1 introduction to phn

Introduction to PHNIntroduction to PHN

Outline

DefinitionsForms of MalnutritionScale of the problemNutrition and DevelopmentNutrition TransitionCauses of Undernutrition

Course content – 2 crd hrsCourse content – 2 crd hrs18 Jun – 06 July 201218 Jun – 06 July 20121. Introduction (5 hrs) – 3 days – 18-

20 Jun - Solomon◦ Human nutrition◦ Public health nutrition◦ Nutrition and development◦ Causes of malnutrition◦ Nutrition through and Life stages

Course content…Course content…2. Nutritional assessment (5 hrs) – 2

days – 21-22 Jun, Jemal◦ Methods of nutritional assessment◦ The present nutrition situation◦ Nutritional surveillance

3. Nutritional problems of public health importance (5 hrs) – 2 days – 25-26 Jun- Jemal

◦ Protein-energy malnutrition – Dr Bilal

◦ Vitamin A deficiency◦ Iron deficiency anemia◦ Iodine deficiency disorders◦ Zinc deficiency

Course content…Course content…

6. Nutrition interventions (4 hrs) –2 days – 27-28 Jun, Mesfin B

◦ Essential nutrition actions◦ Emergency Nutrition Interventions◦ Ethiopian National Nutrition strategy

5. Literature Review (presentation) – 2 days –05-06 July- all

Course ObjectiveCourse ObjectiveEnable the student acquire

theoretical knowledge (principles) and analytical skills (methods) in Human Nutrition

Course OrganizationCourse Organization

Modular training - 5+module

Course delivery modalities;◦Lectures◦Group Assignments

Literature Review and Presentations

◦Reading Assignments

Examples of topics for Examples of topics for Literature Review and Literature Review and PresentationPresentationBreast feeding and cognitive

developmentBreast feeding and Social

development/family attachmentDevelopmental origins of diseasesHIV/AIDS and infant feedingBiofuels and Nutrition securityClimate change and food securityEtc.

Nutrition Nutrition The science of Nutrition:

Nutrition studies the interaction between the individual and the environment mediated by food

Study of food in relation to man, and study of man in relation to food

Science of food as it relates to optimal health and performance

Human NutritionHuman Nutrition

Human Nutrition is a scientific discipline, concerned with the access and utilization of foods and nutrients for life, health, growth, development, and well- being

The science of Nutrition: The science of Nutrition: AreasAreas of Study of Study

◦Food production◦Diet composition (including non-

nutritive substances)◦Food intake, appetite, food

preferences◦Digestion and absorption of nutrients◦Intermediary metabolism, nutritional

biochemistry

The Science of Nutrition - The Science of Nutrition - Areas of StudyAreas of Study

◦Biological actions of essential nutrients

◦Nutrient requirements in individuals and populations

◦Heath effects of nutrient deficiencies and excesses

◦Long-term effects of diet constituents◦Therapeutic and preventive effects of

foods

Nutrition…Nutrition…Dietetics

◦Science/ art of applying the principles of nutrition in feeding

◦Older subject, practiced by Hippocrates 460-360 BC.

Public Health NutritionPublic Health Nutrition

Public Health Nutrition focuses on issues that affect the whole population rather than the specific dietary needs of individuals

MalnutritionMalnutritionA pathological state resulting

from a relative or absolute deficiency or excess of one or more essential nutrients, this state being clinically manifested or detected only by biochemical, anthropometric or physiological tests

Forms of Malnutrition Forms of Malnutrition Under nutrition

◦Pathological state resulting from the consumption of an inadequate quality/ quantity over an extended period of time

Over-nutrition ◦Pathological state resulting from the

consumption of an excess quantity of food, and hence an energy excess, over an extended period of time

Prevalence and number of Prevalence and number of children with chronic children with chronic undernutrition in developing undernutrition in developing regions regions (1969-1992)(1969-1992)

