutrition to mdgs 4 5 6
Centrality of nutrition to MDGs 4, 5, & 6 Nutrition in Global Health

4. Reduce child mortality. Delivery of a live healthy child is dependent, above all, on a well nourished mother. Protein & folic acid are critical here

5. Improve maternal health. Malnutrition accentuates all major risk factors for maternal mortality, e.g., inadequate protein, iron, iodine, vitamin A & calcium

6. Combat serious infectious diseases. Malnutrition aggravates infections, immune competence, transmission & mortality in HIV, malaria, tuberculosis

Adapted from Gillespie and Haddad (2003) http://web.worldbank.org/


Slow progress toward the mdgs
Slow progress toward the MDGs Nutrition in Global Health

At mid-way, most MDGs are partly met.

Only goal #2 is fully within reach!


Nutrition in global health course overview
Nutrition in Global Health Nutrition in Global HealthCourse overview

Overview of nutrition across humankind

Nutrition fundamentals in global context

Top six nutrition problems, & their solutions

Nutrition across the life cycle in rich & poor nations

Cause & effect in population nutrition

Overview and where we are now

Bridge to Part 2, Roadmap to a world without hunger

Page 15


Universal limitations health consequences
Universal limitations & health consequences Nutrition in Global Health

  • We can’t survive without about 15 essential mineral elements, so they are needed in our diets, most in trace amounts

  • We can’t manufacture about 15 vitamins, so they must be provided in our diets

    And in addition……


Universal limitations health consequences1
Universal limitations & health consequences Nutrition in Global Health

Note B

In addition: We lost key metabolic abilities our evolutionary ancestors had. Thus we are vulnerable to 2 dietary risks:

  • In early life – a period of rapid growth, we are vulnerable to “kwashiorkor” (protein insufficiency) because we can’t synthesize 8 “essential” amino acids missing from our diet

    2) In later life: we are vulnerable to obesity & diabetes– in part because we can make fat from carbohydrate, but we can’t easily convert stored fats back to carbohydrates

Page 17


Categories of nutritional status
Categories of nutritional status Nutrition in Global Health

Nutritional status is assessed as one of four categories

  • Good nutritional status: All nutrients (right quantities, time & place) allow optimal, growth, maintenance, & reproduction

  • Overnutrition: An excess of a nutrients (usually calories) is being consumed, so that health is negatively impacted

  • Undernutrition: Insufficient food is consumed to allow for the energy needs of the individual. Inevitably dietary (& then body) protein is burned for energy. A secondary protein deficiency ensues – thus: "protein-energy-malnutrition"

  • Malnutrition: Energy consumption is adequate, but there is an imbalance among constituents of the diet and health is impacted

Note C


Worldwide distribution of malnutrition
Worldwide distribution of malnutrition Nutrition in Global Health

Over 20 million children suffer from acute malnutrition WHO.

Scientific American, Sept 2007


Worldwide nutritional inequities follow poverty as do health inequities life expectancy
Worldwide, nutritional inequities follow poverty Nutrition in Global Health(as do health inequities & life expectancy)

  • Globally, there is plenty of food for everyone but …those who have more than they need find reasons not to share

  • The result – in the time you spend on this module over 1000 children will have died of hunger

  • Each day 1500 children go forever blind from lack of vitamin A

  • The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency).

  • About 2 billion people (56% of pregnant women) have iron deficiency. Their babies have low birth-weight, &  mortality

Note D


The bottom billion title of a book by paul collier
Nutrition in Global HealthThe bottom billion”(title of a book by Paul Collier)

“The poorest of the poor” - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day

  • We define this subclass as people who don't get enough to meet the ordinary demands of life

  • They lack the resources to earn a living, or obtain what‘s needed for normal, growth, maintenance & reproduction

  • It goes without saying that they are unable to provide the necessities for those who depend on them


The bottom billion title of a book by paul collier1
Nutrition in Global HealthThe bottom billion”(title of a book by Paul Collier)

  • Their lack of access to resources is such that a significant fraction will be unable to stay alive

  • They live mostly in isolated rural areas and most are subsistence farmers

    This means that what they eat this month is what they can take out of the ground from last month's planting

Page 22


Unhelpful misconceptions about aid
Unhelpful misconceptions about aid Nutrition in Global Health

False: “Most aid money goes into the Swiss bank accounts of corrupt African dictators”

“Aid creates dependence & impedes self-sufficiency”

“Despite all the aid $, the problems are only getting worse”

The truth is: Overwhelmingly African leaders are not corrupt. When they are, most bribes come from the West

Well planned aid builds capacity & self-sufficiency

Overall, hunger worldwide is diminishing. MDGs go forward because of the countries that honour their pledges!

Note E


Money useless no nearby shops
Money? Useless - no nearby shops Nutrition in Global Health

  • It’s hard to imagine a malnourished community and you may want to experience field conditions in advanceNo commerce! Try it at a Medecins sans Frontieres site:http://www.starvedforattention.org/

  • No shops to spend money in, no one to employ anyone, no one to sell things to

  • Hungry children are all too visible, and those who didn’t survive are in tiny unmarked graves

    Their needs are much more immediate than money

    We don’t need studies to learn what they need - read on!


If they don t need money what do they need
If they don’t need money – what Nutrition in Global Healthdo they need?

Note F

Short term they likely need emergency rations, safe waterIn conflict zones, shelter & safety to live, plant, harvest

Medium term they need to become self-sufficient, with:good seeds, fertilizer, usable water, sanitation, low technology agricultural info & resources, health services, mosquito nets, pharmaceuticals

Long term they need the prerequisites of sustainable economic development - tools for development – see Part 2

Kids need particular attention – see note below & later slides

Page 25


The goal is to see everyone self sufficient
The goal is to see everyone self-sufficient Nutrition in Global Health

  • People in the poverty trap live from hand to mouth, with no opportunity to put resources aside to build a better future

  • Such communities cannot access the ladder of economic development without external help.

