Professional Documents
Culture Documents
2.7
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182
SECTION 2
maternal stature, low maternal body weight and body mass index
at conception, and inadequate weight gain during pregnancy are
all associated with IUGR. Thus IUGR is closely related to conditions of poverty and chronic undernutrition of economically disadvantaged mothers.
More than 96 per cent of low-birth-weight (LBW) infants are
born in the developing world and over 20million children are born
each year with LBW accounting for 15 per cent of all birthsmore
than double the level in the developed world (UNICEF 2012). The
incidence of low birth weight varies across regions, but South Asia
has the highest incidence, at 27 per cent (with India at 28 per cent
and Pakistan at 32 per cent).
LBWs due to IUGR are associated with increased morbidity and
mortality in infancy. It is estimated that term infants weighing
less than 2500 g at birth have a four times increased risk of neonatal death as compared to infants weighing between 2500 and
3000 g and ten times higher than those weighing between 3000
and 3500 g.The risk of morbidity and mortality in later infancy is
also considerably higher in these LBW infants and is largely due
to increased risk of diarrhoeal diseases and respiratory infections.
Barkers studies have consistently demonstrated a relationship
between LBW and later adult disease and provide an important
aetiological role for fetal undernutrition in amplifying the effect
of risk factors in later life thereby increasing the risk of developing diabetes, hypertension, dyslipidaemia, cardiovascular disease,
and obesity in adult life (Barker 2004).
Childhood undernutrition
The clinical conditions of childhood undernutrition like kwashiorkor and marasmus are severe forms of malnutrition. They are
the tip of an iceberg of widespread mild-to-moderate childhood
undernutrition within the community that is relevant from a public health perspective.
The determinants of child undernutrition can be considered as
operating at three levels of causality:immediate, underlying, and
basic. The immediate determinants are dietary intakes and health
status which are in turn influenced by three underlying determinantshousehold food and nutrition insecurity, care for children
and their mothers, and the health environment which includes
access to safe water, sanitation, and health services. Care encompasses such variables as breastfeeding and proper and timely
introduction of complementary feeding, and the education of
womenthe primary caregiver, their status, their autonomy, and
their access to resources. Apoor health environment can result
in frequent episodes of infection. Avicious cycle may be established and children in poor communities fail to thrive once they
have succumbed to an infectious disease and they then languish,
responding poorly to therapy and failing to grow even when presented with apparently adequate amounts of food.
Undernutrition in childhood is characterized by growth failure
and hence, in children, assessment of growth has been the single
most important measurement that best defines their nutritional
status. Measures of height and weight are the commonly used
indicators of the nutritional status of the child and classification
of childhood undernutrition based on height, weight and age
continues to be the backbone of nutritional assessment of both
populations and individuals (WHO 1995)when compared against
international growth reference standards developed by WHO
(2006).
2.7
Children throughout the world when well fed and free of infection tend to grow at similar rates irrespective of their ethnic or
racial origin, and healthy children everywhere can, when fed
appropriately, be expected to grow on average along the 50th
centile of a reference populations weight and height for age. By
expressing both height and weight as standard deviations or
Z-scores from the median reference value for the childs age, the
normal range will correspond to the 3rd and 97th centile, (i.e. 2
SDs or 2 Z-scores). By expressing data in this way, it is possible
to express the weight and height data for all children across a wide
age range in similar Z-score units and thereby produce a readily
understandable comparison of the extent of growth retardation at
different ages and in different countries.
A deficit in height is referred to as stunting whereas a deficit
in weight-for-height is considered as wasting. These two measures are subsumed in the designation of a childs failure to grow in
terms of weight-for-age when the deficit is termed underweight.
