by Hannah Meredith and Devon Paul
In Dr. Steinberg’s lecture,
we heard an overview of nutrition issues on a global scale.
Interestingly, these issues ranged from overnutrition to undernutrition with
both obesity and malnutrition being major causes of morbidity and mortality in
the world. With such a range of nutritional issues and they underlying
causes, how can we make meaningful dietary recommendations for people? Before
addressing this question, there are a number of interesting factors at play
that need to be understood.
The world is currently going
through a significant nutritional transition. There are 5 different
patterns associated with the nutrition transition: hunter gatherer, early
agriculture, end of famine, overeating and obesity-related diseases, and
behavior change. Currently, many low- and middle-income countries (LMICs) are
transitioning from the “end of famine” pattern to the “overeating,
obesity-related disease” pattern. This transition is happening as
Western-styled diets infiltrate different cultures and replace the traditional
diet. Couple this introduction of diet high in animal and partially
hydrogenated fats and low in fiber with a more sedentary lifestyle, and the
result is an obesity epidemic that is beginning to affect low- and
middle-income countries. These dietary and lifestyle changes in LMICs are an
effect of a recent demographic transition from a primarily rural, agrarian
society to an urbanized society centered on large cities. Migrants leave
behind a food safety net of family, friends, and farms for the promise of a
better life in the city; however, in the poorest countries, unemployment rates
are crushing, and people try to make a living on $1-2 per day. With that
money, the city workers not only have to pay for or build their own shelter,
but also have to buy the food that they once grew themselves. It is both a
curse and a blessing that large-scale production has decreased the price of
processed food and drink. On one hand, these foods are affordable to people who
do not have much income. On the other hand, these foods form an unhealthy bulge
in the top of the food pyramid for many.
I have seen plenty of soda bottles and potato chip bags being consumed
by children with evidence of protein malnutrition and stunting. Given the
struggle with food insecurity, economic hardship, and a ready supply of cheap junk
food and empty calories, how we can make meaningful dietary recommendations for
people?
In the US, we have tackled
the issue of food insecurity with a variety of piecemeal programs: food
subsidies for those living below a certain income threshold, subsidized school
lunches (and sometimes breakfast and dinners), food pantries, “soup kitchens”,
or community farmer’s markets that intend to provide low cost fresh fruits and
vegetables in food deserts. Yet even in our own country, we struggle to
meet the nutritional needs of the most vulnerable. What should a program look
like that addresses those living at risk of malnutrition?
I did a project on the health profile of South Africa a couple of years ago, and I remember reading that South Africa has one of the highest national obesity rates and one of the highest national malnutrition rates, simultaneously, of any country in the world. That was really startling to me then, and I'd imagine that the statistics haven't changed too much. It's a country in which you can find both areas of poor public health systems and lack of community development, as well as areas of rapidly growing availability of Western-style processed food that is cheap and present on every corner of major cities (and some smaller ones).
ReplyDeleteThe time I've spent in Zimbabwe in the past has also showed me this stark contrast. The glowing signs of fast food restaurants are all over towns and cities, much like here, but a drive out into rural regions shows that even these options, considered relatively inexpensive, are inaccessible to people living below the poverty line. It's this simultaneous burden of both malnutrition and obesity that I find really striking and that are worthy of attention if policymakers have a goal of national-level comprehensive health and dietary recommendations for any of these countries.
In response to your question, I think finding a solution to address malnutrition would be really difficult as there are so many underlying reasons for which people are not getting the nutrients they need - issues of accessibility, financial concerns, etc. Nutrition programs for children's school lunches address the young generation, and farmer's markets are accessible to other parts of the population, but they don't seem sufficient to cover everyone's needs. Continuing to involve the communities who would most benefit from these programs in the planning process will definitely be key to moving forward. Finding out why they may not be using current programs or what their perceived barriers are to a healthy diet will help keep the conversation open and find solutions that are maximally effective for the people that need them.
Thanks Hannah and Devon for your insight into this issue!
This seems like a very big challenge also for the US and other advanced economies facing similar problems. I think that the regulatory alternatives should for sure include more information awareness campaigns and education about the nutritional values of foods. But the problem of accessible and affordable food remains for many people both in the developed and developing world. Apart from providing nutrition programs and addressing the issue of sustainability (involving farmers, etc.), governments and public health officers should be creative when designing programs and regulations in this area.
