FNH

Identify the AMDR (Acceptable Macronutrient Distribution Ranges) for carbohydrate in North America

AMDR: 45-65% of energy intake added sugars: <25% energy intake

1. Based on the video documentary "A Fistful of Rice"

a. Identify the consequences of protein energy malnutrition (PEM) on children o stunting, poor mental and physical development, little activity, wasting, swollen abdomen, death b. Identify and comment on the various complex causes of malnutrition o unstable government and rapid migration to city - low job opportunities, water shortage, pollution, overcrowding, not used to economy, lack of community/support o SES: literacy of women, job opportunities, hygiene, food security, gender disparity • when women in control and treated as equals there is less malnutrition o having babies too young - prone to illness, infection, low birth weight, PEM o remote districts hard to reach with support, education and supplies o men leave - bring home babies, leave women to do work and send little money (drink most of their money away in city) o family planning doesn't work - want sons, have multiple wives o when children sick, don't want to eat, food not appetizing

complete protein

contain all of the essential amino acids in amounts needed to support the body's protein requirements (food that most closely resembles what our body needs: egg)

10. Identify dietary sources of iron

• egg yolk, rice, corn, spinach, soybeans, wheat = nonheme; fish, beef, liver = heme

7. Compare and contrast marasmus and kwashiorkor

Feature Marasmus Kwashiorkor Edema None Lower legs, sometimes face or generalized Wasting Gradual loss of subcutaneous fat ("skin and bones") Less obvious, sometimes fat/blubbery Muscle wasting Severe Sometimes Growth retardation Severe Less than marasmus Mental changes Usually none Usually present Appetite Usually good Usually poor Diarrhea Often (past or present) Often (past or present) Skin changes Usually none Often: diffuse depigmentation Sometimes: "flaky paint" dermatosis Hair changes Texture modified but usually no depigmentation Often sparse (straight and silky), depigmentation (reddish or grey) Moon face None Often Biochemical abnormalities Normal or slight Common Liver biopsy Normal or atrophic Fatty infiltration

complementary protein

a protein that is incomplete on its own, but becomes complete when combined with another protein source (complementary limiting EAA) o vegetarian foods seemed to "evolve" to compliment each other (ie. legumes + cereals) o doesn't have to be at the same time, just a balance through entire diet

limiting amino acid

present in least amount relative to requirement • complementary proteins: a protein that is incomplete on its own, but becomes complete when combined with another protein source (complementary limiting EAA)

4. Define, explain, and use the term "food security" to understand international nutrition issues

• "Food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life." -World Food Summit, 1996 o key factors: food availability, food access, utilization, stability/security • relates to the fact that while there is technically enough food to feed the world population today, nearly a billion people do not have enough food • also, when food security is prevalent, the food choices that are available are generally very low in micronutrients (ie. rice or fast food)

10. Summarize where hunger is most likely to occur in the world

• "bottom billion" - the people living in the world's poorest countries (58 countries) o poverty continues despite international aid - due to conflict, isolated from possible trading partners and opportunities, bad governance • 80% of world's undernourished children live in 20 countries

14. Indicate why the "first 1000 days" are important and what should be done from a nutrition perspective during that time

• "first 1000 days" = conception to 2 years of age • ensure adequate nutrition for mothers and young children • promote breastfeeding and appropriate, healthy complementary foods • treat malnourished children with therapeutic foods

6. Indicate what the Millennium Development Goals (MDGs) are and give examples related to nutrition

• (1) eradicate extreme poverty/hunger, (2) achieve universal primary education, (3) promote gender equality and empower women, (4) reduce child mortality rates, (5) improve maternal health, (6) combat HIV/AIDS, malaria and other diseases, (7) ensure environmental sustainability, and (8) develop global partnership for development o (1A) halve population living on <$1/day, (1B) achieve decent employment for women, men, and young people, (1C) halve proportion of people who suffer from hunger • key interventions: agriculture/environment, business dev, education, infrastructure, health

9. Summarize some advantages and disadvantages of traditional diets

• + high in fibre and complex carbohydrates • + complementary plant proteins • + lean animal protein • + lots of fruit and veg - most NB as most lacking in SAD, more related to good health outcomes • + lower daily energy intake than S.A.D. (Standard American Diet - "modern diet") o this one is kind of an aggregation of factors above • - may be low in protein, energy, essential nutrients if diversity not high o Vietnam: weaning infants with rice water (water unsafe, low in protein and fat) o Laos: women avoid meat during pregnancy/lactation (hard to meet iron/protein needs)

3. Describe the global prevalence of HIV/AIDS

• 2010: ~34 million people worldwide - up 17% from 2001 o number of new HIV infections per year fell 21% from 1997 to 2010 o 50% women globally (59% in sub-Saharan Africa and 53% in the Caribbean) • 2010: 1.8 million died from AIDS-related causes, but 700,000 deaths were avoided through wider spread use of antiretroviral (ARV) drugs (proportion of deaths prevented is increasing) • South Africa has most living with HIV - 5.6 mil (followed by Nigeria, India, Kenya, Mozambique) o Sub-Saharan Africa ~75%, South/SE Asia ~15%, North America ~5% (not insignificant)

12. Summarize how dietary changes such as reducing meat consumption and increasing duration of exclusive breastfeeding could improve food security and health

• 70% of agricultural land, only 15% of total food energy; takes ~7kg of grain to make 1kg beef • lamb (57:1 energy input:protein) and beef (40:1) worst; turkey (10:1) and broilers (4:1) best

3. Summarize how receiving education affects a girl's life overall and risk for malnutrition in particular

• A girl with a 5th grade education is more likely to: marry later, have fewer children, avoid being infected with HIV, find enjoyment later in life, seek medical care, vote, have access to credit • Sociocultural backlash? Taliban militants bombed girl's high school in Bamiyan (Oct 2012)

6. Indicate how nutritional assessment can detect vitamin A deficiency

• A: none • B: serum retinol • C: xerophthalmia, frequent respiratory or intestinal infections • D: FFQ (LT since fat soluble

3. Summarize protein requirements in terms of both protein quantity and protein quality

• AMDR: 10-35% (adults); 5-20% (children, 1-3 years) • 1-3yrs (1.05g/kg/d) - critical periods of growth that cannot be made up later • quality relates to having a diet that contains all of the EAA in amounts required in the body - through complete or complementary proteins • needs increase in certain circumstances: o infections, burns, fever, surgery (clinical conditions) o pregnancy (second half) or breastfeeding o infants and young children o athletes (?)

2. Discuss the advantages and disadvantages of RUTFs in the treatment of malnutrition

• Advantages: o long shelf life (up to 2yrs without refrigeration) o does not need to be mixed with water (commonly not a safe o source of drinking water, insufficient water sources in camps) o simple for mothers to give children, easy to open/eat (possible to administer at home) o "children love the sweet, sticky stuff" o it works: children will eat it, provides immediate nourishment; observed success in SAM • Disadvantages: o cost (two months for one child = $60) - not sustainable o it is patented (French company Nutriset) - ethical?? keep up with the demand? o doesn't treat any of the root problems o provides very little variety o still quite heavy and bulky in terms of distribution • should it be used to prevent? - "every case of severe malnutrition starts as a milder one" o an example of "blanket distribution": in a region of Niger, MSF (French DWB) provided RUTFs to 80,000 children 6-36 months old (cost = $55/child for ~2 month duration) o contributed to nutritional health, but wasn't just eaten by the targeted children • Long-term solution? - no, but it is still important to focus on downstream solutions while working on more sustainable solutions