Wasting can occur on a short-term basis in response to illness
with anorexia or malabsorption or because the child goes hungry
for several weeks. Changes in weight-for-height therefore reflect
the impact of short-term changes in nutritional status. Growth in
height, however, is much more a cumulative index of long-term
health because growth in length or height stops when a child
develops an infection and the subsequent growth may be slow
during the recovery period. Children normally grow in spurts
and intermittently. Energy intake is not a crucial determinant
of height and the energy cost of growth and weight gain is only
25 per cent of total energy intake once the child is 1year of age.
Impairment of growth in height occurs in many communities at
the time of weaning and up to about 2years of age. Once the children have failed to maintain their proper growth trajectory for
stature they tend to remain on the lower centiles and track at this
low level for many years.
While the MDGs targeted underweight in children, more
recently the emphasis has shifted from underweight to stunting.
The damage caused by lack of good nutrition in the first 5years
of life is largely irreversible and stunted children achieve less in
school, are paid less when they enter the workforce, and are at
greater risk of becoming overweight and developing chronic diseases later in life. There is now a better appreciation of the crucial
importance of nutrition during the critical 1000-day period covering pregnancy and the first 2years of a childs life, that stunting
reflects deficiencies during this period and that health and nutrition interventions need to focus on this crucial period.
Global estimates of the main forms of child undernutrition are
summarized in Table 2.7.1. Comparisons from earlier estimates
indicate that the prevalence of underweight and stunting remain
high despite substantial progress (Black etal. 2013). In most parts
of Africa the numbers of underweight and stunting increased during this period while the dramatic progress in Asia is outweighed
by the persisting high prevalence and numbers of children
affected. Stunting is a serious problem reflecting poor nutrition
and frequent infections during the early growth period. Stunting
in South Asia seems also to be related to the high incidence in
LBW in this region.
Underweight in children is being used as an indicator for monitoring progress towards the MDGs. Overall current analyses demonstrate some progress in reducing child undernutritionbut
progress is uneven and in some countries has even deteriorated.
Stunting
1990
2011
1990
2011
26.5
15.7
33.5
25.7
163.4
100.7
206.5
164.8
Prevalence (%)
23.6
17.7
36.9
35.6
Numbers (10 6)
25.3
27.9
39.6
56.3
35.1
19.3
41.1
26.8
131.9
69.1
154.6
95.8
Prevalence (%)
8.7
3.4
18.3
13.4
Numbers (10 6)
4.8
1.8
10.0
7.1
Global
Prevalence (%)
Numbers (10 6)
Africa
Asia
Prevalence (%)
Numbers (10 6)
Latin America
Adult undernutrition
Undernutrition among adults has been neglected and this may
have profound significance for the economic growth of developing countries. One simple measure of adult nutritional status is
the body mass index (BMI), (i.e. body weight in kilograms divided
by the square of the height in metres); the most suitable index
for both under- and overnutrition in adults (Shetty and James
1994). Adults with a BMI less than 18.5 are considered chronically undernourished while those with a BMI greater than 25.0
or greater than 30.0 are overweight or obese respectively (WHO
2000); the same BMI cut-offs apply to both males and females.
Undernourished adults show impairment of physical well-being
and exercise capacity and susceptibility to illness and the ability to
sustain economic productivity. Hence, it is important to examine
adult undernutrition.
Anthropometric measures of adult undernutrition provide
objective estimates of the prevalence of undernutrition worldwide.
In practice, children and adults may adapt to a shortage of food
by reducing their physical activity without changing their body
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184
SECTION 2
Micronutrient malnutrition
Micronutrient malnutrition, also referred to as hidden hunger, is
caused by lack of adequate micronutrients (vitamins and minerals) in the habitual diet. Diets deficient in micronutrients are characterized by high intakes of staple food and cereal crops, but low
consumption of foods rich in bioavailable micronutrients such as
fruits, vegetables, and animal and marine products, i.e. the lack of
a diversified diet. Micronutrient deficiencies are important from
a public health perspective as they affect several billion people
worldwide (Table 2.7.2) and can impair cognitive development and
lower resistance to disease in children and adults. They increase
the risk to both mothers and infants during childbirth and impair
the physical ability and economic productivity of men. The costs of
these deficiencies in terms of lives lost and reduced quality of life
are enormous, not to mention the economic costs to society.
