Hunger
We define individual hunger as consumption of a
diet insufficient to support normal growth, health,
and activity.
This definition leaves open questions of whether
norms are fixed across populations and over time,
and of what nutritional requirements are associated
with them.
… DeRose and Millman
Analytical Problems
Hunger
► Measurement
► Trends and Patterns
Thematic Frames
► Explanation
► Intervention
Political Economy
Health and Nutrition
Social Conditions
• Food Shortage: area and population.
• Food Poverty: household.
• Food Deprivation: individual
Topics in Political Economy
Famine and Calamity
Episodic, Seasonal, Chronic Hunger
Provisioning Institutions: Markets, States, NGOs,
development agencies
Interventions: Programs and policies, Structural
Adjustment
Topics in
NUTRITION HEALTH
Protein-energy malnutrition Birth
Micronutrient Deficiency Growth
Iron Development
Iodine
Mortality
Vitamin A
Morbidity
Disease Interactions
Capability
Environmental Interactions
Social Conditions
Inequality:
Nationality, Class, Race Gender, Ethnicity
Woman, Mother
Girl,
Fetus, Newborn, Infant, Child
Minority, Discrimination, Disability
Dislocation, Displacement, War
Nutrition and Health
Some basic issues
Protein-energy malnutrition (PEM)
► Combined insufficiency of calories and protein
the most widespread form of hunger.
► kilocalories daily requirement collapses
protein/calories into single calories measure
Food-based poverty lines based on PEM threshold
Food Requirements and Poverty Lines In Bangladesh
► DCI – Direct Calorie Intake – poverty line
1,805 kcal/day for the hardcore poor
2,122 kcal/day for the absolute poor
► FEI – Food Energy Intake – poverty line
monthly expenditure (income) required for calories = food/energy
requirement at 2,122 kilocalories/day in rural areas and 2,112
kcal/day in urban areas.
1995 FEI poverty line = Tk 419.70 per month in rural areas and
and Tk 707.8 per month in urban areas
► CBN – Cost of Basic needs – poverty line
FEI poverty line PLUS non-food poverty line.
Non-food poverty line is set at two levels (upper and lower) for
each of 14 regions.
“Absolute poor” are people below the upper line, and “hardcore
poor” are people below the lower line.
In 1995, the upper lines ranged from Tk563/mo in rural areas of
Khulna, Jessore, and Kushtia, to Tk 950 per month in Dhaka
(standard metropolitan area).
1985 WHO Minimum daily caloric requirements by sector and gender
Urban Rural
Age categories Male Female Male Female
0 to 1 year 820 820 820 820
>1 to 2 years 1,150 1,150 1,150 1,150
>2 to 3 years 1,350 1,350 1,350 1,350
>3 to 5 years 1,550 1,550 1,550 1,550
>5 to 7 years 1,850 1,750 1,850 1,750
>7 to 10 years 2,100 1,800 2,100 1,800
>10 to 12 years 2,200 1,950 2,200 1,950
>12 to 14 years 2,400 2,100 2,400 2,100
>14 to 16 years 2,600 2,150 2,600 2,150
>16 to 18 years 2,850 2,150 2,850 2,150
>18 to 30 years 3,150 2,500 3,500 2,750
>30 to 60 years 3,050 2,450 3,400 2,750
>60 years 2,600 2,200 2,850 2,450
Source: Caloric requirements are from WHO (1985, Tables 42 to 49).
Notes: Requirements used are for men weighing 70 kilograms and for women weighing 60 kilograms. Urban
individuals are assumed to need 1.8 times the basal metabolic rate (BMR), while rural individuals are assumed
to need 2.0 times the average BMR. Children under one year of age are assigned the average caloric need of
children either 3–6, 6–9, or 9–12 months old.
Head-count of Absolute Poverty for Bangladesh
Year Sector BBS FEI Ahmed Ravallion Rahman & Hossain & Sen & Muqtada
1991 et al. & Sen Haque Sen Islam (1986)
method (1991)+ (1994) (1988) (1992) (1993)
1973/ Rural 82.9 - - 65.3 71.3 n.a. 55.9
1974
Urban 81.4 (5.6) 62.5 n.a. 63.2 37.8
1981/ Rural 73.8 71.8 - 79.1 65.3 n.a. -
1982
Urban 66.0 65.3 50.7 n.a 48.4
1983/ Rural 57.0 n.a. 53.8 49.8 50.0 n.a. -
1984
Urban 66.0 n.a. 40.9 39.5 n.a. 42.6
1985/ Rural 51.0 51.6 45.9 47.1 41.3 n.a. -
1986
Urban 56.0 66.8 30.8 29.1 n.a. 30.6
1988/ Rural 48.0 - 49.7 - 43.8 n.a. -
1989
Urban 44.0 35.9 n.a. 33.4
1991/ Rural 50.0 - 52.9 - - - -
1992
Urban 46.8 33.6
LBW, Wasting, Stunting, obesity BMI MUAC obstetric
risk, inf and mat mortal, child development
► http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12259584&dopt=Abstract
► Child development indicators and public health.