3. Summarize key aspects of vit A deficiency: What is the scope of the problem? Who is at risk?

• After PEM and IDA, VAD is the most widespread and serious nutritional issue for young children o VAD is considered a public health problem in >50% of countries • Leading cause of preventable blindness (1990s: 14mil children/yr affected by xerophthalmia) o In South Asia, night blindness occurs in 15-20% of pregnancies • increases risk of infection: 150mil children at increased risk of dying from infectious disease • Who is at risk? poverty, populations in which rice provides bulk of daily diet o can occur at any age, but children <5 and preg/lac women are at greater risk

2. Explain nutrition transition and how it affects nutritional status of developing populations

• All regions (and all countries) of the world are increasing in OWOB prevalence at an average of 0.7% per year - relative increase greater among rural women • Nutrition transition - as dietary and lifestyle practices shift (esp in urban areas), we see the coexistence of under- and over-nutrition in many developing countries o Small undernourished children, who later become overnourished is at even higher risk since they developed at a deficit o leads to "double burden" - have diseases characteristic of both sides of malnutrition

4. Provide examples of how farmers in the developing world have adapted to effects of climate change

• Atlas mountains of Morocco: drip irrigation for high-value crops that can be sold, harvesting wild, drought-tolerant crops (eg. for oil) • Mozambique: lowland productive but sometimes flooded; highland good during floods, poor during droughts → farmers' association reassigned land so each farmer gets some of each • Oueme Valley, Benin: agro-fingerponds (Kanfli), plant dry-season crops on dykes o fingerponds: trap wild fish during low-water periods - increases dietary diversity, income • FAO pilot project in Lesotho: rainwater tank and drip irrigation, poultry farming, fruit trees o now grows surplus of veg BUT $200 (beyond means - very prohibitive - financing?)

7. Define BMI and describe how it can be used to classify weight status

• BMI = weight (kg) / height (m)^2 • underweight <18.5; normal 18.5-24.9; overweight 25.0-29.9; obese >30.0

8. Describe how biochemical measurements and clinical observations can be used in nutrition assessments

• Biochemical: measures metabolite or nutrient in blood, urine or feces (hair, nails and sweat also sometimes used) or other components related to nutritional status • Clinical: use medical history and physical examination to detect signs/symptoms of malnutrition o generally non-specific, people are variable - use in combo with ABD o serial observations are useful in documenting rate of decline or improvement o physical examination: observe, inspect measure

6. Identify other ways that HIV/AIDS threatens food security of households, communities, and nations

• Change in household composition - orphaned children, older children caring for younger • Loss of household income + ↑ health/funeral costs = ↓ overall community income and assets • Need income: liquidate assets (slaughter livestock), sex work, loans (↑ defaults, ↑ interest rates) • proportion of people infected with HIV depends on age, sex and place of residence o non-slum urban men have lowest prevalence - women have higher prevalence o *note that the drop offs may be due to death • When a family member has AIDS: family income drops 52-67%, healthcare costs quadruple • Children of HIV-infected mothers: 28% stunting, 26% wasting, 26% underweight likelihood o reduced breastfeeding?, reduced parental care? • if mother doesn't breastfeed may indicate HIV → negative social consequences • breastfeeding suggested unless safe feeds available • ~10-20% of infants may be infected over 18-24 months of breastfeeding o children may contract HIV - vertical (MTCT) transmission (lessened with ARV drugs) • if no steps taken ~15-45% of children become infected • pregnancy (7%) < labour/delivery (15%) = breastfeeding (15%)

1. Reflect on the documentary "Waiting" and identify key lessons and questions that emerge.

• Culture of waiting for food for days - part of culture (was like hunger and famine were "normal") • people were having to pick up loose kernels one by one off the ground because no one can touch the sacks until drop is done - would be riot - must wait for support team • A lot of food aid isn't sustainable, but is still life or death • Civil war lead to burning crops, stealing livestock • Quote from one of the villagers: "if things come to you without knowing where it comes from, it is not good. But when you cultivate it and make sure it has been done by you, you can be happy. But now it is done like that because of the war."

11. Identify how food waste could be reduced in developed/ing countries and comment on challenges

• Developing: improve infrastructure → India loses 30-40% of fresh produce due to absence of cold storage at wholesale and retail outlets • Developed: increased cost? education? → responsible for 5% GHG emissions of UK o food relatively cheap, want "perfect" food = less incentive to reduce waste

5. Comment on and explain trends in childbearing over time

• Fertility rates drop as wealth increases - occurs within countries as GDP increases Region Children/woman in 1965-70 Children/woman in 2000-05 World 4.9 2.7 Africa 6.8 4.9 Asia 5.7 2.6 Latin America & Caribbean 5.6 2.5 More developed countries 2.4 1.6 • Why is the birth rate high in developing countries? o high infant mortality rate (one of keys - immediate change) o children provide security for old age and labour (food production in home) o culture/social: religious reasons, men want more (status, virility, security), desire sons, culture values large families, lack of access to birth control o overall: economic factors, poverty • Number of children decreases when children survive, many children not needed for work, women are educated, women join labour force, family planning is accessible • if fertility reaches replacement level growth continues for 40yrs due to demographic momentum

1. Describe how food records and food frequency questionnaires can be used to assess dietary intake and comment on the strengths and limitations of using these methods of dietary assessment

• Food records: person records type and amount of food/beverage consumed (right after they are eaten) for a period of time, typically 1-7 days (3 very common) o Estimated food record: size of portions are measured with household measures or estimated (ie. 1 ¼ c. shreddies, 1 med apple) o Weighed food record: size of portions are measured exactly with a scale o Both of these are quite artificial • simplify your diet (so you don't have to measure so much) • by being aware of quantity, we tend to eat less → this is why doing a food record is actually quite effective for weight loss o Strengths: do not rely on memory, can provide great detail, can give insight into eating habits/patterns, multiple days more representative of usual intake o Limitations: takes time and effort to complete accurate record, requires literacy, may alter diet, labour-intensive data entry and analysis, may not represent usual intake • FFQ: questionnaire that determines how often a person consumes a limited number of food, usually 150 or fewer items, over a span of time (usually one month or one year) o Strengths: can be self-administered, machine-readable, inexpensive, may be more representative of usual intake o Limitations: may not include foods usually consumed, may not include information on portion size, requires literacy, cannot as clarifying questions (if self-administered) • 24hr recall/dietary diversity instrument: fuses FFQ & 24hr; grouped according to key nutrients o good when not a lot of dietary diversity, doesn't require literacy, can be made specific to commonly consumed foods in area

8. Summarize why women are disproportionately affected by HIV, poverty & malnutrition

• HIV - biological, cultural, social factors make women more vulnerable o physiologically: greater SA for virus to enter, more susceptible to tears and bleeding o economically and socially vulnerable; lack access to information • "Gender equality is more than a goal in itself. It is a precondition for meeting the challenge of reducing poverty, promoting sustainable development and building good governance." • Poverty - 70% of impoverished people are women, women twice as likely to be illiterate, women paid 30-40% less than men for comparable work on average • cycle of malnutrition in women: o social factors (central): poverty, low social status, discrimination, lack of family planning services, lack of education, lack of health care, early pregnancy o infant (LBW, growth restriction in womb, risk diarrhea, learning difficulties) → young (stunting, wasting, rickets, learning difficulties) → teenagers (delayed menarche, narrow pelvis) → potential mothers (micronutrient deficiencies; risk of anemia, goitre, infection) → pregnant/lactating (more birth complications, risk anemia)

9. Identify clinical signs of malnutrition

• Hair: 'flag sign' (transverse depigmentation) or easily pluckable = protein • Mouth: swollen, retracted, bleeding gums = vit C; glossitis = B vits; dental erosion = bulimia; angular stomatitis = riboflavin • Eyes: xeropthalmia (night blindness, bitot's spots, corneal ulceration, scarring, photophobia) = A o most common in 1-6 y/o; blindness in 6mo - 3yr • Skin: pallor (skin+conjunctiva) = iron; pressure ulcers = vit C; corkscrew hair = vit C; follicular hyperkeratosis (plaques around hair follicles - 'goosebumps') = A/C • Nails: transverse ridging = protein (or damage); koilonychia (spoon-shaped) = iron • Edema: protein, thiamin; bilateral (pitting) edema = more serious higher up (used for screen)