Strategies to combat micronutrient deficiencies in communities
have included:(1)supplementation of specific nutrients to meet
Estimated impact
Vitamin
Adeciency
Iron deciency
Iodine deciency 1.98 billion at risk with insucient or low iodine intakes3
15.8% of population worldwide have goitre3
17.6million infants born mentally impaired every year2
Folate deciency Responsible for 200,000 severe birth defects every year2
Source:data from 1 Standing Committee on Nutrition, Fifth report on the world nutrition
situation:Nutrition for improved development, World Health Organization, Geneva,
Switzerland, Copyright 2004; 2 UNICEF/Micronutrient Initiative, Vitamin and Mineral
deciency:AWorld progress report UNICEF/Micronutrient, Canada, Copyright 2004;
and 3 World Health Organization, Iodine status worldwide, World Health Organization,
Geneva, Switzerland, Copyright 2004.
2.7
Table2.7.3 Numbers of people (in millions) aected with iron deciency anaemia based on blood haemoglobin
concentration in dierent regions of the world
Children
Women (1549years)
Men (1559years)
Elderly
Preschool
(millions)
School age
(millions)
Pregnant
(millions)
Non-pregnant
(millions)
(millions)
(millions)
Global
293.1
305
56.4
468.4
260
164
Africa
83.5
17.2
69.9
Americas
South East Asia
Europe
East Mediterranean
Western Pacic
23.1
3.9
39.0
115.3
18.1
182.0
11.1
2.6
40.8
0.8
7.1
39.8
27.4
7.6
97.0
Source:data from Bruno de Benoist etal. (eds), Worldwide prevalence of Anaemia 19932005:WHO global database on anaemia, World Health
Organization, Geneva, Switzerland, Copyright 2008.
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186
SECTION 2
Total goitre
prevalence
School-age
children
General
population
Africa
42.7%
(59.7millions)
43.0%
(324.2millions)
26.8%
Asia
38.3%
(187.0millions)
35.6%
(1239.3millions)
14.5%
Europe
53.1%
(26.7millions)
52.7%
(330.8millions)
16.3%
Latin America
and The
Caribbean
10.3%
(7.1million)
10.0%
(47.4millions)
4.7%
North America
9.5%
(2.1millions)
64.5%
(19.2millions)
Oceania
59.4%
(2.1million)
64.5%
(19.2million)
12.9%
Total
36.5%
35.2%
(285.4millions) (1988.7millions)
15.8%
spectrum of IDDs in humans, from the fetus to the adult, has been
outlined by Hetzel (1987).
The public health initiatives for correcting iodine deficiency
include the following: iodization of salt has been the most
favoured method and has greatly reduced the prevalence of IDDs
in Switzerland, the United States, and New Zealand. Since its first
successful introduction in the 1920s in Switzerland (Brgi etal.
1990)successful programmes have been reported in Central and
South America, in Europe, and in Asia. However, several developing countries have encountered problems with salt iodization programmes because it is difficult to produce and maintain
enough high-quality iodized salt for large populations such as
in India and Bangladesh. The costs of iodized salt and its availability and distribution to remote regions can also be a problem
and may be compounded by cultural prejudices about the use of
iodized salt and the loss of iodine with cooking if salt is not added
after cooking. Iodized oil injections have been used to prevent goitre and cretinism in New Guinea (Pharoah and Connolly 1987).
Iodized oil is suitable for mass programmes and can be carried
out alongside mass immunization programmes. These methods
have been successful in China, Indonesia, and Nepal. The major
problems with iodized oil are the cost, the initial discomfort, and
the likely potential risk of the transmission of hepatitis B and
HIV. The need for trained personnel to inject iodized oil can be a
further disadvantage. Iodized oil by mouth may be an alternative
and oral iodized oil has been shown to be as effective in a single oral dose as an intramuscular injection (Phillips etal. 1988).