  • The MDG promises of 0.7% of rich country GDP for aid was chosen to eliminate extreme poverty & hunger in 3 decades

  • But there are many nations that failed to meet this goal, including both the US and Canada

  • Thanks to the nations that keep their promises, widespread hunger may be eliminated, but only after 30-50 years. This not, however, cause for undiluted joy. See Note G.

Note G


Some communities subsist in the poverty trap
Some communities subsist in the “poverty trap” Nutrition in Global Health

  • Even among the richest there are some individuals so marginalized that there seems little hope for them The larger culture, if it is compassionate, takes long-term responsibility for ensuring them the necessities of life

  • Globally there are communities that have been denied the resources to ever become wealthy. Often from geography, climate, invasion, or appropriation of their natural resources

    Regardless, a world community of compassion can provide the necessities of life, & offer new life to the dispossessed, as North America once opened its doors to the poor

Note H


Nutrition in global health c auses mechanisms solutions nutrition is crucial to global health mdgs
Nutrition in Global Health Nutrition in Global HealthCauses, mechanisms, solutionsNutrition is crucial to global health & MDGs

Overview of nutrition across humankind

Human nutrition fundamentals in global context

Top Six nutrition problems, & their solutions

Nutrition across the life cycle in rich & poor nations

Cause & effect in population nutrition

Overview and where we are now

Bridge to Part 2, Roadmap to a world without hunger

Page 28


Human nutrition fundamentals in global context
Human Nutrition Fundamentals in Global Context Nutrition in Global Health

The next set of slides covers the critical skill set needed for understanding nutritional issues in the context of global health

They are not a substitute for nutritional training, but rather a catalog of nutritional tools applicable to problems a health practitioner might encounter in the field

From this you can learn when to call in a nutritional expert, what kind, & what to you might reasonably ask for & receive

If you have learned nutrition in a developed country, this may help you to expand your knowledge of nutrition and public health in the context of 3rd world health problems


Dietary patterns across cultures
Dietary patterns across cultures Nutrition in Global Health

1. Hunter gatherers – the earliest category

Benefits: mixed diet, well nourished in good times

Risks: famine or drought, warfare & plunder, resource- depletion through population pressure

Prevalent problems: starvation, thirst,  life-expectancy

Note I


Dietary patterns across cultures1
Dietary patterns across cultures Nutrition in Global Health

2. Peasant agriculturalists – successful small scale farmers (currently the largest group)

  • Benefits: close to food sources; if no punitive taxes or rents;usually well adapted to their traditional diets

  • Risks: single crop emphasis malnutrition, plagues (locusts, rodents), exploitation, warfare and plunder

  • Prevalent problems: vitamin deficiency, starvation, alcoholism

Page 31


Dietary patterns across cultures2
Dietary patterns across cultures Nutrition in Global Health

3. Indigent, landless crop planters

Benefits: Community, share with family, neighbors, income is typically less than a dollar a day

Risks: Crop failure, drought or famine, erosion, soil-exhaustion, pestilence, economic exploitation (by landlords, seed providers, loan-sharks), displacement, forced migration, civil unrest or foreign invasion

Problems: multiple vitamin deficiencies, kwashiorkor (protein malnutrition), infectious disease epidemics. Too poor, powerless to help themselves, most of them will never escape their circumstances, nor achieve full health


Dietary patterns across cultures3
Dietary patterns across cultures Nutrition in Global Health

4. Urban slum dwellers – fastest growing group

Benefits: hope for jobs, escape from drought or crop failure

Risks: overcrowding, poverty, poor hygiene, limited food choice, social disruption loss of traditional diets, crime

Prevalent problems: deficiencies of essential nutrients, alcoholism, obesity, kwashiorkor, epidemics


Dietary patterns across cultures4
Dietary patterns across cultures Nutrition in Global Health

Note J

5. Affluent urbanites – most recent category

Benefits: many food choices (appropriate and inappropriate)

Risks: inactivity along with high fat, sugar, alcohol intakes

Prevalent problems: overnutrition, obese babies and adultsdiabetes (carbohydrates), cholesterol, atheroma (lipid), strokes, heart disease diabetes, gout (uric acid - meat sources)

Page 34


Nutrition in global health c auses mechanisms solutions nutrition is crucial to global health mdgs1
Nutrition in Global Health Nutrition in Global HealthCauses, mechanisms, solutionsNutrition is crucial to global health & MDGs

Overview of nutrition across humankind

Human nutrition fundamentals in global context

Top six nutrition problems & their solutions

Nutrition across the life cycle in rich & poor nations

Cause & effect in population nutrition

Overview and where we are now

Bridge to Part 2, Roadmap to a world without hunger

Page 35


Top 6 global manifestations of malnutrition
Top 6 global manifestations of malnutrition Nutrition in Global Health

We begin with a perspective, then we take each of the 6 in turn

  • Water is a food (“food” is the material we eat & drink”)In hot climates, we can die in a few hours from a lack of it

    2) Protein-energy malnutrition

  • The machinery of life, sculpted from 20 different amino acids

  • Deficiency is most serious in children (time of fastest growth): "failure to thrive", stunted growth

The material in this section is well reviewed at:http://www.pitt.edu/~super1/lecture/lec0141/index.htm

Iron, vitamin A, iodine – check the latest information at:http://www.micronutrient.org/English/view.asp?x=1


Top 6 global manifestations of malnutrition cont
Top 6 global manifestations of malnutrition Nutrition in Global Health(cont.)