► Measurements of physical development - height, weight, cranial
circumference, and arm measurements - are called better predictors of
nutritional and developmental status than mortality and morbidity figures.
► Low birth weight is directly associated with poor maternal nutrition while
poor development is associated with malnutrition or undernutrition of the
child.
► There is a critical period from Month 6 of pregnancy to about Year 2 of life
when brain cells develop; poor nutrition during this critical period will result
in permanent lack of mental capacity.
► Studies in Africa, Latin America, and Asia all point out the extremely
damaging effects of poor nutrition during this critical period. Malnutrition or
undernutrition occuring later in life can be reversed with proper feeding.
► The problems of obesity are as serious as those of malnutrition. The baby who
collects a surplus of fat cells under the skin during the 1st year of life is likely
to be overweight most of the rest of his life. Lowering age of maturation is
another indication of improving nutrition. This phenomenon has been
observed in all industrialized countries and is the basis of much of the
adolescent PROBLEM.
► Child development indicators should be used to point out areas of a country
or sectors of the population in need of additional health or nutritional aid.
Wasting and Stunting
► PEM reduces growth in children
► Energy expenditure in excess of consumption leads to
metabolizing nutrition reserves in the form of stored body fat.
► Lean body mass in the form of muscle and even organ tissue
will also be consumed if PEM persists.
► Weight loss accompanies the initial stages of inadequate
energy intake but, if prolonged, is followed by wasting, called
in its severe clinical form, marasmus.
► In children, PEM delays or permanently stunts growth and
increases morbidity and mortality.
Measuring Healthy Growth
► Body Mass Index (BMI)
► BMI is a measure that adjusts bodyweight for height. It is calculated as
weight in kilograms divided by height in meters squared. Overweight
for children and adolescents is defined as BMI at or above the sex-and
age-specific 95th percentile BMI cut points from the 2000 CDC Growth
Charts. Healthy weight for adults is defined as a BMI of 18.5 to less
than 25; overweight, as greater than or equal to a BMI of 25; and
obesity, as greater than or equal to a BMI of 30.
► http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm
► BMIWeight Status:
► < Below 18.5 = Underweight.
► 18.5 – 24.9 Normal.
► 25.0 – 29.9 Overweight
► 30.0 and AboveObese
► lbw in US < 5 lbs 8 oz or 2500 g
► very low birth weight (VLBW) <1500 grams
► The following charts are from NATIONAL CENTER FOR HEALTH
STATISTICS http://www.cdc.gov/nchs/
OK135S053
OK135S054
OK135S055
OK135S056
OK135S057
OK135S058
OK135S059
OK135S060
OK135S061
OK135S062
OK135S063
OK135S064
OK135S065
OK135S066
OK135S067
OK135S068
OK135S069
OK135S070
OK135S071
OK135S072
Child Morbidity and Mortality
► Health statistics tend to ascribe child deaths to malnutrition
or infectious disease, but causes tend to be interlinked.
► Using case studies from poor countries, David Pelletier
concluded that malnutrition contributed to 56 per cent of
all child deaths, owing to its interaction with infectious
disease.
► About 83 per cent of these malnutrition-related deaths
were attributed to mild-to-moderate malnutrition.
► Elevated morbidity and mortality are also associated with
micronutrient malnutrition, especially vitamin A and iron
deficiencies.
Disease Interactions
► The relationship between malnutrition and infection is
reciprocal and synergistic.
► Disease leads to a deterioration in nutritional status at the
same time that malnutrition increases susceptibility to
disease.
► Effects of disease on nutritional status involve shifts in the
types and quantities of foods consumed (whether due to
custom or loss of appetite) and to decreased absorption
and diarrhea.
► Parasitic organisms, as in malaria or schistosomiasis, or
intestinal worms, divert nutrients for their own use.
► Energy, protein, and micronutrient needs are elevated in
order to fight off infection.
► Immune function deteriorates with extreme PEM; evidence
is more mixed as to possible increases in susceptibility to
infection with mild to moderate malnutrition.
water
sewage
pollution
parasites
diarrhea
malnutrition
dehydration
sickness
(WDR2000/1)
Iron Deficiency
► Irondeficiency is believed to be the most common
micronutrient deficiency in the world today.
► It appears most common in South Asia and Africa.
► About 22 per cent of the world's population is
thought to have deficiencies of iron extreme
enough to cause anemia.
► Iron deficiency is especially common among
reproductive-aged women, whose requirements
are higher than those of others.
Anemia in Bangladesh
Gender and Ethnic Inequality
UNICEF/BRAC/BBS 2004 study of anemia prevalence:
urban adolescent girls = 29%
urban adolescent boys = 17% (lowest of all
groups)
Chittagong Hill Tracts adolescent boys = 40%
CHT adolescent girls = 50%
Iodine Deficiency Effects are physical and mental
► Cretinism results from severe deficiency during gestation.
It is irreversible and includes "profound mental deficiency.”
► Goitre, a pronounced swelling of the thyroid gland, may
develop at any time.
► High rates of milder mental impairment have been found in
areas where goitre and cretinism are common.