Estimated prevalence and number of Estimated prevalence and number of underweight children 0−5 years old underweight children 0−5 years old 1990−20051990−2005

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Global Distribution of Global Distribution of MalnutritionMalnutrition

Trends of malnutrition in Sub-Trends of malnutrition in Sub-Saharan Africa (1983-2001)Saharan Africa (1983-2001)

Global Distribution of Global Distribution of Malnutrition (Lancet Nutrition Malnutrition (Lancet Nutrition series, 2008)series, 2008)

Global Distribution of Global Distribution of Malnutrition…Malnutrition…

Nutrition and Nutrition and DevelopmentDevelopment

Poor nutrition perpetuates the cycle of poverty and malnutrition through 3 main routes -

direct losses in productivity from poor physical status and losses caused by disease

indirect losses from poor cognitive development and losses in schooling

losses caused by increased health care costs.

Nutrition, economic growth, and Nutrition, economic growth, and marketsmarkets

◦The income–malnutrition relationship is modest

◦When gross national product (GNP) per capita in developing countries doubles, nutrition does improve but the changes in underweight rates are much more modest— from 32 to 23 percent

◦it is estimated that sustained per capita economic growth of 2.5 percent between the 1990s and 2015 would reduce malnutrition by 27 percent—only half of the MDG

Markets are failingMarkets are failing

◦ Market forces do not suffice to improve nutrition; public investment is necessary

◦Informational asymmetries of two kinds: People cannot tell when their children are

becoming malnourished b/c healthy growth rates, can't be detected with the naked/‘untrained’ eye

Good nutrition is not intuitive: people do not always know what food or what feeding practices are best for their children or for themselves

Nutrition and income Nutrition and income povertypoverty◦Undernutrition and micronutrient

malnutrition are themselves direct indicators of poverty, in the broader definition of the term that includes human development

◦The prevalence of malnutrition is often two or three times - and sometimes many times - higher among the poorest income quintile than among the highest quintile This means that improving nutrition is pro-poor

and increases the income-earning potential of the poor

Human DevelopmentHuman Development

“Wealth is evidently not the good we are seeking, for it is merely useful for the sake of something else.” Aristotle

Human DevelopmentHuman Development

"The basic purpose of development is to enlarge people's choices. In principle, these choices can be infinite and can change over time.

People often value achievements that do not show up at all, or not immediately, in income or growth figures: greater access to knowledge, better nutrition and health services, more secure livelihoods, security against crime and physical violence, satisfying leisure hours, political and cultural freedoms and sense of participation in community activities.

The objective of development is to create an enabling environment for people to enjoy long, healthy and creative lives.”

Nutrition and Human Nutrition and Human RightsRights

◦The 1948 Universal Declaration of Human Rights established adequate health, including adequate food, as a basic human right

◦The right to adequate nutrition is also enshrined in the constitutions of many countries—for example, those of Ethiopia, Guatemala, India, Peru, and South Africa

The The Know-HowKnow-How for Improving for Improving NutritionNutrition◦we know what to do to improve nutrition

and the expected rates of returns from investing in nutrition are high

◦Compared with many possible development investments, including trade reform and private sector deregulation, malaria eradication, and water and sanitation, the provision of micronutrients was identified as the second best opportunity for meeting the world’s development challenges

The Know-How for Improving The Know-How for Improving Nutrition…Nutrition…

◦The final argument for investing in nutrition is that there are tried and tested models and experiences for reducing most forms of malnutrition - that have not been adequately exploited and scaled up

◦In some exceptional countries, nutrition programs have virtually universal coverage (Chile, Costa Rica, Cuba, and Thailand) and malnutrition has declined rapidly

Nutrition and Nutrition and Development…Development…Nutrition and economic development have

a two-way relationship

MDGs ; focus the efforts of the world community on achieving significant, measurable improvements in people's lives

The first seven goals are mutually reinforcing and are directed at reducing poverty in all its forms. The last goal -- global partnership for development -- is about the means to achieve the first seven.