3. Define diabetes and comment on the rising incidence observed worldwide

• High blood glucose levels; includes T1, T2, gestational • Blindness, renal failure, lower extremity amputation, hypertension, impotence, nerve damage, CVD (80% die of CVD/stroke) • T1: genetic, lifespan shortened by ~15yrs, insulin-dependent • T2: obesity, lifespan shortened by 5-10yrs (growing), 90-95% of cases, insulin-resistant • Linked to obesity epidemic, first time non-infectious disease as global health threat (diabesity) - 70% in developing world (worst in India)

7. Provide examples of how religion affects food choice

• Hinduism: cow is symbol of wealth, strength, abundance...forbids the slaughter and consumption of beef • Jewish - Kosher: based on scholarly interpretations of the Torah o eg. no pork, kashering (rabbis ensure preparation methods actually kosher) • Islam - Halal: also has rules about what foods are permitted • be aware of what would happen and how you would feel if your cultural foods were unavailable

7. Summarize what is known and what is projected regarding global warming

• Human activity has rapidly changed since the beginning of the industrial revolution (see notes) • Human activity is affecting world's climate through affected the carbon cycle o taking a lot of carbon out of ground and releasing it to atmosphere (fossil fuels) o cutting and burning forests (decreasing carbon sinks) • average temperatures have increased by 0.13ºC per decade since 1950 o consider that ice age was only 6ºC colder worldwide o 9/10 warmest years in modern meteorological record (since 1880) occurred since 2000 • warmest years on record: 2010/2005, 2009, 1998, 2002, 2003 o 2012 global average surface temp (GAST) was 1ºC warmer than 1951-80 average o 2012 was 36th consecutive year when GAST was hotter than 20th century (51-80) avg • temperature increases are uneven - greater increases... o in higher latitudes, over land, continental interiors (ocean = carbon sink; moderates)

5. Define and appropriately use key terms: hunger, malnutrition, famine, secondary malnutrition

• Hunger: when people lack the basic food intake needed to provide them with the energy and nutrients for fully productive, active lives • Malnutrition: poor nutritional status due to dietary intake either above or below optimal level • Famine: widespread lack of access to food due to a disaster, drought, political conflict, or war that causes a collapse in the region's food production and marketing (farm to table) systems • Secondary malnutrition: loss of appetite associated with many illnesses and deficiencies

4. Clearly identify how HIV/AIDS affects agriculture in regions greatly affected by the virus

• In the 25 most-affected countries: 2/3 of the population live in rural areas • As pandemic shifts to rural areas, development is threatened o Regions lose farmers, food producers, agricultural labour force • By 2020, up to 1/5th of agricultural labour force will die in many southern African countries • Loss of productive/working members of households threatens food security of remaining family o less land cultivated o less weeding, pruning, mulching...leads to decline in crop yield and LT soil fertility o less labour-intensive work can be done o missed planting seasons o loss of agricultural knowledge and skills passed to next generation

7. Identify ways in which vitamin A status can be improved

• Increase dietary sources of vitamin A o promote breastfeeding (even in malnourished women, contains vit A) o promote consumption of available foods - palm oil, greens o breeding maize varieties with higher beta carotene content • estimated could provide 50% of avg requirement • challenges: white preferred, maize seen as "drought food" (food aid) • think of how food can take on sociocultural identity in times of trouble • education and awareness - target women o Malawi: "eat Vitamin A rich foods to prevent infection" promotion posters • local (household, community) food production • increase distribution of vitamin A supplements (effect lasts 4-6mos) o huge difference with little cost - most cost-effective intervention to save children's lives/sight - 2 doses per year = ~$1/child/year • fortification: sugar, oil, margarine, golden rice o should provide at least 15% of daily kcal intake for target group o needs to be combined with other strategies (ie. supplementation) o needs to be monitored (ensure fortification level sufficient and accurate) o advantages of oil/margarine: vit A is a fat-soluble vitamin, used for daily cooking, sugar could take on a yellow colour (oil/margarine already yellow)

7. Describe and critically evaluate the jaboya system in fishing communities along Lake Victoria in Kenya, and how the system and other cultural practices in the region contribute to the spread of HIV

• Jaboya System: Fishermen in fishing towns of Kenya form sexual relationships with women who wish to buy fish (to take it to the market to sell) • Each person may have multiple partners - Contributes to increase in HIV/AIDS in the area • Wife inheritance - considered socially unacceptable to refuse • Condom use - women commenting that some men use and others don't, but don't care • Kenya HIV prevalence: 7.4%; Nyanza: 14.9% - fishing communities in particular: ~30% • mixing a feeling of helplessness with that of feeling that if it comes to you it was "meant to be" • Immediate needs override concern of HIV: "You know you can get HIV... but then you remember you have a family that needs to be provided for, and you say, let me die providing for them." • Issues re. condom use: "I can't use one with my fiancée because we want to show some level of trust; I already have his child and we are looking forward to getting married. I know they're good, and I would want to use them if I had the power, but the power belongs to somebody else."

4. Describe how migration studies help us understand the effect of diet on disease

• Japanese Americans: increased rates of "western" diseases • % calories from fat: 16.7 (Japan) - 32.4 (USA) • % calories from carbs: 61.1 - • Diabetes incidence: 5.3 - 20 • Link to obesity - developing world carries 70%

2. Compare and contrast marasmus and kwashiorkor (adding to what you know already and consider which methods of nutrition assessment would be best suited to their detection)

• MUAC best for marasmus, Edema (clinical) for kwashiorkor • Fat metabolism is disrupted (LDL and HDL transport fat) with kwashiorkor o not enough protein to make LDL/HDL o fat stays in liver, clogs liver; liver cells atrophy and die - frequently causes death • Marasmus can be fed easily and immediately, as long as it's not too fast • Kwashiorkor may lead to death if re-fed too fast

7. Evaluate the application of MDGs to increasing food production in Africa

• Malawi - maize is staple food crop, 2.4 million subsistence farmers, erratic rainfall • able to get fertilizer and seeds for all the farms in the town and surrounding area o payed back with one bag of grain for most in need and emergency fund • benefits: people happy because they can observe change; no need to migrate to city for work; school attendance improved; no longer rely on food aid; building bigger/better houses o can think of diversifying into high-value crops and purchasing livestock o more than double, sometimes triple or more the yield for the same amount of work • challenges: don't know how to store or sell extra grain; food stores from previous year were not sufficient 9 mo before harvest; requires inputs (not sustainable when subsidies gone) • limits: water supplies few and unsafe; malaria continues to be a problem; no telephone or transport in case of emergencies; schools are poorly equipped and staffed; no electricity • moving forward: cannot directly apply the same thing everywhere; know that we have the knowledge, just need the action; villagers willing to put in the work to make a difference

5. Describe the Green Revolution and evaluate its advantages and disadvantages

• Norman Borlaug; increase agricultural production via high yield varieties of cereal grains (breeding for desirable characteristics, not GM), irrigation, fertilizers, pesticides/herbicides • 1950: world produced 700 million tons of grain from 600 million hectares • 40 years later: 1.9 billion tons from roughly same amount of land (↑ of 170%) • advantages: dramatic increase in yields of staple cereal grains, reduced/eliminated need for food imports in some countries, reduction in poverty/hunger (but effects uneven - rich benefitted) o yields attributed to new varieties (23%), fertilizers (25%) and irrigation (29%) • disadvantages: dependent on inputs (not energy neutral), environmental effects, expensive (cost ↑ 60%, high interest), ↓ crop diversity, ↑ disparity between landowners and tenant farmers