ReplyDeleteThe field of behavioral economics and now the "nudging" field, provides some suggestions to tackle the problem of providing the right incentives for people to choose what is good for them. For some people this sounds paternalistic. But in the area of health and nutrition, people are usually dealing with too many choices and they are seldom rational when they choose what to eat. Provided that people "do" have a choice (in the sense that they have enough money to buy food), some nudging could be able to help them make the right choice for their food baskets.
I had a very similar experience to Leah's in Zambia and, in hindsight, observed the shift from the "end of famine stage" to the "overeating and obesity related disease" stage. When my family moved to the country in 1997 being fat was a trait associated with the very wealthy. In fact, culturally it was a compliment to tell someone that they were growing fat (much to my sisters horror during her teenage years). The fact was that in order for someone to be overweight not only did it mean that they had enough to eat but that they could spend extra money on the things that were unhealthy. Since almost everything processed and packaged was imported from South Africa these goods were fairly expensive. In addition to that, there was a lack of unhealthy eating options. When we first moved to Ndola there was one fast food restaurant in the entire city (appropriately named the Hungry Lion). Over the next decade we watched as the number of cars on the road increased exponentially, massive strides were made in development, shopping malls were built, and people we knew grew fatter. While Zambia does not yet have a heavy burden of obesity related disease what we witnessed was the start of the transition. By the time we moved away in 2008 Ndola had gone from having one lowly fast food restaurant to having shopping mall food courts providing 8 different options of getting fried fatty foods.
ReplyDeleteMost Zambians didn’t see it as a problem either, in fact many saw it as progress. Progress towards the goal of an "American" diet. For those who have not lived outside of the country and already have the "American dream" it can be easy to be unaware that our lifestyle is desired by a great number of people in LMICs. The concept of the American life is idealized world wide. The range and scope of our media, products, and advertising also mean that our actions here have repercussions world wide. So perhaps we should start here in the US, counter our obesity epidemic at home and maybe in doing so affect those who look to America in a positive way.
In developing countries, and in the U.S. breastfeeding is a recommended way to meet the important nutritional needs of a baby in early stages of development. The nutritional benefits of breastfeeding are well known and babies who are breastfed have shown to have a much higher survival rate than those who were not breastfed. Exclusive breastfeeding is promoted around the world as a way to prevent malnutrition in children. What do you think should be the breastfeeding recommendation for HIV positive mothers in the developing world? Do the benefits of exclusive breastfeeding outweigh the small chance (if the mother is taking ARV drugs properly) of the mother transmitting HIV to her child?
ReplyDeleteI really enjoyed Dr. Steinberg’s lecture on global nutrition and the intersection of malnutrition and obesity. Thanks Hannah and Devon for posing your question of “what should a program look like that addresses those living at risk of malnutrition?” I’m not sure I know how to tackle that question…so instead I’ll comment on Leah’s comment about South Africa having some of the highest obesity and malnutrition rates simultaneously and Daniel’s regards about Zambian’s feeling like obesity and access to “unhealthy foods” being progress. I have friends, here and in South Africa who started businesses in food delivery services (Dashed in the US and Mr. Delivery in South Africa). Mr. Delivery, or Mr. D. has done very well in South Africa in part because of the transitional and burgeoning so-called ‘middle class’ – or an echelon of individuals and families who are able to afford restaurant food, but can not afford cars, and for people who are moving to more urban or densely populated areas where cars are not needed or are not utilized as much (i.e. Johannesburg, Boston, and Washington DC). These two companies offer a service for restaurants who do not provide delivery service on their own, and for people who want delivery from those exact restaurants. This doesn’t seem like a such a novel idea, but when put in the context of nutrition and over eating, obesity, malnutrition, inactivity, and the like, it is an interesting concept. Instead of the hunter-gatherer method of foraging for food, now we companies who – in high-, middle- and possibly low-income countries will do all of the leg work for you even when the restaurant of your desire does not offer delivery on their own. I still think back to Dr. Bloomfield’s presentation about cardiovascular disease in developing countries and the fat giraffe. With the changing landscape of food availability around the world and access to unhealthy (and arguably some healthy!) food, critically assessing all of the players – even novel delivery services – should be considered.
ReplyDeleteAs a side note - an interesting documentary, somewhat chronicling two college student's summer in Guatemala working on a microfinance project is "Living on One Dollar a Day"; however, a main focus of the film (I would argue THE main focus of the film) is their struggle to survive by eating each day on their meager wages similar to their host community. They try to figure out how to get dense yet affordable calories (i.e. lard) to maintain their weight and metabolic needs.
http://livingonone.org/livingonone/film/
http://www.dashed.com/
https://www.mrd.com/
Best,
Brittney
This comment has been removed by the author.