2.7
Although the effects of oral iodized oil seem to last for only half as
long as a similar dose of injected iodized oil, oral iodized oil does
not suffer from the disadvantages of iodized oil injections and
so is a preferred method for use in remote areas. IDDs are excellent examples of nutritional deficiency disorders of public health
importance which can readily be addressed if mass community
programmes are undertaken.
Zinc deciency
Zinc deficiency is the result of inadequate intake or absorption of
zinc from the diet. Excess losses of zinc during episodes of diarrhoea also contribute to deficiency. The composition of the diet
can influence zinc bioavailability as high levels of phytates in the
diet may result in poor absorption while animal source foods
increase availability. Based on inadequate intakes in the diet it has
been estimated that globally 31.3 per cent of the population have
inadequacy of zinc in the diet (Caulfield and Black 2004)while
zinc deficiency has been estimated globally at 17.3 per cent (Black
etal. 2013).
Worldwide, zinc deficiency is responsible for approximately
16 per cent of lower respiratory tract infections, 18 per cent of
malaria, and 10 per cent of diarrhoeal disease and 1.4 per cent
(0.8 million) of deaths worldwide. Attributable DALYs were
higher, with zinc deficiency accounting for about 2.9 per cent of
worldwide loss of healthy life years. Dietary diversification and
the addition of animal source foods in the diet have helped reduce
zinc deficiency and agricultural technologies such as addition of
zinc enriched fertilizer to the soil (Gibson etal. 2007)and the use
of biofortified crops with higher zinc and iron content have also
been successfully tried to reduce the burden of zinc deficiency as a
public health problem.
Vitamin Adeciency
Vitamin Adeficiency (VAD) is a major public health problem in
many developing countries. VAD leads to night blindness and
xerosis of the conjunctiva and cornea and disrupts the integrity
of their surface and causes corneal clouding and ulceration and
may lead to blindness in children. Xerophthalmia continues to be
a major cause of childhood blindness despite the intensive prevention programmes worldwide. The parts of the world most seriously
affected include South and South East Asia, and many countries in
Africa, Central America, and the Near East. Extrapolations from
the best available data suggest that 140million preschool children
and more than 7million pregnant women suffer from VAD every
year (Standing Committee on Nutrition 2004). This report also
states that another 4.4million children and 6.2million women
suffer from xerophthalmia. Nearly half the cases of VAD and
xerophthalmia occur in South and South East Asia.
VAD manifests as night blindness and it is estimated that globally 5.17million preschool age children and 9.75million pregnant
women suffer from night blindnessthe highest prevalence in
pregnant women in Africa and South and South East Asia (WHO
2009). Global estimates are 0.9 per cent for preschool children
and 7.8 per cent for pregnant women (Black etal. 2013). Based on
low serum retinol levels the estimates globally are much higher at
190million preschool children and 19.1million pregnant women
with Africa and South and South East Asia having the highest
prevalence. Global estimates are 33.3 per cent for preschoolers
and 15.3 per cent for pregnant women (Black etal. 2013). About
187
188
SECTION 2
Folate deciency
Folate enables cell division and tissue growth. Adequate folate in
the diet helps prevent malformations that affect the neural tube
and spinal cord such as anencephaly and spina bifida as well as
birth defects like cleft lip and palate. Without adequate folate in
the diet, two in every 1000 pregnancies may end up with a serious birth defect. Folate deficiency is also associated with increased
risk of preterm delivery and LBW (Scholl and Johnson 2000)and
may also contribute to anaemia, especially in pregnant and lactating mothers (Dugdale 2001). It may thus contribute indirectly
to increased maternal illness and mortality. With the increasing
awareness of the role of folate in reducing the risk of heart disease
and stroke, a case is being made for folate fortification of flour, a
strategy already adopted in the United States and Canada.
