more_vertIn her World Report (Aug 8, p 519),1 Ann Danaiya Usher noted that key donors intend to reinstate health funding to Zambia 6 years after a corruption scandal that led them to withdraw funding. It is true that an immediate decline in health indicators—such as antenatal coverage, tuberculosis, malaria, and diarrhoeal and respiratory infections—was seen after the loss of funding. However, between 2007 and 2013, Zambia recorded huge reductions in maternal and child mortality—with under-5 mortality declining by 37% and maternal mortality by 33%—and improvements in several other service delivery indicators and health outcomes (eg, family planning, deliveries by skilled providers, treatment of fevers and acute respiratory infections in under-5 children, use of insecticide-treated bednets, total fertility rate, and prevalence of chronic malnutrition among children younger than 5 years).
Preference: Nutrition
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[Comment] Should serial fetal biometry be used in all pregnancies?
Serial measurements of an infant’s height, weight, and head circumference to monitor growth have been a cornerstone of routine paediatric care. This practice is based on the premise that detection of growth disorders, such as failure to thrive, can be manifestations of malnutrition, metabolic and genetic disorders, or infection and can be treated.1 The frequency with which infant growth is monitored is associated with growth velocity. A general principle in developmental biology is that organisms are most susceptible to insults during periods of rapid growth.
Food stars changing habits
The nation’s food ministers are hailing the success of the breakthrough front-of-packet health star labelling system amid evidence that it is changing eating habits and encouraging the production of healthier foods.
The Australia and New Zealand Ministerial Forum on Food Regulation was told that 55 companies have adopted the voluntary Health Star Rating system since it was introduced last year, and it is now displayed on more than 1500 food products.
In a sign that the labelling system is exerting an influence, the health ministers noted that “a number of major companies have reformulated some of their most popular products to make them healthier, achieving a higher star rating”.
They were also encouraged by evidence it may be leading to better food choices.
The results of a consumer study presented to the ministers found one in six consumers were changing their shopping behaviour based on the system, and awareness of it had grown from 33 per cent in April to 42 per cent in September.
The system was introduced in controversial circumstances last year when Chief of Staff to the-then Assistant Health Minister Fiona Nash ordered the system’s website pulled down just hours after it was launched.
It was later revealed that at the time he retained an interest in a consultancy that had major food manufacturers among its clients, and he was forced to resign.
The website was eventually reinstated late last year.
But although the system is considered to be an advance in food labelling standards, the AMA has said that it should be mandatory, and public health experts are critical of its central message that “the more stars, the healthier the food”.
Professor of Public Health Nutrition at Deakin University, Mark Lawrence, and Christina Pollard of the Curtin University School of Public Health argue that, because it only applies to packaged foods, the system misses the fresh foods, particularly fruits and vegetables, that people should eat most.
And, in an article in The Conversation, they warned that it encouraged food manufacturers to make minor tweaks to their products which would earn them more stars without making significant difference to nutritional value, while avoiding using the system altogether for products that would rate poorly.
Adrian Rollins
Malnutrition: a global health perspective from a Timorese mountain
Malnutrition is an unacceptably prevalent and preventable global scourge
Winner — Medical practitioner category
Her name was Rosa and she hailed from a small rural hamlet about 6 hours’ “drive” from Dili in Timor-Leste, as the snaking, boulder-choked mountain pass permitted no more than a crawl past the rusted chassis and blown tires dotting the unforgiving terrain.
Rosa’s story typified so many of Timor-Leste’s young. A 6-year-old girl from a remote subsistence village, she presented to our outreach clinic simply hungry. The rudimentarily performed anthropometry and growth charting was arresting, but then so are national statistics. According to UNICEF, malnutrition is despairingly rife in Timor-Leste. About 58% of children are stunted, 19% severely malnourished with endemic micronutrient deficiency, with poorer outcomes still for rural dwellers. To benchmark, malnutrition in Timor-Leste eclipses that of Ethiopia and Malawi, traditional purveyors of poster-children for global hunger.