  • 4) Vitamin A deficiency

  • Over 100 million children under 5 suffer vitamin A deficiency

  • In high deficiency areas vit. A tabs child mortality by >20%

  • & child blindness by 80%. Night-blindness is an early sign

3) Iron deficiency - prevalent in Africa and Asia

  • Women & children are the most seriously affected

  • In parts of Africa 60% of children have blood iron

  • About a quarter of these have symptoms of anaemia

Page 37


Top 6 global manifestations of malnutrition cont1
Top 6 global manifestations of malnutrition Nutrition in Global Health(cont.)

Note K

5) Don’t underestimate iodine deficiency disorders

  • WHO 2003: “1.6 billion people don’t get enough iodine”. This is the major cause of preventable brain damage.

  • Thanks to MDG programmes the problem is shrinking! http://www.who.int/vmnis/iodine/status/en/index.html

    In addition nutrition determines chronic disease risk

  • Heart disease, osteoporosis, cancer, diabetes, strokes, etc.

    We’ll go through these one at a time in the following slides and Note K lists categories of at risk people across countries

Page 38


Top 6 global manifestations of malnutrition cont2
Top 6 global manifestations of malnutrition Nutrition in Global Health(cont.)

Page 39

6) Folic Acid is required for healthy babies

  • A deficiency causes spina-bifida – a common birth defect

  • Supplements are recommended before start of pregnancy

  • 50% of pregnancies are unintentional!

    Women who might become pregnant, need advice

    More details on these nutrients in the ensuing slides


Water one of our most important foods
Water: one of our most important foods Nutrition in Global Health

  • Adequate safe water is most important dietary component

  • 9 million worldwide have water-borne diseases

  • In India, contaminated water kills 300,000 children annually

  • Problems relating to water supply & safety have simple, relatively inexpensive solutions

  • Water “ownership” is, however, contentious & usually follows military power (e.g., in Middle East)

  • In hot humid conditions workers may need over 5 liters / day & to replace the NaCl lost along with water in sweat

http://www.who.int/water_sanitation_health/mdg1/en/index.html


The special importance of proteins
The special importance of proteins Nutrition in Global Health

  • Proteins are the machinery of life. We have no storage form. If we must use protein “stores”, tissues lose function

  • Plasma, liver and kidney lose function first. Their proteins are the most “labile”. Then, digestive tract, muscle & heart

  • Proteins are made up of 20 amino acids. 12 are non-essential and can be made from other dietary components

  • 8 amino acids are “essential”. If even one is missing, no protein can be synthesized. A protein lacking any one essential amino acid has zero “biological value


Dietary deficiency of proteins is deadly
Dietary deficiency of proteins is deadly Nutrition in Global Health

  • When any essential amino acid is missing, all the rest are burned & no protein synthesis can occur – zero!

  • All essential aa’s must be there at the same time. Meeting an amino acid need one day later is useless

  • A diet previously adequate in essential amino acids becomes inadequate if non-essential amino acids are removed. Because, although the body can make missing non-essential aa, it uses up essential amino acids to do so

  • Protein complementarity, de-emphasized in nutrition courses, can be vital where protein intake is compromised


Humans adapt to low protein intakes
Humans adapt to low protein intakes ... Nutrition in Global Health

  • ... otherwise impact of protein deficiency would be even higher

  • Endocrine changes improve the recycling of proteins. As tissues repair, the released amino acids are reused more efficiently

  • In the African presentation of kwashiorkor, a child is exposed to a protein deficient diet (ages 1 to 5) & adapts successfully

  • Then a 1-week lack of protein (parent loses job, baby is fed glucose-water only, or a gastro-intestinal infection)  kwash

  • Child is treated for kwash, sent back to home to same diet, & reaches adolescence, usually without recurrence.


Protein energy nutrition are inseparable
Protein & energy nutrition are inseparable Nutrition in Global Health

  • When the diet lacks carbohydrates, it uses some amino acids to make glucose for brain, muscle, etc.

  • When a diet lacks total calories, proteins are co-opted, first dietary, then plasma, liver, kidney, etc.

  • For these reasons, a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed.

  • Do an internet search on “protein-sparing effects of carbohydrates” if you want to understand this further

Page 44


Protein energy malnutrition in adults
Protein-energy malnutrition - in adults Nutrition in Global Health

  • Tissues are raided, with the following consequences:

    • Loss of plasma proteins  oedema*

    • Loss of liver & kidney function diminished inactivation & excretion of carcinogens and toxins

    • Loss of immune function gastro-intestinal infections

    • Loss of digestive tract / liver function amino acids can’t be utilized for proteins. No treatment can prevent death

    • Loss of muscle and heart tissue weakness, heart failure

*Oedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities


Hungry kids difficulties in diagnosis
Hungry kids – difficulties in diagnosis Nutrition in Global Health

  • Marasmic babies may not seem undernourished until a check for “pitting oedema” reveals that what appear to be strong arms and legs, are in reality oedematous

  • Another diagnostic complication is that most deficiencies are combined, as in protein energy malnutrition (“PEM”) with multiple vitamin deficiencies

  • The distinctions are crucial both in determining treatment, and in determining if the underlying problem in the community is scarcity of food, a protein, or many nutrients

Page 46


Protein malnutrition is different
Protein malnutrition is different Nutrition in Global Health

  • In uncomplicated kwashiorkor, only protein is lacking - “Malnourished, not undernourished”

  • The risk of death or permanently retarded development is great, and the risk is increased because its easier to miss the diagnosis

  • Kwashiorkor babies may have more than adequate calories in their diets. They may be chubby, with substantial subcutaneous fat

  • Kwashiorkor may go unnoticed even when urgent hospitalization is needed, or when death is imminent


Protein malnutrition diagnosis
Protein malnutrition: diagnosis Nutrition in Global Health

When there are many sick kids in a community, but none look undernourished, be sure to look for protein deficiency. Why?