Millennium Development Millennium Development GoalsGoals1. Eradicate extreme poverty and

hunger 2. Achieve universal primary education3. Promote gender equality4. Reduce child mortality5. Improve maternal survival6. Combat HIV/AIDS, malaria & other

diseases7. Ensure environmental sustainability8. Develop a Global Partnership for

Development

Goal 1: Eradicate Extreme Goal 1: Eradicate Extreme Poverty and HungerPoverty and Hunger

Target 1: Halve, between 1990 and 2015, the proportion of people whose income is less than $1 (0.80 Euros) a day

Target 2: Halve, between 1990 and 2015, the proportion of people who suffer from hunger◦Prevalence of underweight in children

under five years of age ◦Proportion of population below minimum

level of dietary energy consumption

The Nutrition TransitionThe Nutrition TransitionAn Emerging Global Epidemic of ObesityAn Emerging Global Epidemic of Obesity

BMI > 30 kg/m2; Overweight BMI > 25 kg/m2

Trends in Prevalence of Underweight and Trends in Prevalence of Underweight and Obesity in the Poorest and Richest 25% of Obesity in the Poorest and Richest 25% of Brazilian WomenBrazilian WomenMonteiroC, CondeW, PopkinB. AJPH 2004;94:43326101418MonteiroC, CondeW, PopkinB. AJPH 2004;94:43326101418

Prevalence of stunting in < Prevalence of stunting in < 5 yr/old children5 yr/old children

World poverty, 1981-2001World poverty, 1981-2001% of people living with <US$2 per % of people living with <US$2 per dayday

The Nutrition The Nutrition TransitionTransitionDemographic trends◦ Urbanization◦ Increase in life expectancy◦ Reduction in infant mortality

Food availability and cost◦ Changes in food type, availability and cost◦ Changes in eating behaviors

Lifestyle◦ Reduction in energy demands at work ◦ Reduction in energy demands of daily

survival activities◦ Limited leisure physical activity◦ Television

Age shifts in world Age shifts in world populationpopulation

Population over 59 Population over 59 yearsyears

Urban growthUrban growthAnnual increase, 1990-Annual increase, 1990-2000 2000

Food commodities –Global Food commodities –Global trendstrends

Trends in employment type in Trends in employment type in South Asian transitional South Asian transitional countries countries

Disease burden in the Disease burden in the developing worlddeveloping world

Causes of MalnutritionCauses of Malnutrition

Malnutrition, is not a simple problem with a single, simple solution

Multiple and interrelated determinants are involved in why malnutrition develops, and a similarly intricate series of approaches, multifaceted and multisectoral, are needed to deal with it

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Causes of Malnutrition…Causes of Malnutrition…

Causes could be categorized as:◦Immediate causes◦Underlying causes, and◦Basic causes

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Malnutrition - Immediate Malnutrition - Immediate causescausesImmediate causes

The interplay between the two most significant immediate causes of malnutrition - inadequate dietary intake and illness - tends to create a vicious circle:

A malnourished child, whose resistance to illness is compromised, falls ill, and malnourishment worsens

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Malnutrition - Immediate Malnutrition - Immediate causes…causes…

Children who enter the malnutrition-infection cycle can quickly fall into a potentially fatal spiral as one condition feeds off the other

Malnutrition lowers the body’s immune-response mechanisms.◦ This leads to longer, more severe and

more frequent episodes of illness

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Inadequate dietary Inadequate dietary intake/disease cycleintake/disease cycle

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Malnutrition - Immediate Malnutrition - Immediate causes…causes…

Infections cause loss of appetite, malabsorption and metabolic and behavioral changes.