Consequences of undernutrition
andmicronutrient deciencies
An issue that that deserves attention is to ask the question: humanitarian considerations apart, does widespread undernutrition and
micronutrient malnutrition matter? And is there a case for investing in better nutrition? According to UNICEF, approximately half
the economic growth achieved by developed countries of Western
Europe since 1790 until 1980 can be attributed to better nutrition
2.7
189
190
SECTION 2
saturated fat intake varied between 3 per cent total energy in Japan
and 22 per cent in Finland while the 15-year CHD incidence rates
varied between 144 per 10,000 in Japan and 1202 per 10,000 in
Finland. The annual incidence of CHD among 4059-year-old
men initially free of CHD was 15 per 100,000 in Japan and 198
per 100,000 in Finland. Evidence from 16 well-defined cohorts in
seven countries and its correlation to the 10-year incidence rate of
CHD deaths provided further support for this causal association.
The strongest correlation was noted between CHD and percentage
of energy derived from saturated fat, while total fat was not significantly correlated with CHD.
In the Seven Country Study, the serum total cholesterol values
were 165 mg/dL in Japan and 270 mg/dL in Finland, and the variation in serum total cholesterol levels between populations could
largely be explained by differences in saturated fat intake. The risk
of CHD seemed to rise progressively within the same population
with increases in plasma total cholesterol. Observational studies
suggest that one population with an average total cholesterol level
10 per cent lower than another will have one-third less CHD and
a 30 per cent difference in total cholesterol predicts a fourfold difference in CHD (WHO 1990). The Seven Country Study showed a
strong positive relationship between saturated fat intake and total
cholesterol level; populations with an average saturated fat intake
between 3 per cent and 10 per cent of the energy intake were characterized by serum total cholesterol levels below 200 mg/dL and by
low mortality rates from CHD. As saturated fat intakes increased
to greater than 10 per cent of energy intake a marked and progressive increase in CHD mortality was noticed. Saturated fats raise
total and low-density lipoprotein (LDL) cholesterol; and of these
fatty acids myristic and palmitic acids abundant in diets rich in
dairy and meat products have the greatest effects (Table2.7.5).
Several prospective studies have shown an inverse relation
between high-density lipoprotein (HDL) cholesterol and CHD
incidence. However, HDL cholesterol levels are influenced by several non-dietary factors and HDL levels do not explain differences
in CHD mortality between populations. HDL levels are increased
by alcohol, weight loss, and by physical activity. Populations who
have high intakes of mono-unsaturated fatty acids (from olive
oil) or have diets rich in n-3 polyunsaturates of marine origin
(like Eskimos) also have low CHD rates. Both mono-unsaturated
and n-3 and n-6 polyunsaturated fatty acids (PUFAs) lower
plasma total and LDL cholesterol; PUFAs are more effective than
monounsaturates (Kris-Etherton 1999; Mori and Beilin 2001).
There is good evidence that some isomers of fatty acids, such as
trans fatty acids, increase the incidence of CHD by increasing LDL
cholesterol levels and decreasing the HDL levels, by interfering
with essential fatty acid metabolism and by enhancing the concentrations of the lipoprotein Lp(a) which, in genetically susceptible
people, seems to be an additional risk factor through mechanisms
which include an antiplasminogen effect to limit fibrinolysis.
Other dietary components, for example, dietary fibre or complex carbohydrates, seem to influence serum cholesterol levels and
the incidence of CHD. Populations consuming diets rich in plant
foods high in complex carbohydrates have lower rates of CHD;
vegetarians have a 30 per cent lower rate of CHD mortality than
non-vegetarians and their serum cholesterol levels are significantly
lower than that of lacto-ovo-vegetarians and non-vegetarians.