  • It’s important not to miss the diagnosis. Kwashiorkor has a high fatality rate even with hospitalization

  • The 1st symptom to present is often diarrhoea, or oedema

  • The child may be treated for a gastrointestinal infection while the underlying cause, kwashiorkor, goes undiagnosed

  • Oedema is an early symptom, and may be mistaken for chubby limbs, so test if nutrition may be compromised


Tracking protein energy malnutrition in kids
Tracking protein-energy malnutrition in kids Nutrition in Global Health

Failure to thrive may be an early warning of flagrant PEM in an individual child or a community. Always investigate the cause

  • Growth charts give weight for stature / length across age. They provide criteria to estimate severity. Proper use requires training!

  • Change in position on a chart shows effectiveness of treatment & probability of survival

  • If many children in a community show up at risk on growth charts, authorities must be alerted to endemic problems

Page 49


Early measures required on pem diagnosis
Early measures required on PEM diagnosis Nutrition in Global Health

  • Treatment is urgent - hospitalization is preferred if available

  • Delayed physical growth is often restored in catch-up growth when a good diet is provided

  • Cognitive disabilities may be irreversible if prolonged

  • Ready-to use foods (RTUF) for PEM have saved many lives

  • Oral rehydration salt (ORS) therapy is also life-saving when there is accompanying diarrhoea (which is usually the case)

Note L


Early measures required on pem diagnosis1
Early measures required on PEM diagnosis Nutrition in Global Health

Both RTUF and ORS can be given at home in a bottle (Wikipedia). World production of ORS is around 500 million sachets / year. Improvisation of ORS is described at http://rehydrate.org/ors/made-at-home.htm#recipes

Powdered milk protein in boiled water can be very helpful as an emergency measure

Acute fatality rate can be 25% even with prompt treatment

Page 51


Iron deficiency affects 500 million globally
Iron deficiency affects 500 million globally Nutrition in Global Health

http://www.micronutrient.org/English/view.asp?x=579

  • Causes: insufficient availability of dietary iron, or increased iron requirements to meet reproductive demands, haemmorhage, parasitic infections (often concurrently)

  • The result is an increasingly severe anaemia, reduced work productivity →poverty, diminished learning ability, increased susceptibility to infection

    For more on consequences of iron deficiency, see Note M

Note M


Iron deficiency affects 500 million globally1
Iron deficiency affects 500 million globally Nutrition in Global Health

Iron deficiency is best diagnosed in the preclinical stage, by measurement of transferrin saturation

Females > males due to iron loss at menstruation -- >50% of pregnant women are affected in the developing world – 3 times as many as in developed countries

25% of men also are deficient in iron in the developing world

Page 53


Treatment of iron deficiency rebuilding iron reserves
Treatment of iron deficiency: Nutrition in Global Health rebuilding iron reserves

  • Iron tablets are effective within weeks, but non-compliance is common so compliance must be checked

  • Increase iron intake through combining iron-rich foods with agents that  iron absorption (like vitamin C)

  • Encourage availability and consumption of iron-fortified foods


Treatment of iron deficiency rebuilding iron reserves1
Treatment of iron deficiency: Nutrition in Global Health rebuilding iron reserves

Weekly / daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency

Treat causes of diminished iron reserves: haemorrhage, parasites (including malaria), and hemolytic conditions.

Be alert! Iron may be lethal in some inherited anaemias (thalassemias, sickle cell, or Hb M) common in Africa & Asia

Page 55


Iron excess dangerous to some
Iron excess - dangerous to some Nutrition in Global Health

  • Those with haemolytic anaemias: (e.g., thalassaemia – common in people of African or Asian descent). Iron should not be prescribed until the cause of an anaemia is known

  • Where iron pots are used for cooking or beer: Siderosis: iron deposition in liver, kidney, heart, pancreas organ failure

  • Children: Parents' iron pills are attractive to kids in developed countries. The most common of fatal childhood poisonings

  • Those with familial haemochromatosis: This common inherited disease has symptoms similar to siderosis (above)The first sign of this disease is often inoperable liver cancer

Note N


Vitamin a deficiency in public health
Vitamin A deficiency in public health Nutrition in Global Health

  • Vit. A deficiency is a public health problem in over 70 countries, especially in Africa, SE Asia & the W Pacific where it affects 250 million mostly aged 0-4 years

  • Night blindness may predict vitamin A deficiency, with risk of permanent total blindness if it progresses

  • There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles

  • Vitamin A supplements can be beneficial when given as seldom as once a year. Check the latest information at:

    http://www.micronutrient.org/english/View.asp?x=577


Vitamin a deficiency perinatal health
Vitamin A deficiency & perinatal health Nutrition in Global Health

  • Vit. A is crucial for maternal & child survival, supplements in high-risk areas can dramatically decrease maternal mortality*

  • In pregnant women Vit. A deficiency is seen in the last trimester when demands by unborn child & mother are highest

  • Partnerships for progress in vitamin A nutritionIn 1998 WHO, UNICEF, CIDA, USAID (ia) launched a global initiative in 40 countries that has to date averted 1.25 million deaths, by giving vitamin A to kids at clinics

*This issue is under active investigation. For the status at time of writing see Lancet, Volume 376, Issue 9744, p 873 - 874, 11 September 2010


Vitamin a deficiency perinatal health1
Vitamin A deficiency & perinatal health Nutrition in Global Health

  • Night blindness in pregnant women - an early danger sign

  • In children, the cost-effective prevention is breast-feeding

  • Genetically engineered high Vit. A rice crops could help

    Caution: Vit. A supplements as retinol are controversial. It can be toxic & teratogenic ( birth defects). However, given as carotene, vitamin A supplements are safe, leading only to an orange tinge in skin colour.