ReplyDeleteBoth Leah's and Daniel's comments on this subject are interesting. It's almost unbelievable that in so many LMICs, an epidemic of malnutrition and and epidemic of obesity may exist side by side - or even within the same person. In some places of the world, the evidence of malnutrition is so blatant - stunted growth, distended bellies, irritability, and emaciation. The evidence of obesity is completely blatant too. But it is too soon, I think, for the nutritional problems associated with obesity to be seen by these people who, as Daniel put it, are "working towards a goal of the "American" diet." This post highlights that even in our own country, we fail to meet the nutritional needs of the most vulnerable, highlighting that severe nutritional deficiencies exist even in those who are overfed. It's an interesting question: 'how can we make meaningful dietary recommendations for people given all of the difficulties surrounding this issue' and unfortunately, I think it isn't a question that needs to be asked solely about the developing countries of the world. The starkest difference between so many Americans living on an "American" diet and those in LMICs living on the same is that more Americans likely have a choice in the matter. But why do they choose wrongly? If those of us who have a choice - cheap or healthy? chips or vegetables? mcdonalds or homemade salad? - are even more often than not making the wrong decisions on what to eat, how can we possibly convey to others that given the higher prices and the lack of relative convenience, that they should make the right choices? I think this is what was being asked. Unfortunately, I think it is human nature to learn from our own mistakes and not from the mistakes of others. I think we can make recommendations all we want and I don't particularly think they will make a difference. Here in America, we are taught the food pyramid from the time we're in grade school, but still, until last year, we were the most obese country in the world. I wish this was an issue that the appropriate recommendations would fix but unfortunately, I think it's an issue that will exist in every part of the world after the end of famine stage and until the behavior change stage. I think no place can skip the overeating phase but I am hopeful that eventually all of us will reach behavior change. Only then will dietary recommendations truly be "meaningful."
ReplyDeleteBoth Leah's and Daniel's comments on this subject are interesting. It's almost unbelievable that in so many LMICs, an epidemic of malnutrition and and epidemic of obesity may exist side by side - or even within the same person. In some places of the world, the evidence of malnutrition is so blatant - stunted growth, distended bellies, irritability, and emaciation. The evidence of obesity is completely blatant too. But it is too soon, I think, for the nutritional problems associated with obesity to be seen by these people who, as Daniel put it, are "working towards a goal of the "American" diet." This post highlights that even in our own country, we fail to meet the nutritional needs of the most vulnerable, highlighting that severe nutritional deficiencies exist even in those who are overfed. It's an interesting question: 'how can we make meaningful dietary recommendations for people given all of the difficulties surrounding this issue' and unfortunately, I think it isn't a question that needs to be asked solely about the developing countries of the world. The starkest difference between so many Americans living on an "American" diet and those in LMICs living on the same is that more Americans likely have a choice in the matter. But why do they choose wrongly? If those of us who have a choice - cheap or healthy? chips or vegetables? mcdonalds or homemade salad? - are even more often than not making the wrong decisions on what to eat, how can we possibly convey to others that given the higher prices and the lack of relative convenience, that they should make the right choices? I think this is what was being asked. Unfortunately, I think it is human nature to learn from our own mistakes and not from the mistakes of others. I think we can make recommendations all we want and I don't particularly think they will make a difference. Here in America, we are taught the food pyramid from the time we're in grade school, but still, until last year, we were the most obese country in the world. I wish this was an issue that the appropriate recommendations would fix but unfortunately, I think it's an issue that will exist in every part of the world after the end of famine stage and until the behavior change stage. I think no place can skip the overeating phase but I am hopeful that eventually all of us will reach behavior change. Only then will dietary recommendations truly be "meaningful."
ReplyDeleteOne project I had the privilege and opportunity to work on was exploring the potential of fortified salt. Similar to how table salt is enriched with iodine in many parts of the world, the laboratory was examining encapsulating micronutrients into a hydrogel and then coating the particle in salt. I think an approach like this has huge potential to address malnutrition in the US and around the world, because everyone regardless of culture, religion, race, etc. uses salt in their food; it's one of the essential components to human survival. By encapsulating micronutrients into a hydrogel, the nutrients would stay inside the particle while the food was being prepared and consumed. Hydrogel degrades at highly acidic conditions like gastric fluid and so the nutrients would be released during digestion. This approach avoids altering the way food tastes or is prepared, individuals essentially continue living their lives as normal but receive the essential micronutrients through the fortified salt consumption.
ReplyDelete