3. Identify ways in which maternal malnutrition can lead to negative birth outcomes

• Obstructed labour: passage of fetus through the pelvis is mechanically blocked or too small o growth stunted, early vit D deficiency can lead to malformed pelvis, young pregnancy • look back to cycle of malnutrition; importance of nutrition during pregnancy/lactation

2. Describe what has occurred among the Pima in Arizona upon adoption of a modern diet

• Pima indians in central Arizona replaced traditional foods (which have become scarce) with "modern" foods (wheat flour, lard, sugar) • Result: highest per capita rate of diabetes in the world • Mexico = BMI 24.9, obesity 13%, diabetes (T2) 6.4% • Arizona = BMI 34.2, obesity 69%, diabetes (T2) 50%

12. Describe how 24-hour recalls can be used to assess dietary intake and comment on the strengths and limitations of using this method of dietary assessment

• Trained interviewer asks respondent to recall in detail all food & drink consumed in past 24 hrs • "Multiple-Pass" method for 24-hr recalls o Participant asked for quick list of foods/beverages consumed in the past 24 hours o Starting with the first item on the list, the interviewer probes for details (type, amounts, additions or condiments, preparation method) o Review details and amounts and correct any inaccuracies • Strengths: quick, inexpensive, easy for person to complete, can be used in variety of settings, does not alter diet • Limitations: under/over-reporting of certain foods (ie. salty snacks), relies on memory (harder if more diverse), labour-intensive data entry (bad for screen), doesn't represent typical intake

8. Identify four micronutrient deficiencies of particular concern worldwide, describe the consequences of these deficiencies and identify actions that have been taken to try to address them

• Vitamin A: 140 million preschoolers deficient → 500,000 partially/totally blind as a result o compromises immune system o 40+ developing countries reach 70% with at least one vit A capsule per year (cost = $1) • Iron: 1.6 billion people o associated with cognitive impairment and reduced resistance to disease in childhood; 40-60% of 6 - 24 month/olds in developing world have impaired mental development o severe deficiency results in 50,000 deaths per year in pregnancy and childbirth o lowers productivity of workforces: estimated losses of 2% of GDP in worst areas • Iodine: 700 million people worldwide have goitre o major preventable cause of compromised cognitive development worldwide o 16 million with overt cretinism (severely stunted physical and mental growth usually due to maternal hypothyroidism), 20 million babies born mentally impaired per year o 49 countries now add iron to flour • Zinc: Contributes to growth failure and weakened immunity in children o Contributes to 800,000 child deaths per year (from diarrhea, pneumonia, malaria) o zinc supplements can help treat diarrhea and reduce diarrheal mortality by 50% o WHO recommends 10-14 days zinc supplementation with diarrhea episode - but this recommendation has not been widely adopted

4. Identify reasons why children may not go to school and strategies that can increase attendance

• Western Honduras: 50% of households reported nearest school within 10 min walk, 90% within 30 min walk BUT only half of children finish primary school → access may not be the problem o child not interested - code? (36%), economic problems (19%), child must work (9%) • Ghana: school too expensive or child must work (46%), parents view education as having little value (22%), school too far away or of low quality (7%) • everything interwoven, complex → poverty, sociocultural issues, disease....see figure in notes o issues regarding HIV/AIDS (educated parents, wealth, adopted children) o culture, economic factors, facilities, SES factors, demographics • problem often that parents do not send children to existing schools • school meals can double attendance (who's paying for that, where does it come from....?) • financial incentives (~equivalent of $1/day) can increase attendance by 3-12% - tries to solve the issue that kids need to work instead of going to school • mother's education can improve child nutrition: focusing on girls can help break poverty cycle

5. Describe the types of aid that may be offered and consider which type(s) may be most effective

• What are the goals of aid? - think of difference between emergency aid and development aid o emergency is easier - trying to keep people alive during an acute issue • Three views of aid's role and timeline o aid as permanent: global social safety net, redistribution o aid as temporary: "big push" out of poverty traps, cope with short-term crises & disasters o aid as distortion: distorts markets and causes dependency • Aid tends to go to the same countries, despite changes in country classification (corrupt) o could this be problematic, or is it helping foster an environment that could move it out of the classification as a corrupt state • Food aid: shift from in-kind donations to "food assistance" (funding local/regional procurement) • Tied aid: conditional on receiving nation spending donations on products or services from the donor country → viewed as ineffective since it helps donor more than recipient • Aid should be an investment to build capacity of a region

4. Identify dietary sources of vitamin A

• Wide variety of plant and animal foods • Conversion factors: 1 μg vitamin A activity = 1 retinol activity equivalent (RAE) = 1 μg retinol = 12 μg dietary β-carotene = 24 μg other carotenoids • Industrialized countries: ~2/3 of dietary vit A from animal sources as preformed vit A o Liver, milk products, eggs, fish, butter/ghee o generally 70-90% bioavailable • Developing world: mostly provit A from carotenoids in plant foods (lower meat consumption) o Yellow and orange fruits and veg, dark leafy greens - even wild cabbage (colour hidden by chlorophyll content), red palm oil (NB source in many countries) o B-carotene is basically 2 retinol molecules that needs to be separated and converted into the active form

5. Give examples of hunger and food insecurity affecting populations (eg. famine, chronic hunger)

• Worst 10 famines of 20th century - what it can teach you o common time periods - WAR o how long they typically last (usu. 1yr) o what areas are worst affected (areas with lack of stability - political) o huge numbers of death (total ~70 mil) and how imprecise it is (poor records) • avoid generalizations, but find themes - ie communism does not cause famine • DRC conflict: "the forgotten war" - why do we not hear about this more? o perceive not really important - not a nation we're closely related to, lack of resources o we don't have a direct link o when a conflict is so long it starts to feel like the norm o some of the news coming out of the DRC can be repressed; lack of internet access o type of war today and the long conflicts can make the anger and conflict move externally o global politics: human rights not really talked about, focus on trade when Harper went • is it our responsibility to have our politicians know we find this to be an issue o the war needs to end, ultimately, to truly address malnutrition in the DRC • India has succeeded in preventing famines since independence...but home to ~25% of global hungry population; 43% children <5yrs are malnourished; >50% pregnant women have IDA

5. Describe consequences of vitamin A deficiency

• Xerophthalmia: Night blindness, conjunctival xerosis, bitot's spots, corneal xerosis, ulceration, necrosis/keratomalacia o Night blindness ("chicken blindness"): poor vision in dim light, earliest clinical symptom o Bitot's spots: can disappear if treated early (preschool children; adults usu irreversible) • Compromised immunity: "nutritionally acquired immunodeficiency disorder" o mucous barriers not as effective, immune response impaired • Increased infection: respiratory infection, infectious diarrhea, dysentery, measles, HIV, malaria o VAD increases risk of infection and infection increases risk of VAD • relatively higher nutrient needs from infection, lack of appetite o Measles: contagious respiratory infection (fever, cough, runny nose, red eyes, rash) • without vaccinations, outbreaks occur on 2-3 year cycle • VAD child contracts measles = 50% chance of dying from measles • more likely to get it and 50% chance of mortality • Vitamin A supplement at birth associated with fewer cases of measles and less severe cases if they occurred....in boys, but not in girls (may not have been enough girls in study, girls treated differently in culture....but not sure) • 2010: ~140,000 deaths from measles (380/day) • Measles vaccine for children under 1 year: 72% of children in 2000, 85% of children in 2010...74% drop in measles deaths during that time • Increased morbidity and mortality: community-based improvement in vit A status of deficient children (aged 6mo - 6yrs) reduces overall risk of dying by 20-30% • Effects on growth: vit A supports growth