Surprising, then, that this mountainous district and Timor-Leste at large are not bedevilled by drought or infertility; rather the contrary. The causes of malnutrition are thus manifold and complex. They offer an instructive and galvanising tale on the merits and methods of combining clinical and global health responses to combat global malnutrition. In Timor, the Ministry of Health cites a panoply of local contributors, many transferable to the Global South at large: the abiding and disruptive legacy of war/decolonisation; extreme poverty with attendant low agricultural productivity and capital investment; overemphasis on staple mono-cropping (eg, rice) with reduced agricultural diversity/resilience; underresourced and inaccessible health services; inadequate sanitation, food hygiene and clean water; population pressures; insufficient public education regarding nutrition; and degradation of ecosystem services underpinning food production.
Malnutrition in Timor (and globally) represents the intersection of multiple demographic, agricultural, economic, ecological and political forces. It is foremost the preserve of the clinician to attend to malnutrition within the medical paradigm; that is, triaging at-risk populations, diagnosing individual cases, intervening early with nutritional supplementation, and serial monitoring to assess effectiveness. However, the contemporary clinician must also be cognisant of “big picture drivers” behind “small picture disease”. Working in concert with population-based public health approaches in sometimes unfamiliar disciplines with implications for malnutrition will yield the profoundest dividend. To this end, an approach that enjoins public health programs and clinicians in the four components of the food security equation is potentially gainful in addressing malnutrition; namely, the adequacy, availability, utilisation and security/sustainability of food supplies.
Adequacy of food is rightly the starting point for malnutrition. Targeted public health interventions can helpfully augment the argument for reform by entering the discourse on 1) local/international market integration; 2) education for farmers regarding sustainable agriculture; 3) loss of arable land due to urban encroachment and erosive farming; 4) land tenure instability stymieing investment; 5) loss of youth interest in agriculture; 6) prohibitive investment climates; and 7) research and development in country-specific technology/methods to increase yield.
Second, public health and clinical responses might usefully assist with measures to render food more available. In Timor, like in much of the malnourished world, food, even if plentiful, is unavailable because of redistributive failure, poverty, market incentive for diversion and population pressure. Without adequate food hygiene, sanitation, refrigeration, road/rail networks and vehicle support, populations are confined to consuming what they can produce locally. Again, there is a role here for the public health professional and clinical outreach services to take opportunities to both agitate against and ameliorate infrastructure bottlenecks. Realistically, resource constraints are insurmountable and encouraging diversification to engender more self-sufficiency by remote communities, while preserving trade competitiveness in cash commodities, will help health outcomes. This is often (and understandably) limited by inducements for communities to divert arable land to cultivation of cash crops for Western markets; for example, the internal market in Timor for expatriates or, in Bolivia, international markets for traditional and highly nutritious superfood staples like quinoa.
This segues into another important dimension to the availability challenge, which should be part of the public health clinician’s bailiwick: poverty alleviation through trade reform and development finance. Trade liberalisation instruments, such as the beleaguered Trans-Pacific Partnership, stalled Doha development round of global trade reform and parallel non-governmental organisations’ trade campaigns, such as “Fair Trade”, offer far-reaching potential to realise wealth transfers to developing country farmers. Public health campaigners and individual clinicians could laud trade liberalisation for its hunger-ameliorating potential. Internalising the costs for minimum labour and environmental standards into price signals for Western consumers (through Fair Trade) is also a salutary exercise in health advocacy for the same reason. Similarly, it is timely for public health campaigners to vocally interpose health imperatives into negotiations regarding global financing instruments for development and the soon to be minted Sustainable Development Goals. Population controls and contraception counselling represent another crucial but much more established method for clinical and public health approaches to easing demands on dwindling food stocks.
Appropriately utilising foods is a further component of the malnutrition challenge requiring intervention by the health care community at both public health and clinical levels. There is a sinister double burden of malnutrition in Timor and globally — obesity and non-communicable diseases coexist with hunger and micronutrient deficiencies. Much of this trend is the result of imported processed food and departure from nutrient-dense traditional diets, as well as more sedentary lifestyles. Here, clinicians must offer tailored dietary and lifestyle counselling opportunistically at the coalface. Public health approaches can assist through education programs and “Let’s Go Local” food campaigns to address deficiencies in iron, iodine and vitamin A, aided by food fortification where feasible. Appropriate food handling and safety also looms large as markets fragment and contaminants from co-located industry concentrate up the trophic chain. Again, the case of Timor (and the Pacific) is illustrative: cyanide in cassava; cadmium in taro; mercury, histamine and ciguatera in fish; and Escherichia coli in fish. Foods can degrade and spoil in the tropics and infective hazards compound malnutrition but they offer prize opportunities for material intervention by clinicians and public health specialists alike.