Page 59


Iodine deficiency disorders
Iodine deficiency disorders Nutrition in Global Health

  • The world’s major cause of preventable brain damageIn 1990: 1.6 billion people were at risk in over 100 countries, mainly in parts of Africa and Asia where soil is iodine-deficient

  • Close to 40 million children have mental impairment from lack of iodine

  • As a result of the micronutrient initiative, this number is falling

For latest data, see:http://www.micronutrient.org/english/View.asp?x=578


Iodine deficiency disorders1
Iodine deficiency disorders Nutrition in Global Health

  • Consequences start before birth and continue afterward

    • In utero, spontaneous abortion, congenital abnormalities & retarded foetal development

    • In early childhood and progress toward adolescence iodine deficiency causes cretinism, an irreversible retardation. Impacts home, school, & work

    • Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox & polio

Page 61


Toward iodine sufficiency iodized salt
Toward iodine sufficiency – iodized salt Nutrition in Global Health

  • A cost-effective low-tech therapy, iodized salt costs just $0.05 per person per year

  • UNICEF, ICCIDD (International Council for Control of IDD), & the salt industry have set up iodization programmes.Globally, 66% of households have access to iodized salt.

  • As of 2009 the number of at risk countries has been halved!

  • However, progress has slowed and we are a decade behind promises of the international community.

  • 54 countries are still affected – efforts must continue


Nutrition in global health c auses mechanisms solutions nutrition is crucial to global health mdgs2
Nutrition in Global Health Nutrition in Global HealthCauses, mechanisms, solutionsNutrition is crucial to global health & MDGs

Overview of nutrition across humankind

Human nutrition fundamentals in global context

Top 6 nutrition problems, & their solutions

Nutrition across the life cycles of rich & poor

Cause & effect in population nutrition

Overview and where we are now

Bridge to Part 2, Roadmap to a world without hunger

Page 63


Nutrition through the life cycle
Nutrition through the life-cycle Nutrition in Global Health


Factors in perinatal nutrition see also acute malnutrition module
Factors in perinatal nutrition Nutrition in Global Health(see also Acute Malnutrition module)

  • Nutritional health begins in the womb – a healthy outcome to a pregnancy requires that mother be well nourished; good feeding must initiated early

  • The most common birth defects result from a deficiency of folic acid in the diet of the pregnant mother, Best outcomes require folic acid supplementation beforeconception!


Factors in perinatal nutrition see also module on acute malnutrition
Factors in perinatal nutrition Nutrition in Global Health(see also Module on Acute Malnutrition)

Delaying clamping the umbilical cord until it stops pulsing iron stores see: www.naturalchildbirth.org/natural/resources/labor/labor04.htmhttp://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/jccom/en/index.html

Ideally, babies should receive vitamins E & K injections at birth

A baby who’s healthy at birth may experience "failure to thrive" (or "growth faltering") in the first year of life. So …..

Good infant feeding behaviors must start early. Most importantly, breast-feeding should be initiated within an hour of birth & maintained exclusively for 6 months.

Breastfeeding could prevent 1.3 million deaths each yearhttp://www2.unicef.org/nutrition/index_22657.html

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Perinatal nutrition requires attention 1
Perinatal nutrition requires attention Nutrition in Global Health1

  • Malnutrition in pregnancy birth defects & low birth-weight

  • Failure to thrive is an early danger sign, requiring investigation

  • Nutrition in infancy to early life impacts physical & cognitive development. It determines immediate & future risks of blindness, thyroid function, bone development, & more

  • Under-nutrition or deficiencies of many micronutrients can cause failure to thrive“

  • Iron, vitamins K and E are of particular importance. Refer to:

    1http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html


Malnutrition in early childhood
Malnutrition in early childhood Nutrition in Global Health

  • Children are at special need because they are at the fastest-growing stage of life. Problems an adult could survive can be lethal to a child

  • This is the most vulnerable period – a child is developing physically & mentally. Damage can be permanent

  • Most importantly, they are unable to fend for themselves & depend on others (parents, others) for health & survival

  • They are the planet’s future. We owe it to them & to ourselves to ensure that they grow well, with a sense that they have reason to invest in the future, in a caring world


Parenthetically a personal perspective
Parenthetically – a personal perspective Nutrition in Global Health

How easily we see the moral failings of the past. Slavery, the holocausts & genocides, conquests motivated by greed

When future generations look amazed at the moral blindness of this generation, what will stand out? Clearly child hunger

Where life expectancy is short, toddlers are orphans. In war or famine a region may lack necessities. You can’t blame a child

Yet in many rich countries, including the US & Canada, we turn our empty eyes and hands away from those outside our borders

A napalmed child turned a nation’s mind to peace. What will it take to open our eyes to children dying of hunger?

Page 69


Nutrition through the life cycle adolescence
Nutrition through the life cycle - adolescence Nutrition in Global Health

Adolescence carries risks for both poor & affluent

  • Adolescent & adult patterns of food consumption & activity massively impact immediate & future health risks

  • Adolescents are notoriously careless about health. Their eating patterns can lead quickly to obesity or anorexia.