Alcohol consumption also reduces the incidence of CHD. Anumber of observational studies suggest that light-to-moderate drinkers
Decreased risk
No relationship
Increased risk
Convincing
Regular physical
activity
Vitamin E
supplements
Myristic and
palmitic acids
Linoleic acid
High sodium
intake
Vegetables and
fruits
Overweight
Potassium
High alcohol
intake4
Linolenic acid
Stearic acid
Oleic acid
Dietary cholesterol
Unltered boiled
coee
NSP3
Wholegrain cereals
Nuts (unsalted)
Plant sterols/stanols
Folate
Notes:
1 Eicosapentaenoic acid and docosapentaenoic acid.
2 For CHD risk.
3 NSP, non-starch polysaccharide.
4 For risk of stroke.
Adapted with permission from World Health Organization/FAO, Diet, nutrition and
the prevention of chronic diseases, WHO Technical Report Series 916, World Health
Organization, Geneva, Switzerland, Copyright 2003, available from http://whqlibdoc.
who.int/trs/who_trs_916.pdf.
2.7
191
192
SECTION 2
Breast
Lactation
Physical activity
Alcohol
Obesity
Colorectal
Physical activity
NSP1/dietary bre
Milk, calcium
Endometrium, and
kidney
Physical activity
Obesity
Liver
Aatoxin
Alcohol
Lung
Fruits
Physical activity
High-dose supplements of
-carotene
Mouth, larynx,
pharynx
Alcohol
Salted sh2
Nasopharynx
Oesophagus
Alcohol
Obesity
Pancreas
Obesity
Prostate
Stomach
Notes:
Both convincing and probable evidence for decreasing and increasing risk combined.
1 NSP, non starch polysaccharide/dietary bre
2 Specically Cantonese style salted sh
Source:data from World Cancer Research Fund / American Institute for Cancer Research,
Food, Nutrition, Physical Activity, and the Prevention of Cancer:a Global Perspective,
American Institute for Cancer Research, Washington, USA, Copyright 2007 World
Cancer Research Fund International All rights reserved.
2.7
for Cancer Research 2007) makes the following recommendations:(1)be within the normal range of body weight for height
and be physically active; (2) eat mostly foods of plant origin
and limit intake of red meat and avoid processed meat; (3)limit
consumption of energy dense foods and avoid sugary drinks;
(4)limit alcohol intake; (5)limit consumption of salt, and avoid
mouldy food; (6)mothers must be encouraged and supported to
breastfeed their children.
Weight-for-height
>+ 2 Z scores
Overweight
BMI-for-age
>85th percentile
Obese
BMI-for-age
Triceps-for-age
Subscapular-for-age
BMI
18.524.9
Overweight or
pre-obese
BMI
25.029.9
ObeseGradeI
GradeII
Grade III
BMI
BMI
BMI
30.035.9
35.039.9
> 40.0
Adolescents
Adults
193
194
SECTION 2
Decreased risk
Increased risk
Convincing
Physical activity
Sedentary living
Probable
Energy-dense foods2
Sugary drinks3
Fast foods
Television viewing
Notes:
1 Low energy-dense food, wholegrain cereals, cereal products, non-starchy vegetables,
and dietary bre.
2 Energy-dense foods are mostly from animal fat and fast foods.
3 Sugary drinks have sucrose or high fructose corn syrup.
This material has been adapted with permission from the 2007 WCRF/AICR Report
Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective.
management of diabetes, and the reduction of secondary complications which include CHD risk and renal, ocular, and neurological complications of diabetes. Prevention of weight gain and
reduction of obesity is the key, as is increasing levels of physical
activity. The specific dietary recommendations include providing
diets with carbohydrates contributing 5560 per cent of energy,
maximizing content of complex carbohydrates and dietary fibre,
and reduction of simple sugar intakes. In addition the general recommendations for fat (saturated fat to <10 per cent of calories) are
emphasized due to the associated high risk of CHD. Maintaining
a desirable body weight and preventing weight gain is most
important.
2.7
encouragement of balanced diets with plenty of fruit and vegetables, adequate dairy and other protein foods, and limitation of
foods with low nutrient density. Moderate alcohol intake shows
positive effects on bone, particularly in older women, while high
intakes of alcohol increase risk of osteoporosis. Convincing evidence indicates that physical activity is an important determinant of bone health.