8. Define acculturation and ethnocentrism

• acculturation: the adoption of behaviour patterns of the surrounding culture o results in changes in culture and customs, food, clothing, language o takes place to varying degrees and over different periods of time after immigrating • Canada = cultural mosaic (multiculturalism) - still visible, all fits into big picture • US = cultural melting pot (assimilation) - less visible, expected to transition to "American way" to greater extent • ethnocentrism: the belief that one's own value system and lifestyle is most appropriate o judging another culture by the values and standards of one's own culture o generally ignore another person's culture and judge based on your own o be careful not to impose own values and beliefs on others

6. Describe and differentiate between different types of growth failure

• acute: wasting, edema; poor long-term survival rates o includes marasmus, kwashiorkor, marasmic-kwashiorkor • chronic: stunting (shortness, poor cognitive development) • acute and/or chronic: underweight

6. Describe how modern food habits have developed from the time of hunter-gatherers to the present day (including the influence of the Agricultural Revolution and the Industrial Revolution)

• agricultural revolution: human culture moved away from HG to agriculture and settlement approx. 12,000 years ago o staying in one spot to grow and cultivate foods; rice planting and harvesting o developed the ability to grow more food - sustain population and community • industrial revolution: changes in agriculture and industry; began in UK ~1750-1850 o whole grains/sugar refined - remove most of the fibre and vitamins, can enrich o can help make food last longer (pasteurization, refrigeration) • we've moved away from "real food" and to a modern food environment and lifestyle BUT our genes stay relatively the same so we respond to the same dietary benefits as ancestors o body functions best with diet emphasizing lean protein, high fibre, complex carbs, fruit & veggies and minimizing sugar and sodium o most food available now doesn't resemble what our ancestors ate o we do not engage in strenuous activity to get food o feasts no longer followed by famines

8. Describe, with examples, ways in which increases in global temperatures would affect food crops

• amount of grain harvested in the world right now could support 2.5mil people eating SAD • livestock prod accounts for 18% of greenhouse gas emissions (more than all forms of transport) • diseases such as malaria expected to become more widespread • how climate change will affect food crops o pollination interference - corn most vulnerable (need husks to be moist to be pollinated) • pollination of rice ~100% at 34ºC to ~0% at 40ºC o reduce photosynthesis - declines from 35ºC to 40ºC at which point it ceases o dehydrate plants o mountain glaciers melt...rivers that rely on them will disappear...irrigation systems that rely on the rivers will be challenged (Indus, Ganges, Yellow and Yangtze Rivers) • 2012 was the 21st year in a row of reduced glaciers • glaciers melting twice as fast as 10 years ago (problem in Himalayas) o melting glaciers and Greenland and Antarctic ice sheets raise sea level...poses particular risk for river deltas of Asia where rice produced (and may people live) • sea level predicted to rise 6ft this century o more drought o more heat waves - ie. Western Europe in 2003, Russia in 2010 • summer 2003: hottest summer since 1540; ~50-70,000 deaths (mostly elderly) • GAST 3.5ºC above average...20-36% decrease in grain and fruit yields • using temperature and precipitation data from 1980-2008 estimate: o 3.8% less maize, 5.5% less wheat produced o net impact on rice and soy insignificant (losses in some countries and gains in others) • 1ºC rise in temp during growing season → 10% reduction in wheat, rice, maize yields o 4ºC could lead to catastrophic climate changes

6. Describe anthropometric measurements such as height, weight, and mid upper arm circumference (MUAC) and indicate how these measurements can be used to classify malnutrition

• anthropometry: measurement of physical dimensions and gross composition of the body; results compared to standard values to give purpose to the data • height - stadiometer or recumbent length (if cannot stand erect w/o assistance - usu <2yrs) • MUAC - muscle content + subcu (correlates with total muscle mass) so reflects protein status o quick and easy, better measure of wasting since not affected by edema and easier o SAM = <11cm (<3SD below mean), MAM = <12.5cm (between 2 & 3 SD) o used for children between 6mths and 59mths of age • WHO growth charts: breastfed, 6 nations differing in race and GDP

8. Evaluate the application of Green Revolution strategies at community and national levels

• april 2005: 5 million Malawians required food aid • october 2005: farm households receive fertilizer and improved maize seed at 37% market price • on national scale, these are making a difference - % maize req from -43% to +53% o ⅔ increase due to subsidies, ⅓ due to better rains that year

4. Consider some possible ways to reduce PEM malnutrition in Nepal and associated challenges

• assess → plan → implement → evaluate (→ assess...) a. what information do you need? • assess, describe, understand • Current diet, income, education, # children/family, food available, weight, # with PEM, nutritional content of food, demographics, resource availability, water sources • Statistics, nutrition screening/assessment, field measurements, get information from government and organizations that already work there, interviews b. what needs to be included? • plan to address immediate (generally lack of food) and underlying causes (ie. infrastructure, education) • Educating women, improved distribution of food, providing supplements and/or food aid, regular doctor's visits, prenatal classes, government aid, food guide, more job opportunities, family planning, improve sanitation, introduce different values/ways of thinking, knowledge re. symptoms of PEM, resources and volunteers c. what challenges may you encounter • anticipate and plan to overcome • Language barriers, cultural differences, gender inequality, food availability, low literacy, lack infrastructure, needs to be self-sustaining, cost/funds, time, resistance to change, do not want people to feel judged

3. Indicate how nutritional assessment can detect iron deficiency

• average 1000kcal of mixed diet provides ~6mg iron o nonheme iron: bound to phytates, oxalic acids, less bioavailable = need 1.8X more

3. Identify and describe 3 energy-requiring processes of the human body

• basal metabolism - the energy required to maintain normal body functions while at rest o this accounts for about 60-75% of total kcal needs (think about how easily the body has to compromise when food consumption falls below recommended amount) o more metabolically active tissues (brain, liver, kidneys and muscle) accounts for ~80% of energy used for basal metabolism o less metabolically active tissues (body fat) accounts for <20% of energy used • physical activity - energy needed for muscular work o this can have a very wide range • dietary thermogenesis - energy used to ingest and digest food

6. Define "carbohydrates" and differentiate between simple sugars and complex carbohydrates

• carbohydrates are water-carbon compounds which include three types of chemical substances: simple sugars, complex carbohydrates and fibre • simple sugars - small molecules that require little to no digestion o monosaccharides (glucose, fructose, galactose) can be absorbed "as is" (do not need to be broken down by digestive enzymes) o disaccharides (sucrose, maltose, lactose) must be broken down into monosaccharides before they can be absorbed from the GI tract o why do we need them? • provides energy (40-80% of total food intake); glucose is the only sugar which can be used for energy • provide taste and sweetness • prevents protein breakdown for energy • complex carbohydrates - polysaccharides o starches: glucose molecules linked together o glycogen: storage form of glucose in liver and muscle (animal starch) o dietary fibre: non-digestible polysaccharides (humans lack enzymes to digest them)

7. Summarize major sources of dietary carbohydrate in the world

• cereals: harvested for dry grain o rice, wheat, maize, barley, rye, oats, millet and sorghum o >1/2 of worlds food energy is from wheat, rice and maize - may be problematic considering climate change and crop susceptibility • sugar crops: sugar cane and sugar beet o sweeteners account for ~10-12% of the world's food energy (18% in USA, 5% in Africa) • root crops: tubers o potatoes, cassava, yams, sweet potatoes, taro • pulses (legumes) o beans, peas, lentils, chickpeas, peanuts (edible seeds) o ~22% protein + fat (peanuts ~45% protein, soybeans ~35% protein) • fruit and vegetables: carbohydrates + vitamins o avocados, olives, durian - fat o plantains and green bananas - starch, very low in protein (~1% protein) • milk products: lactose + protein, fat and calcium o milk, cheese, yogurt, ghee, etc