Nutrition through the life cycle adolescence1
Nutrition through the life cycle - adolescence Nutrition in Global Health

Adolescence carries risks for both poor & affluent

  • Dieting can lead to deficiencies of vit. C, protein, folic acid in a sedentary person. Even if a good mix of foods is consumed, total food intake may be insufficient.

  • A pattern of healthy eating in adolescence sets a pattern that can promote lifelong health

  • A foundation for healthy bones is set by exercise, calcium, & vitamin D. After early adult life, bones go slowly downhill

Page 71


Nutrition through the life cycle adult life
Nutrition through the life cycle – adult life Nutrition in Global Health

Nutrition & acute & infectious diseases

  • Malnutrition depletes immunity leading to increased risk & severity of infections & parasites: AIDS, malaria, etc.

  • Flagrant deficiencies of specific micronutrients can put at risk the life & health of the mother in pregnancy & lactation

  • Nutritional anaemias, pellagra, blindness, skin disordersberiberi, scurvy, etc, can range in severity from mild to fatal

Page 72


Adult life degenerative diseases
Adult life Nutrition in Global Health- degenerative diseases

  • In late life, risk of breast, prostatic, & most other cancers are predicted by diet, obesity, inactivity or smoking in adult life

  • Also heart disease, strokes, osteoporosis, diabetes

  • Cancers and diabetes are now leading causes of death & disability in low- and middle-income countries (see Lancet, August 13, 2009)

  • Nearly two-thirds of the world’s 7.6 million cancer-related deaths now occur in developing nations.


Differential nutritional vulnerability of females
Differential nutritional vulnerability of females Nutrition in Global Health

  • Women are much more prone to nutritional anaemias since they need to replace red cells lost in menstruation

  • Women are the majority of elders, increasingly so in Asia and Africa. Osteoporosis is more common in the elderly

  • Osteoporosis is a major cause of illness, disability and death. The annual number of hip fractures worldwide will rise from 1.7 million in 1990 to around 6.3 million by 2050.


Differential nutritional vulnerability of females1
Differential nutritional vulnerability of females Nutrition in Global Health

Women suffer 80% of hip fractures; lifetime risk 30 - 40% compared with 13% for men.

Osteoporosis prevention (exercise, calcium, & vitamin D) must start well before age 30 when bones still respond.

Negative calcium balance in later life is not very responsive to nutritional measures.

Page 75


Under over nutrition occur in all cultures
Under- & over-nutrition occur in Nutrition in Global Healthall cultures

  • Disparities in income, nutrition & health care are increasing between countries & within groups in the same country

    In addition, in low and middle income countries diseases of overnutrition are increasingly common

  • Obesity related disorders, including diabetes, are now as important in some lower to middle income countries as in North America and the European Union


Also under nutrition occurs in many rich nations
Also, under-nutrition occurs in many rich nations Nutrition in Global Health

In rich nations, enormous wealth for some has left others ravaged by health costs, unemployment, foreclosures

Developed countries have marginalized cultural groups. Hunger is common in N & S America, China & E Europe

For example, ~49% of US children (and over 80% of black children) require food-aid at some time during childhood

Scandinavia & few western European countries are almost the only exceptions

Page 77


Overnutrition is no longer limited to rich countries
Overnutrition is no longer limited to rich countries Nutrition in Global Health

Obesity is a growing problem worldwide, particularly among those who lack resources for a wide range of food choices.

  • All too often, the cheapest foods are high calorie, poor in nutrients, rich in sugar, salt, fat, & trans-fats

  • The predominant cause of obesity is under-exercising rather than overeating. On average, overweight people eat slightly fewer calories than lean people, but are much less active

  • Obesity increases risk of many disorders, most notably cardiovascular disease, cancer, adult-onset diabetes. “Prevention is much better than cure”.


Overnutrition is no longer limited to rich countries1
Overnutrition is no longer limited to rich countries Nutrition in Global Health

Previously, the poorest were almost immune to diabetes, hypertension, gout, & atherosclerosis & heart disease

No longer. These are growing problems, impacting health worldwide. In the next few slides we’ll consider prevention.

Diabetes has reached epidemic proportions threatening, vision, kidney function, mobility, heart-health & life itself.

A cluster of symptoms, hypertension, hyperlipidemia, and hyperglycemia is sometimes called “metabolic syndrome”

Each of them increases risk of heart disease, and together the risk is greatly amplified. Read on…..

Page 79


Prevention of heart attacks and strokes
Prevention of heart attacks and strokes Nutrition in Global Health

  • Risk factors: hypertension, hyperlipidemias (LDL / “bad” cholesterol), inactivity & diabetes. All correlated with obesity

  • Smoking is the most life-shortening risk factor of all

  • These risks can be changed earlier or later, by modification of diet & other life-style changes or medication

  • In the past 5 years research has established that exercise & a lean body are the most powerful predictors of a long healthy life, and also of clear thinking into old age


Prevention of heart attacks and strokes1
Prevention of heart attacks and strokes Nutrition in Global Health

There is no easy solution to obesity. In a typical study: <10% of people dieting, <10% of those exercising, and <15% of those exercising & dieting, lost weight.

However, over 80% of those who underwent stomach stapling or banding lost weight!

Not very encouraging for lifestyle treatment. Many argue that surgery to control weight should be done more often

Page 81


Measures to diminish cardiovascular risks
Measures to diminish cardiovascular risks Nutrition in Global Health

Lifestyle measures: have greatest impact in older people!