It is generally believed that populations in developing countries
are at less risk of developing osteoporosis in spite of low calcium
intakes. This may be related to the fact that they do more physical work, smoke less, drink less alcohol, and have diets which are
generally not high in protein or salt content. However, osteoporosis is seen in developing countries in regions where low intakes
of dietary calcium are associated with high fluoride intakes. No
osteoporosis occurs if high intakes of fluoride are accompanied by
dietary intakes of calcium which are also high.
PNI goal1
Total fat
1530%
Saturated fat
< 10%
610%
n-6 PUFAs
58%
n-3 PUFAs
12%
< 1%
By dierence
Total carbohydrate
5575%
Free sugars
<10 %
Protein
1015%
Cholesterol
Sodium chloride
195
196
SECTION 2
Food safety
Food safety refers to whether food is safe for human consumption
and hence lacking in biological and chemical contaminants that
have the potential to cause illness. The increasing concern over the
safety of foods in the West is a paradox in that the epidemiological
evidence on the safety of foods is quite contrary to the perceptions
of the public and the media that the food available now is less safe
than it used to be. The improvements in public health have virtually eradicated primarily food-borne infections that were associated with morbidity and mortality. The common food-borne
diseases currently encountered in the West are usually associated
with mild self-limiting gastroenteritis. Studies of risk perception
suggest that the public becomes alarmed by health threats which
are disproportionate to the actual risk associated with the disease
and that this public concern is fuelled by the media which make
health issues into media health scares depending on the newsworthiness of the incidents.
There have been several food-borne epidemics that have raised
concerns about food safety in recent years. These include for
instance the Salmonella enteritidis pt4 (Se4) epidemic. This was
attributed to the ability of Se4 to invade the oviduct of poultry
and get deposited in the albumin of the egg. At the consumer
level the outbreak of the infection was linked to the use of raw
egg in recipes or cross-contamination from raw to cooked foods.
Campylobacter infection is the commonest food-borne disease in
the UK and the increase in its incidence may partly be explained
by the better ascertainment and reporting of cases with this infection. The more recent food scare was the emergence of Escherichia
coli O157 in Scotland which caused several deaths and was attributable to changes in husbandry and the movement of livestock
and the rapid growth of the fast food industry. Listeria is another
cause of food-borne disease exemplifying of the role of globalization and international trade in the spread of food-borne diseases.
In the developing world the issues of food safety are related
to microbiological agents that contaminate food and water and
spread disease rapidly in the warm humid environments aided by
the improper or poor food hygiene practices, poor environmental
sanitation, and inadequate regulation of food-related commerce.
The safety of foods in the developing world is also compromised
by the presence of toxins like aflatoxins due to poor food storage
practices or due to cyanogens in the diet due to inadequate preparation of foods such as cassava. Aflatoxins are linked to hepatocellular cancer and the risk appears to be higher among those who
are likely to be hepatitis B positive. In addition, the food chain in
poor countries is contaminated by pesticide and chemical residues
compromising the safety of the food consumed by populations in
these countries.
Food labelling
An important source of information for the consumer about the
food on the supermarket shelf is the label on a food product. Food
labels provide information that may be of interest to the consumer,
especially with regard to the added chemicals (additives, pesticide
residues, colouring and flavouring agents, and preservatives), fats,
sugars, and energy content. Although about two-thirds of shoppers claim to read the information on the labels of new or unfamiliar food products to check their contents, this interest in labels
does not mean that consumers always understand the information
in the labels. Consumers are even more confused by the nutrition
information panel which appears on many food labels.
Food label information is usually designed by experts. Aprototype label was produced by the Codex Alimentarius Commission
of the FAO and WHO, which is the organization charged with
advising on international food standards, and this prototype
is followed by Food Standards Committees around the world.