► UNICEF estimated that 30 per cent of the world's
population is at risk of mental and physical impairment due
to iodine deficiency, though less than half that number
manifest visible signs of goitre or cretinism.
► According to Stanbury (1991), "Iodine deficiency is the
most frequent cause of preventable mental
retardation today."
Iodine Deficiency
► The most severe problem is restricted to areas
with iodine-poor soils, typically mountainous,
glaciated, and/or subject to heavy rainfall or
flooding.
► Milder forms may occur in these and other
regions (including European countries) where
intakes of iodine-adequate foods are low.
► The greatest concentrations of population in
areas of iodine deficiency are in South-East
Asia, and pockets of Africa and Latin America.
Vitamin A Deficiency
► Deficiency of vitamin A was estimated to affect some 231
million children in 1994, over half of them in just three
countries - Bangladesh, India, and Indonesia.
► Vitamin A comes from a wide range of vegetable and
animal sources but children, especially, may lack adequate
access, owing to culture or economic restrictions in diet.
► Vitamin A deficiency is a major cause of blindness, mainly
in childhood.
► Many of those blinded die shortly thereafter.
► It has been linked to increased vulnerability to infectious
disease, with some studies claiming dramatic reduction in
child mortality when vitamin A supplementation is provided
to all children in areas in which even a few show the visible
signs of vitamin A deficiency
Maternal and Child Malnutrition
► Malnutritionof pregnant women may lead to
serious problems for children.
► Mostdramatic is cretinism resulting from
severe maternal iodine deficiency
► More commonly, children born to chronically
undernourished women are likely to be small
at birth.
► Low birth weight is associated with increased
risk of mortality and with a range of health
and developmental problems.
JAMA MUAC BMI (see link syllabus)
► MUAC measurement was easier to perform on severely malnourished
adults than BMI assessment.
► For MUAC, the patient could be standing, sitting, or, in extreme cases,
lying. For BMI, patients were required to stand. Measuring BMI
requires a height board, weighing scales, and mathematical
calculations; to measure MUAC, only a tape measure is required.
► A correlation between measurements of MUAC and BMI was
demonstrated (r=0.88; 95% confidence interval, 0.82-0.92 P<.001).
The proportions of the population and the actual individuals identified
as malnourished by the 2 indicators were similar.
► CONCLUSIONS: The MUAC measurement reflects adult nutritional
status as defined by BMI. During famine, MUAC may be better suited
to screening admissions to adult feeding centers than BMI. Studies to
assess the capacity of MUAC cutoffs to predict mortality in severe adult
malnutrition are needed.
Risk factors for stunting and wasting at age six, twelve and twenty-four
months for squatter children of Karachi, Pakistan.
Fikree FF, Rahbar MH, Berendes HW.
►
At two years the proportion of stunting and wasting was
41.8% and 10.6% respectively.
► Intrauterine growth retarded children had a higher risk of
stunting and wasting at all reference ages as compared to
children who were appropriate for gestational age.
► In the logistic regression models, intrauterine growth
retardation was the only significant risk factor that
remained in all models at each reference age.
► CONCLUSION: The consistent association of IUGR for
stunting and wasting adds to the growing body of evidence
that by improving maternal health we will ultimately break
the vicious cycle of malnourishment and improve the
health and well-being of future generations.
Malnutrition among girls can affect their
babies later in life
► Undernutrition in childhood can cause growth
stunting and influence the size of the child a woman
can bear later in life.
► Maternal pelvic size is a strong determinant of
neonatal survival and universally correlated with
height in populations.
► The proportions of low birth-weight infants are
much higher in populations identified as poorly
nourished according to adult anthropometric
indicators, ranging from lows of 4-6% in affluent
countries to highs of 25% or more in Pakistan,
India, Bangladesh, and Laos.
Food Shortage. Food Supply
► Isthere enough food for population in given
area?
► “Global” supply scenario is aggregation of
national scenarios:
gross food supply (total production)
net food stocks (after waste, import export,
animal feed, etc)
How do markets influence food
shortage? Discuss (from Uvin)
► p.4. “A low food self-sufficiency ratio is not an
indicator of hunger within countries, nor is a high
food self-sufficiency ratio a guarantee of the
absence of hunger.”
► “The smaller and poor a country, the more
pronounced will be its vulnerability to …
fluctuations [in world markets], and the less it will
be capable of influencing them.”
► “To the extent that declining food self-sufficiency
ratios reflect declining entitlements to [farmers
and agricultural laborers] declining rations can
coincide with icnreasing hunger.”
Countries with DES below requirement, 1988-90 (Uvin table 1.6),
and FAO 1992 est of malunourished (table 1.10),
Number of Population, People % total
Countries millions (%) malnourished
SS Africa 32 459 (57) 128 16
Near East and 1 13 (2) 15 2
North Africa
Asia 4 262 (33) 653 (w/China) 77
Latin America 7 67 (8) 47 6
N Am, Aus, 0 0 (0)
Europe, CIS
Small Islands 4 1 (0) 1
Total 48 802 843 100