  • Increasing consumption of fruit & vegetables by one to two servings can cut cardiovascular risk by 30%

  • Reduction of blood pressure by 6 mm Hg reduces stroke risk by 40% & heart attack by 15%. Hydrochlorthiazides (diuretics) are inexpensive and effective

  • Moreover, a 10% reduction in LDL cholesterol reduces the risk of coronary heart disease by 30%


Measures to diminish cardiovascular risks1
Measures to diminish cardiovascular risks Nutrition in Global Health

Modest cutbacks in saturated fat & salt improve blood pressure & lipids; & diminish risk of cardiovascular disease

Lifestyle measures are, optimally, combined with pharmaceutical intervention

Best practices regarding diabetes & cardiovascular disease are a moving target. Anyone teaching or practicing in this area needs skills in finding evidence-based information in an ocean of misinformation.

Page 83


Nutrition in later life and old age
Nutrition in later life and old age Nutrition in Global Health

  • Worldwide, the proportion of people over 60 is increasing. By 2025, the world will have more than 1.2 billion older persons – two-thirds of them in low income countries

  • The foundation laid in earlier life determines risk ofdiabetes, heart disease, hypertension, strokes, osteoporosis, cancer, etc. All these bring special nutritional concerns.

  • Many of the diseases of late life are diagnosed too late for effective treatment. Prevention at an early age is the goal


Nutrition in later life and old age1
Nutrition in later life and old age Nutrition in Global Health

Old age can be cut short by many kinds of malnutrition

Deficiencies of calcium, iron, water, vit. B12 can severely compromise old age

Loss of taste and smell can render the elderly at risk for food poisoning from spoiled food

Loss of thirst sensitivity in this age group makes dehydration (inadequate water intake) a common cause of confusion, headache, & occasionally kidney stones

Prevention is better than cure, & symptomatic treatments that are effective, are often unavailable to the aged in LMICs

Page 85


Nutrition in global health causes mechanisms solutions nutrition is crucial to global health mdgs
Nutrition in Global Health Nutrition in Global HealthCauses, mechanisms, solutionsNutrition is crucial to global health & MDGs

Overview of nutrition across humankind

Human nutrition fundamentals in global context

Top six nutrition problems, & their solutions

Nutrition across the life cycles of rich & poor

Cause & effect in population nutrition

Overview and where we are now

Bridge to Part 2, Roadmap to a world without hunger

Page 86


Determinants of population nutrition
Determinants of population nutrition Nutrition in Global Health

Any broken link can  nutritional inequities.

(think about how …)


The mechanisms of hunger many paths
The mechanisms of hunger – many paths Nutrition in Global Health

Notice how one path can feed-back to affect others

As diagrammed by WHO

in

“Repositioning Nutrition as Central to Development:  A Strategy for Large-Scale Action”


Sub determinants of nutritional sufficiency
Sub-determinants of nutritional sufficiency Nutrition in Global Health

  • Each factor has its own contingencies. Here are a few:

  • Economic development depends on agricultural sustainability

  • irrigation & soil maintenance (crop rotation, contour plowing)

  • seeds, fertilizers, appropriate insecticides

  • Agricultural productivity depends on good harvests

  • climatic: drought and floods

  • drought - and frost-resistant crops

  • hybrid seeds and related biotechnology

  • market for any excess crop, non-exploitative trade


Sub determinants of nutritional sufficiency1
Sub-determinants of nutritional sufficiency Nutrition in Global Health

  • Each factor has its own contingencies. Here are a few more:

  • Stability includes freedom from disruptive forces

  • war (revolts, invasion, political upheaval, social disruption)

  • exploitation from outside – unequal trading practices

  • corruption externally – multinational corporations offer bribes and rich nations tolerate this because it benefits them

  • corruption internally – where some developed nations set a poor example e.g. non-transparent procurement policies

Note O

Page 90


Poverty - greatest cause of malnutrition Nutrition in Global Health(hunger, blindness, disease, birth defects, maternal/neonatal death)

The causes of poverty are disputed – no one wants to be part of the cause. What we know is….

  • Poverty doesn't just happen, it is caused by economic, political, social & geographical circumstances & decisions

  • Usually these decisions are made outside the groups of people most affected by it!

Note P


Poverty - greatest cause of malnutrition Nutrition in Global Health(hunger, blindness, disease, birth defects, maternal/neonatal death)

  • Old people, women and under-supported children are most likely to be impacted by poverty

  • Uneven distribution: 2/3of undernourished people live in Asia

  • Hunger is growing fastest in Sudan, Rwanda, Burundi, Chad D.R. Congo, Sierra Leone, Zimbabwe, Somalia

Page 92


Nutrition in global health nutrition is crucial millions more are fed but nutrition is crucial
Nutrition in Global Health Nutrition in Global HealthNutrition is crucial: Millions more are fed, butNutrition is crucial

Overview of nutrition across humankind

Human nutrition fundamentals in global context

Top six nutrition problems, & their solutions

Nutrition across the life cycles of rich & poor

Cause & effect in population nutrition

Overview and where we are now

Bridge to Part 2, Roadmap to a world without hunger

Page 93


Where are we considerable hope for the future with great distress urgency in the present
Where are we? Nutrition in Global HealthConsiderable hope for the future,with great distress & urgency in the present

  • Globally, more are now adequately fed than ever before.

  • Many populations are growing ... and yet the percentage being fed continues to increase

  • The MDGs will mostly be mostly met ... but not on schedule.


Where are we great hope for the future with great distress urgency in the present
Where are we? Nutrition in Global HealthGreat hope for the future,with great distress & urgency in the present

  • Does that mean we are doing enough? Absolutely not!