8. Define vitamins and differentiate between water-soluble and fat-soluble vitamins

• chemical substances that perform specific functions in the body; organic compounds o they are essential nutrients; body cannot produce them or in sufficient amounts o must be consumed in small amounts o function of coenzymes that work in reactions: • convert protein, carbohydrate and fat into energy • build and maintain body tissues • inadequate intake leads to deficiency disease • water soluble: B-complex, vitamin C o on small amounts stored in body, intake beyond needs is excreted in the urine almost immediately (exception: B12 recycled) o deficiency disease can develop quite quickly (within few weeks/months) • fat soluble: ADEK o stored in body, primarily in fat and liver, so deficiency takes longer but excess intake is more likely to result in toxicity

9. Identify who is at greatest risk for malnutrition, and explain why

• children: Most vulnerable when weaned from breastfeeding and reliant on other foods o Time of rapid growth and development - nutrition needs are relatively highest o First 1,000 Days (conception to 2nd birthday) critically important for lifelong health o Interventions aimed at improving nutrition and health during the first 1,000 days have potential for very significant impacts • pregnant and lactating women: protein and energy needs relatively highest • older women: culturally, less access to food o represent 50% of population but own less than 1% of world's property o perform nearly 2/3 of the world's work - receive only 1/10 of the world's income

1. Identify other impacts of climate change on food security

• climate refugees, regular moving around, etc - more slums, water scarcity • resources funneled to repair damages after natural disasters - affect safety net • flooding and drought ruin crops and communities (less land, less subsistence farmers) • conflicts over food and resources; more crime • difficult to store foods; increased food prices • impact on education - schools may be destroyed • loss of biodiversity, natural resources, trade, transportation, work capacity

2. Describe consequences of iron deficiency

• consequences of IDA in children o premature birth (small, less body fat), LBW, increased infection, death, impaired growth o impaired cognitive development, negative impact on learning (NB long term) • consequences of IDA in adults o reduced productivity (acute effects o increased likelihood of death during childbirth (~20% of all maternal deaths) • with good iron status, may lose up to a litre of blood during childbirth, but for a woman with iron-deficiency anemia, the loss of 1 cup of blood can be fatal

1. Describe what is meant by dietary diversification and why it is important

• consume a variety of different foods from each food group • more likely to consume adequate nutrients, associated with better overall nutritional status • eat at least one dark green (folate) & one orange (B-carotene, carotenoids) vegetable each day • eat a variety of whole grains such as barley, brown rice, oats, quinoa, and wild rice o some people are better off eating refined grains.... • refined convenient (shorter cooking time, less water) → less fuel may be NB • dangers of gathering wood, lack of supplies • whole grains have more fat → go rancid faster • What good is it for subsistence farmers? could improve yields, more types of foods to sell, improving soil fertility, sometimes a crop will fail (safety net)

4. Summarize factors influencing food selection

• culture: acceptable foods; customs; food symbolism; religious beliefs • nutrition knowledge & beliefs: health concerns; attitudes and values; education • practical considerations: food availability and cost; hunger; convenience; health status (SES) • food preferences: taste, smell, colour, texture, temperature; heredity; familiarity o primarily learned, therefore it can adapt and change

5. Define culture and describe how it affects food choice

• culture: the system of shared beliefs, values, customs, behaviours, and artifacts that the members of society use to cope with their world and with one another, and that are transmitted from generation to generation through learning; customary ways of thinking and acting • all cultures are equally developed - none is better or more advanced than any other • importance of cultural factors in food selection: how food is acquired and stored; which foods are selected for consumption (food availability); how foods are prepared; meal patterns

2. Describe population growth and urbanization and comment on consequences related to nutrition

• current = 7.1 bil → projected 10 bil by end of 21st century (growth greatest in developing world) • urbanization: search for work, find no work, poverty, malnutrition, poor sanitation, overcrowding o better infrastructure, less overall toll on environment, etc...but leads to urban slums • slum: run-down area in a city with substandard housing, squalor, lacking in tenure security o most lack clean water, sanitation and electricity o more than 1 bil people live in urban slums (expected to double by 2030) o the ability to promote health and food security is very limited • lots of whole foods, F/V but lack diversity, complementary proteins, total protein • 60% severely food insecure; 24% food secure • severe food insecurity associated with - lower monthly income and women primary income earner, older, less educated o community/household gardens: think of the kinds of foods grown, nutrients they provide • low calorie but nutrient dense; leafy greens source of C, A, folate, iron, etc

9. Describe "sustainable intensification" and give examples of how it has been applied

• definition: more output from same land area, while reducing environmental impacts and considering social, political, and economic factors o use resources at a rate that does not exceed Earth's capacity to replace them • use crop/livestock varieties with a high output:input ratio; avoid unnecessary external inputs; use agroecology (nutrient cycling, nitrogen, fixation, predation, parasitism); minimize strategies with negative effects on environment/human health; using human/social capital; minimize greenhouse gas emissions, water, pollution, negative impacts on biodiversity, etc

5. Explain the difference between "digestion" and "absorption" of nutrients

• digestion: the mechanical and chemical processes whereby the food you eat is converted into substances that can be absorbed by the intestinal tract and used by the body • absorption: the process by which nutrients and other substances are transferred from the digestive system into body fluids for transport throughout the body o most macronutrients absorbed within 30 minutes of chyme reaching the small intestine

Define "energy" within a nutritional context

• energy is defined as the "ability to do work" o from a nutrition perspective, it is the caloric content of a food • caloric content is determined by burning a food in a bomb calorimeter, a container surrounded by water, and measuring the amount of heat energy released o a calorie is the amount of energy needed to raise the temperature of 1 kg of water (about 4 cups) one degree Celsius (from 15°C-16°C)

7. Define fat, identify its functions and differentiate between triglycerides, saturated fat, and unsaturated fat

• fat: lipids, cholesterol, oils, triglycerides; non water-soluble • functions of fat o concentrated energy source o carrier for essential fatty acids, fat soluble vitamins (ADEK) o adds flavour and palatability to food o contributes to feeling of satiety o component of cell membranes, vitamin D, sex hormones • types of fat o triglycerides: the FA that may be unsaturated or saturated; short, med. or long chain • 98% of dietary fat intake and vast majority of body's fat stores • used by cells for energy and tissue maintenance o saturated fat: carbon atoms attached to as many hydrogen atoms as possible • solid at room temperatures; mostly animal (exceptions: palm and coconut oil) o unsaturated fat: contain fewer than the maximum hydrogens • monounsaturated - one double bond • polyunsaturated - EPA, DHA; ALA (w3) & LA (w6) - >1 double bond • liquid at room temperature; best sources are plant o cholesterol (animal sterol)

8. Describe "Golden Rice" and discuss its potential strengths and limitations in combating VAD

• genetically engineered rice - produces beta-carotene • unlike plumpy'nut, will not make a profit from this • different from many other GM foods in that it is working just to benefit consumers • "This rice could save a million kids a year...but protesters believe such GM foods are bad for and and our planet" - TIME • Jimmy Carter: "Responsible biotechnology is not the enemy, starvation is." • Pros: humanitarian intention (really advantage??), would be distributed for free, easy substitution, increases beta carotene in staple food • Cons: concerns re. GM foods, concerns re. possible ecological effects (insects, plants, may become invasive), emphasizes reliance on cereal grains (still lack of protein) - dietary diversity would be better, yellow colour or taste may not be accepted (fatal flaw?)