According to this prototype the nutrientsenergy, carbohydrate,
protein and fatsare listed according to their amounts per serving and per 100 g.Most consumers, however, have hardly any idea
of what a 100 g serving is, or for that matter what a normal or
average serving is. Afurther problem is that these labels designed
2.7
Functional foods
New food products are being marketed as health-enhancing or illness-preventing foods. These are called functional foods or otherwise pharmafoods, nutriceuticals, or novel foods. Functional
foods are generally defined as food products that deliver a health
benefit beyond providing nutrients. The health benefits of functional foods may be conferred by a variety of production and
processing techniques which include: fortification of certain food
products with specific nutrients, using phytochemicals and active
microorganisms, and by genetic modification of foods. The topic
of functional foods is complex and controversial. An assumption
implicit in the functional foods and health benefit claims is that
the food supply needs to be fixed or doctored (or medicalized)
on public health grounds. The assumption therefore is that the
current food supply is in some way deficient, that the habitual
diets are inadequate, and a technological fix will solve the problem. Thus the emerging debate viewed from the perspective of
the proponents of functional foods is that these novel foods may
reduce healthcare expenditure by promoting good health and
that functional foods are a legitimate nutrition education tool,
which will help inform consumers of the health benefits of certain
food products. The opponents on the other hand rightly state that
it is the total diet that is important for health. They believe that
the functional foods are a magic bullet approach which enables
manufacturers to indulge in marketing hyperbole, exploit consumer anxiety, and essentially blur the distinction between food
and drugs. Ironically the production and marketing of functional
foods is on the rise in most developed countries. Regulatory bodies in developed societies have a huge and uphill task ahead to
ensure that health claims made for these novel foods is evidence
based.
197
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2.7
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2.8
The environment
andclimate change
Alistair Woodward and Alex Macmillan
Introduction to the environment
and climate change
In 2006, George Pell, Archbishop of Sydney, compared those who
seek cuts in greenhouse gas emissions with pagans who seek to
pacify the gods by animal and human sacrifice. In both cases, he
argued, spiritual emptiness and fears about the natural world lead
to extreme and unreasonable behaviours (Pell 2006).
Cardinal Pell is not alone. Climate change attracts a lot of attention, and many people are prepared to express an opinion, often
strongly worded and frequently poorly informed. This chapter
aims to introduce readers to the basic science underlying climate
change, so they are better placed to judge extreme claims of all
kinds. We will explore the links between climate change and
health, and examine the implications of this knowledge for public
health policy and practice.
As a start, readers are invited to check their understanding of
the field against the multiple-choice questions in Box 2.8.1. (The
answers are shown at the end of the chapter in Box 2.8.4.) This is
not a comprehensive test but a starting point and a guide to what
is contained in the chapter.
The Earth has an average surface temperature suitable for life that
is the product of a number of natural influences on the balance of
radiation (radiative forcing at the top of the atmosphere). These
include solar activity (the amount of energy produced by the sun),
the tilt and orbit of the planet, volcanic activity that injects gases and
ash into the upper atmosphere, other dusts and aerosols that block
incoming solar radiation, and the amount of reflection (albedo)
by clouds, ice, and snow. Also important is the concentration of socalled greenhouse gases. These gases are transparent to relatively
high-frequency incoming solar radiation in the visible spectrum.
However, when this radiation is absorbed on the surface of the earth
it is re-emitted in the infra-red range, which is trapped by the greenhouse gases. This action is similar to the effect of a pane of glass in
a greenhouse (or the window of a car sitting in the sun). Without
the blanket for the planet that is provided by the greenhouse gases,
the Earth would be approximately 30 degrees centigrade (C) colder
than it is at present. Carbon dioxide (CO2) is the most abundant of
these heat-trapping gases.
CO2 levels in the atmosphere vary over long timescales due to
transfers from the atmosphere to the biosphere and the oceans,
and from the oceans carbon is eventually sequestered in sedimentary rocks. In the very long term, carbon from the earths crust is