  • Improvements in nutrition are not equally spread: in Africamore are hungry

  • Most of those born today will live to see hunger shrink to temporary pockets, managed by relief aid

  • Meanwhile, even as extreme hunger decreases, it’s too slow to stop the needless loss of millions of lives each year

Page 95


What has changed at last it s clear
What has changed? Nutrition in Global HealthAt last it’s clear

Disparities are now so great that there is almost complete agreement that the plight of the poorest must be addressed

The cost of conferring great benefits is a fleabite to the rich. $20 from an individual can save a child’s life and 0.7% of GDP from the richest nations could, in two decades, wipe out the deadliest disparities


What has changed at last it s clear1
What has changed? Nutrition in Global HealthAt last it’s clear

What’s needed was defined in 2001. Amazingly 22 nations signed on to fund 7 MDGs with 60 indicators of success, and to provide the funds!1st aim: eradicate extreme poverty & hunger

We’ve seen what worked & what didn’t. The MDG projections were accurate, but ...

Page 97


While some well intended nations
While Nutrition in Global Healthsome well-intended nations ...

... honoured their commitments in full, or at a higher level (here we honour northern EU, Luxemburg & Netherlands)

... most provide approximately half the aid that they undertook and are increasing – (here, much of west-central EU)

... a very few provided a third or less & are decreasing – (here we include the nations of N. America & Japan)

the consequences are unsurprising….

Page 98


The consequences are unsurprising Nutrition in Global Health

  • Thanks to nations & individuals who put worthwhile goals ahead of strictly national interests, a better nourished world emerges

  • The majority of nations are now solidly on the development ladder and the number grows each year

  • Millions die unnecessarily in E and S Asia, & sub-Saharan Africa, and the major cause rests with a few nations

Page 99


Nutrition in global health bridge to a roadmap to a world without hunger
Nutrition in Global Health Nutrition in Global Health Bridge to a roadmap to a world without hunger

Why nutrition is crucial to global health & MDGs

Overview of nutrition across humankind

Human nutrition fundamentals in global context

Top six world nutrition problems, & their solutions

Nutrition across the life cycle & in rich and poor nations

Cause & effect: Determinants in population nutrition

Where we are now: Overview Millions more are fed but without urgent action, millions more will starve

On to Part 2: Roadmap to a world without hunger

Page 100


Roadmap toward a world without hunger
Roadmap toward a world without hunger Nutrition in Global Health

We’ve concluded Part I of the nutrition modules with a preliminary assessment of prospects for “eradicating extreme poverty & hunger.” In Part II we ask “what works and what doesn’t?” We will…

… discuss the confounders & wild cards & elaborate on the range of possible future scenarios

… contend that many controversies fail to see that many “competing” approaches are, in fact, complementary

... categorize competing viewpoints as evidence- or ideology- based & subject them to the test of science

… survey current strategies, assessing their strengths, weaknesses, & applicability to real life problems


Review your pre-quiz* to confirm that you have advanced your knowledge. As we move now to the future, here is part of the pre-quiz* for the Part II Nutrition module (*Quiz feature pending upgrade of GHEC IT platform)

  • Does globalization promote nutritional health? For whom?

  • Is free enterprise good for everyone? If not, for whom?

  • Are most African leaders dictators?

  • Does most aid to Africa end up in Swiss bank accounts?

  • Does food aid do more harm than good?

  • Academics & politicians argue about these questions and what should be done. Does that mean that we don’t know what to do? We will see in Part II that the answers are clear


Summary what you ve learned
Summary: What you’ve learned … knowledge. As we move now to the future, here is part of the pre-quiz* for the Part II Nutrition module

  • Nutritional health is not equitably distributed worldwide

    Correcting nutritional inequities is crucial to a viable future

  • We've reviewed nutritional principles in global context

    Nutritional health, public health, & economics are inseparable

  • Worst nutritional risks: unsafe / inadequate water and protein, iron, vitamin A & iodine deficiencies

    As you reframe this information in your own context , it will help you see: what to look for, what to ask for, & what to do


Applying what you ve learned
Applying what you’ve learned knowledge. As we move now to the future, here is part of the pre-quiz* for the Part II Nutrition module

  • Ranking risks in the life cycle - kids & mothers are top priority

    Help you set priorities & best practices for risk mitigation

  • We have seen setbacks, slow progress toward the MDGs. Yet

    There is substantial agreement about what needs to be done

  • Reasons for hope: Fortunes given away, crazy ideas, loans to the poorest repaid, workable strategies toward a world without hunger & clear-sighted agents of change

    We return to our task with renewed clarity & energy


References and resources
References and resources knowledge. As we move now to the future, here is part of the pre-quiz* for the Part II Nutrition module

  • See the notes for much additional information about resources, books, compilations of government information, and toolkits for finding more information.

Note Q


Case study analysis of progress
Case study analysis of progress knowledge. As we move now to the future, here is part of the pre-quiz* for the Part II Nutrition module

  • See Note P for a Case study Analysis of Progress in a cluster of Millennium Villages. The MDVs are described in GHEC’s module #2, “Millennium Village Project: A Demonstration of Reaching the MDGs”

Note P


Acknowledgments
Acknowledgments knowledge. As we move now to the future, here is part of the pre-quiz* for the Part II Nutrition module

I single out a few of many whose insights, persistence, and courage dispelled the pessimism I felt when I began this task.

Jeffrey Sachs, Yunus Muhammad, Raj Patel, Kumi Naidoo, Paul Collier, Howard Zinn, Vandana Shiva, & Frances Moore Lappé

Also the hundreds of passionate students, practitioners, and researchers at meetings of the Canadian Consortium of Global Health who passed on to me their energy & vision. Pre-eminent among those who encouraged me are Vic Neufeld & Tom Hall


End of module

End of module knowledge. As we move now to the future, here is part of the pre-quiz* for the Part II Nutrition module

Please refer to the supplementary contents for more information about this module.

[Reserved for GHEC notes]


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