2. Reflect on what should be done to mitigate the effects of climate change

• greenhouse gas emissions drive climate change - burning fossil fuels (transportation/electricity) • deforestation • farming - especially livestock, especially beef • breakdown of waste • industrial processes

4. Summarize factors influencing household and national food security

• household food security: o req. depend on family size; age, sex, working status, health status, pregnancy/lactation o food production affected by land, capital, education, technology, climate • national food security: total gross food req. on a national, regional or global scale depend on... o physiological food req (PFR): critical threshold estimating %undernourished in country • age/gender profile of pop; avg BMI of each age/gender group, PA patterns; prevalence of pregnancy, infections, conditions that req additional energy • lowest = 1690 (guatemala, eritrea, occupied palestinian territory) • highest = 2000 (netherlands); Canada = 1950 o dietary factors: amount of agricultural production needed depends on type of diet • 2.5 bil at avg US level; 5 bil at italian (highest life expectancy); 10 bil at indian • ~12.5% of grains consumed directly - most used as feed o food system efficiency factors: worldwide, food waste is a major problem • as wealth of nations increase, amount of food wasted increases • 10% food energy lost/wasted in low-GDP countries vs. 40% in affluent • Canadians waste more than $27 bil (40%) of food per year - that is more than the GDP of 32 of the world's poorest countries (~1/6 of the world's countries) • only considers food that could still be consumed at time of disposal • leftovers disposed of in household trash = 51% • packaging and processing = 18% • waste in retail stores (ie. grocers) = 11% • loss during farming = 9% • waste in food service industry = 8% • loss during transportation and distribution = 3% • Canadian per capita waste of edible food: 172 kg • 122kg F/V, 6kg dairy, 10kg poultry, 16kg red meat, 18kg fats and sugars o population size: growth and changes in dietary preferences determine demand for food

10. Discuss the role of GM crops

• in coming decades, polygenic traits may be feasible (ie. drought or salinity tolerance) • many issues - need to be rigorously evaluated (new alliances in development/evaluation) • a lot of what has been done benefits producers more than consumers

4. Identify and evaluate ways in which iron status can be improved

• increase intake and absorption: o include iron-rich foods; dietary diversification o cook with cast iron (esp when cooking something acidic) o increase enhancers/reduce inhibitors; consume vit C with non-heme sources • education and awareness • fortification and supplementation (industrial or household) o industrial fortification needs to be in a "staple" food (ie. wheat flour) • cost of fortifying flour = $2/lifetime; productivity benefit = $15,000/lifetime o many people in rural areas don't purchase industrially processed and fortified foods, they grow and grind their own grains - packages of at-home fortification can be helpful • sprinkles = easy to use, highly acceptable, can be added to soft cooked food, encapsulated in lipid (prevents transfer of taste to other food o control malaria, hookworm, and other infections • nets cost ~$10, last 5 years (~$1/child/year); shoes prevent hookworm

Describe patterns of intake of meat and other livestock products throughout the world

• increasing worldwide due to population growth, rising affluence o main determinant of per capita meat consumption: wealth • projected per capita consumption of meat between 2000 and 2050 o east and south asia: 28 - 51 (82%) o latin america, the caribbean: 58 - 77 (33%) o north america and europe: 83 - 89 (7%) o sub-saharan africa: 11 - 22 (100%) • they are all complete proteins, energy dense...but are more resource-intensive so may have a negative impact on a global scale

at influences the absorption of iron

• individual's iron status: typically 14-18% absorbed, but if status low, can absorb up to 30-40% • amount of iron in diet: proportion absorbed higher when intake is low (spread out; # receptors) • type of iron: heme iron (part of hemoglobin and myoglobin, only in blood and animal tissue) o animal tissues = 40% heme; plant foods = 100% non-heme • NB: eggs and dairy have non-heme iron only • amount of stomach acid: plays important role in absorption of non-heme iron; more = good o acidity decreases with age, therefore can make iron level problematic • other dietary factors: vegan diet 1.8X less bioavailable (~10% absorbed) o increase: ascorbic acid (acidity!), MFP factor (non-heme iron) o decrease: phytates, oxalates, polyphenols, fibre, calcium, zinc (receptors), EDTA

4. Define and describe maternal mortality

• it is a measure of the risk of each pregnancy • "Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration of the pregnancy, from any cause related to or aggravated by the pregnancy." o 20% due to iron deficiency o Other causes: complications during preg or delivery, infection, high BP, unsafe abortion o At greatest risk: poor, young • 800 women die daily from preventable causes, 99% in developing countries • In 2010: 287,000 women - 47% less than 1990 • Where are most maternal deaths occurring? - India (56,000)

Broadly describe what is meant by "malnutrition" and factors that contribute to over- and under-nutrition

• malnutrition is: the condition that results from eating a diet in which certain nutrients are lacking, in excess (too high an intake), or in the wrong proportions; the interaction of complex factors leading to over- and under-nutrition o inadequate diet, disease, politics and economics, geography and climate, culture (things encouraged or prohibited), education, and gender disparity • undernutrition: not enough calories/protein; vitamin/mineral deficiencies o underweight, stunting (in children) and wasting (lack of adipose and muscle) • overnutrition: too many calories; over-consumption of specific nutrients o overweight/obese; specific vitamin/mineral toxicity

9. Define minerals and identify the most common mineral deficiency in the world

• minerals are elements - specific single atoms that perform particular functions in the body • human body contains 40 or more minerals, but only 15 are essential in the diet (obtain others through air we breathe, etc) • single atom of a mineral typically carries a charge, so minerals quite reactive o they can bond with minerals with the opposite charge, and form stable compounds that become part of tissue (ie. hydroxyapatite - bone) o their electrical charge can stimulate muscles to contract and nerves to fire (electrochemical gradient) o may combine with other substances in foods to reduce bioavailability • zinc in whole grains is bound to "phytate" and so it is very poorly absorbed • iron can bind with tannic acid to decrease absorption by up to 50% • iron deficiency affects 1 in 3 people worldwide o symptoms:weakness, fatigue, shortened attention span, reduced appetite, susceptible to infection, iron-deficiency anemia o needs: males = 8mg, females = 18mg; vegetarians 1.8X higher o average mixed diet provides ~6mg of iron per 1000kcal of food - adult males easily meet their needs...females and vegetarians may have difficult o sources: liver, beef, pork, beans, dried fruit, spinach, blood, cooking tools (acidic foods!)

3. Compare and contrast mitigation and adaption

• mitigation: global, affects greenhouse gas concentrations o can have a broader impact (act locally, impact globally) • adaption: local, effects impacts of climate change o need knowledge regarding how to adapt, especially at the local level o long-term, ongoing process

2. Identify and explain 5 reasons why it is important to assess the nutrition status of a population

• monitor nutritional status of population • identify groups at risk for deficiencies • reveal relationship between diet and health • evaluate effectiveness of programs (ie. folic acid in grain products) • track food consumption trends

9. Summarize key aspects of iron deficiency: what is the scope of the problem? Who is at risk?

• most common and widespread nutritional disorder - "public health condition of epidemic proportions" - 66-80% low in iron, 30% (~2 bil) anemic • IDA is "microcytic" - less oxygen supplied to cells... tiredness, lethargy, apathy, pallor • causes of iron deficiency: o low dietary intake (due to poverty, etc) o poor absorption (ie. diarrhea, presence of inhibitors in plant foods) o increased needs (growth, pregnancy, lactation) o infection (malaria, HIV/AIDS, hookworms, schistosomiasis, tuberculosis)

11. Summarize the limitations of a physical examination in the assessment of nutritional status

• non-specificity of physical signs (esp if mild or moderate) o Some signs may result from more than one deficiency o Some signs may result from non-nutritional factors or be inherited • Multiple physical signs may exist if there are several deficiencies • Examiner inconsistencies - may need experience to determine if particular sign is significant o Reduce this by training, standardizing observations • Variations in pattern of physical signs between different people (inter-individual variation)