These, in turn, increase the body’s requirements for nutrients, which further affects young children’s eating patterns and how they are cared for

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Malnutrition - Underlying Malnutrition - Underlying causescauses

Three clusters of underlying causes lead to inadequate dietary intake and infectious disease: ◦inadequate access to food in a household;

◦insufficient health services and an unhealthful environment; and

◦inadequate care for children and women

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Malnutrition - Underlying causes Malnutrition - Underlying causes (HHFS)…(HHFS)…

Household food security (HHFS)

◦is defined as sustainable access to safe food of sufficient quality and quantity - including energy, protein and micronutrients - to ensure adequate intake and a healthy life for all members of the family

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In rural areas, HHFS may depend on access to land and other agricultural resources to guarantee sufficient domestic production

In urban areas, where food is largely bought on the market, foods must be available at accessible prices

Other potential sources of food are by exchange, gifts from friends or family and in extreme circumstances food aid provided by humanitarian agencies

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HHFS depends on access to food - financial, physical and social - as distinct from its availability

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Malnutrition - Underlying causes Malnutrition - Underlying causes (Services and sanitation)…(Services and sanitation)…Health services, safe water and sanitation◦access to curative and preventive

health services that are affordable and of good quality

◦Families should have a health centre within a reasonable distance, and the centre’s staff should be qualified and equipped to give the advice and care needed

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Malnutrition - Underlying causes Malnutrition - Underlying causes (caring)…(caring)…Caring practices

◦ even when there is adequate food in the house and a family lives in a safe and healthful environment and has access to health services, children can still become malnourished

◦ Inadequate care for children and women, the third element of malnutrition’s underlying causes, has only recently been recognized and understood in all its harmful ramifications

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Malnutrition - Underlying causes Malnutrition - Underlying causes (caring)…(caring)…

Care is manifested in the ways a child is fed, nurtured, taught and guided

Nutritionally, care encompasses all measures and behaviors that translate available food and health resources into good child growth and development

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In communities where mothers are supported and cared for, they are, in turn, better able to care for young children

Among the range of caring behaviors that affects child nutrition and health, the following are most critical:

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Malnutrition - Underlying causes Malnutrition - Underlying causes (caring)…(caring)…Feeding:

◦ The introduction of complementary foods is a critical stage. A child will be put at increased risk of malnutrition and illness if these foods are introduced much before the age of six months, or if the preparation and storage of food in the home is not hygienic

◦ Good caring practices need to be grounded in good information & knowledge and free of cultural biases and misperceptions

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◦Other behaviors that affect nutrition include whether children are fed first or last among family members, and whether boys are fed preferentially over girls

Protecting children’s health:◦Ensure that children receive essential

health care at the right time (e.g. immunizations, and early treatment)

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Malnutrition - Underlying causes Malnutrition - Underlying causes (caring)…(caring)…Support and cognitive stimulation for children:◦For optimal development, children

require emotional support and cognitive stimulation, and parents and other caregivers have a crucial role in recognizing and responding to the actions and needs of infants

◦Breastfeeding affords the best early occasion to provide support and stimulation

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◦Verbal stimulation by caregivers is particularly important for a child’s linguistic development

◦Ill or malnourished children who are in pain and have lost their appetite need special attention to encourage them to feed and take a renewed interest in their surroundings during recovery

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Malnutrition - Underlying causes Malnutrition - Underlying causes (caring)…(caring)…Care and support for mothers:

◦ As long as the unequal division of labour and resources in families and communities continues to favour men, and as long as girls and women face discrimination in education and employment, the caring practices vital to the nutritional well-being of children will suffer

◦ Adolescent pregnancy is a major risk factor for both mother and infant, as the girl may not have finished growing before her first pregnancy, making childbirth dangerous

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Malnutrition - Basic Malnutrition - Basic causescauses

◦It is often said that poverty at the family level is the principal cause of child malnutrition

◦Political, legal and cultural factors at the national and regional levels may defeat the best efforts of households to attain good nutrition for all members

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Malnutrition - Basic Malnutrition - Basic causes…causes…

◦These include: the degree to which the rights of women

and girls are protected by law and custom;

the political and economic system that determines how income and assets are distributed; and

the ideologies and policies that govern the social sectors

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1 introduction to phn

Health & Medicine

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