2. Reflect on "Living with Hunger" and consider factors contributing to malnutrition in Ethiopia

• not enough food aid - food aid for entire family, but only given enough for one person o walk 11km for food aid, not getting to where it's needed most o no food aid to church school, must beg for food by walking to villages • can't grow enough food/not reliable - even market doesn't have much food (geography/climate) • very dramatic poverty divide • lack of diversity in diet

5. Define nutrition assessment and nutrition screening and differentiate between the two

• nutrition assessment: an evaluation of nutritional status of individuals or populations through measurements of food and nutrient intake and evaluation of nutrition-related health indicators. • Why:Identify occurrence, nature, extent of impaired nutritional status + To improve human health (WHO) o Anthropometric, Biochemical, Clinical, Dietary (+ Ecological) o measures extent to which the individual's physiological needs for nutrients are met • intake + absorption = stress + growth + maintenance o nutritional assessment enables us to determine what optimal nutritional status is and whether it exists or not in an individual • nutrition screening: process of identifying characteristics known to be associated with nutrition problems • Why: To quickly identify individuals who are malnourished or at nutritional risk + Determine if a more detailed assessment is warranted • Must be: simple, quick, reliable, inexpensive, and collects relevant data on risk factors (valid)

3. Describe how nutrition monitoring of populations can be done (what can be measured and how)

• nutrition monitoring: the assessment of dietary or nutritional status at intermittent times to detect changes in the dietary or nutritional status of a population • measures: nutrition and health status; food consumption; food composition (nutrients, pesticides); dietary knowledge, behaviour, attitudes; food supply and demand • food disappearance data: (production + beginning stocks + imports) - (exports + farm and industry use + ending stocks) = food disappearance o food disappearance / population = per capita disappearance (per capita availability) o not an actual measure for food consumption o does not account for losses from spoilage, disposal, trimming and cooking o useful for examining food trends, making comparisons between populations • correlation =/= causation (think carbs and obesity)

2. Comment on how supplement and fortification programs can be used to reduce malnutrition

• priorities for supplementation: iron, iodine, vitamin A, zinc (NB: prevalence, disease risk....) • fortification: relevant for everyone (iron, vitamin A) o needs to be appropriate "vehicle" - doesn't interfere with taste/colour, consumed enough, stable; needs to be affordable (ie. salt and iodine) o water-soluble vitamins - they aren't stored, so a daily consumption is important, folic acid or B12 could be candidates (more in western context) • supplements - targeted populations, better in rural areas (don't purchase many foods - usually grind their own grains, etc) → "home fortification" might be a viable "in between" choice

2. Define protein and identify four functions of protein

• protein is an essential structural component of all living matter; involved in almost every biological process in the body • protein has four major functions o structural material in muscles, connective tissue, organs, hemoglobin o basic component of enzymes, hormones, transporters, immune system o maintains and repairs protein-containing tissues o energy source • primary: amino acids linked in a chain (20 amino acids; 9 essential) • secondary: primary structure linked by hydrogen bonds in a-helixes and b-sheets • tertiary: attraction present between secondary structure (ie. sulfide bonds) • quarternary: protein consisting of more than one amino acid chain

13. Summarize the importance of exclusive breastfeeding for 6 mo and discuss why it does not occur

• reduces child mortality rate, helps with child spacing, helps with overall family food security, passive immunity - antibodies, prevents drinking of unsafe drinking water - risk for diarrhea • Breastfeeding saves more lives than any other preventative intervention • WHO recommendation: exclusive breastfeeding for up to 6 mo, with continued breastfeeding along with appropriate complementary foods up to 2 years of age and beyond o Exclusive breastfeeding for 6 mo estimated to save 6 million lives per year (~3,000/day); continued to age 2 (with foods) would save another 5,500 lives/day • Begin within hour of birth (breast crawl) → if not, may become drowsy and more difficult to feed • Should be "on demand" → watch for feeding cues from infant; typically feeds 8-10 times per day • Avoid bottles/pacifiers → nipple confusion = poor latch/suck, lower breastmilk production • How many people follow it? Worldwide: <35%, developing countries: <50% o What affects this? can feed right away, information and support (family and culture), HIV • Exclusive breastfeeding can give a woman 98% protection against pregnancy for 6 mo o dependent on frequency, exclusivity, and times of feeding (variety but night most NB) • Colostrum: concentrated, very nutritious, mild laxative, contains growth factors and antibodies - even if mother is not interested in breastfeeding should try and feed colostrum o However, viewed as "dirty", even by mothers who planned to breastfeed

3. Describe factors associated with stunting, wasting, and underweight in Nepal

• risk: low BMI of mother, child's age, higher birth order, lower standard of living • protective: mother's education >5 years, participating in vit A or nutrition program

10. Differentiate between signs and symptoms

• signs: observations made by qualified examiner; patient usually unaware of the • symptoms: clinical manifestations reported by patient

5. Indicate how the agricultural sector could help mitigate impacts

• so far, response mostly from health sector BUT ~80% affected depend on subsistence farming • the agricultural industry cannot continue as "business as usual" o changes to farming practices: increase use of machines and tools, plant crops that need less work/weeding, teach children about farming when they're young o social changes: increase farming in small groups/collectives, share, policy change o interventions: medications, spread awareness on HIV and its impact on food security, pay agricultural workers higher wages

5. Comment on consequences of inadequate (or excessive) protein intake

• specific nutrient deficiencies associated with inadequate protein - B12, Zinc, Niacin, Iron • PEM (protein-energy malnutrition) - a form of severe undernutrition o easily irritated, apathetic, small, vulnerable to infection o most commonly affects children aged between 6 mo (post breastfeeding) and 5 yrs o marasmus: skin & bone, mainly due to energy deficiency, higher survival rates • loss of >30% of body protein causes less strength for breathing, susceptibility to infections, abnormal organ function and death o kwashiorkor: accompanied by edema and metabolic abnormalities; primarily protein • difficult to treat since must balance metabolic abnormalities • if intake >45%: nausea, weakness, diarrhea, eventually death o no UL, but high chronic intakes linked to osteoporosis, kidney stones, cancer, heart disease and obesity

2. Define stunting, wasting, and underweight

• stunting - low height for age - reflects chronic malnutrition • wasting - low weight for height - reflects acute malnutrition (metabolic prioritization) • underweight - low weight for age (children); BMI <18.5 (adults) - chronic or acute (or combo)

4. Describe Plumpy'nut, its history, and its use

• targeted at children, but anyone can use it • 500kcal; 25% peanut butter, 25% oil, 25% sugar, 25% milk powder, micronutrients added • when distributed to 40,000 starving children during famine in Niger in 2005, 90% recovered • Unicef bought 10,500 tonnes in 2009 (up from 4000 tonnes in 2005) • better than nutrient biscuits - more calorically dense, more palatable (since fat based) • commonly used in internally displaced peoples camps, and as outpatient care (at home use)

6. Describe connections between improvements in education/status of women and food security

• women in parliament: critical mass = enough women to represent interests; minimum = 30% o Scandinavian countries tend to a higher proportion and less income discrepancy o Rwanda has 56% - could be partly due to the loss of men due to the genocide o Canada and Iraq = 25%; US = 17% • agricultural productivity increases dramatically when women get same amount of inputs as men o example: in Kenya, one year of primary education provided to all women farmers would increase maize yields by 24% • educating women reduces proportion of population living in poverty o example: if mothers complete primary school, proportion of population living in poverty would decrease by ~34% in Egypt and ~23% in Mozambique • Women's education and status contribute more than 50% to reductions in child malnutrition o example: child malnutrition in developing world decreased by ~15% from 1970-95 due to 43% increase in women education, 26% improved food availability, and 12% improvement to status of women