Finally, food security demands attention by the broader health care community to put a dent in malnutrition. Farming less vulnerable to volatility in commodity or climate cycles is more sustainable. The latter bears closer attention. Climate change stands to disproportionately affect the Global South where nutritional adequacy is already marginal, with potential impacts all along the food supply chain. By instilling resilience and adaptive potential, malnourished populations can ensure surety and sustainability of food supply in the face of potentially catastrophic climate change. It behoves health care practitioners to underline this point as malnutrition is an unacceptably prevalent and preventable global scourge. It predisposes to diseases of reduced immunological and physiological reserve, and clinicians have a unique vantage point and political clout in their communities to assist with adaptation (and mitigation endeavours). Climate change portends a host of indirect sequelae ranging from increased (and potentially violent) competition for arable land, increased glacial melt flows with attendant water scarcity, loss of agro-diversity, increasingly frequent and intense weather events, sea water incursions into freshwater supplies, and more far-ranging food, water and vector-borne disease which will further imperil food supply and disproportionately afflict already benighted populations.
Rosa’s story well demonstrates the arcane and complex aetiology of global malnutrition. While focusing on the clinical dimensions of malnutrition is traditionally the province of medicine, the medical practitioner — whether physician or policymaker — must confront its socioecological and politico-economic determinants to consign it to history.
[Perspectives] A sweet and sticky end
Too much sugar is bad for you. After the furore there has been over sugar in the past couple of years, together with the launch of new nutritional guidelines from WHO, most of us know that. So the outcome of Australian film maker and actor Damon Gameau’s human experiment—on himself—is predictable. Gameau, who has not eaten added sugar in his food for some years, sets out to discover how his health will be affected if he eats the equivalent of 40 teaspoons a day for 2 months. Even though we are told that is the intake of an average Australian, nobody who begins to watch That Sugar Film (video) will have much doubt that by the end of the 60 days, Gameau is not going to feel so good.
[Perspectives] Ending mass atrocity and ending famine
On Sept 29, 2015, world leaders at the United Nations General Assembly adopted Sustainable Development Goal (SDG) 2—“end hunger, achieve food security and improved nutrition, and promote sustainable agriculture ending world hunger by 2030”. Meeting this goal is likely to be a complex and difficult undertaking: conquering endemic hunger and malnutrition will demand a raft of international policy measures for agriculture, poverty reduction, and nutrition. But one dimension of hunger in human civilisations—eliminating epidemics of starvation, namely famines—looks very hopeful.
Food avoidance: some answers, more questions
The growing number of consumer foods and ingredients branded as “gluten-free” and/or “lactose-free” suggests that avoidance of specific dietary factors is common. CSIRO (Commonwealth Scientific and Industrial Research Organisation) survey data indicate that this behaviour is a real phenomenon, with one in seven adult Australian respondents not diagnosed with coeliac disease reporting avoidance of wheat or dairy foods. The behaviour is largely self-initiated, occurring predominantly without a formal medical diagnosis and is driven principally by adverse reactions attributed to those foods. Mostly, these comprise gastrointestinal symptoms that include bloating and cramps, commonly associated with irritable bowel syndrome. Wheat contains gluten, which provokes an immune reaction in susceptible individuals. However, the pattern of survey responses regarding symptoms does not suggest an allergenic or autoimmune cause; wheat avoiders do not seem to be undiagnosed coeliacs (Public Health Nutr 2014; 18: 490-499).
Our results raise several causes for concern. Translation of the data to the general population suggests that a significant proportion of adult Australians are at risk of nutritional imbalance. Wheat- and dairy-based foods are important sources of essential nutrients, so their exclusion could lead to dietary deficiencies (eg, of fibre, calcium) or, of equal concern, dietary imbalances caused by consumer overcompensation for perceived deficiencies. Clinically, self-diagnosis of symptoms of intolerance also carries the risk of delays in the identification and treatment of potentially serious medical conditions (BMJ 1988; 297: 719-720). For the majority of avoiders, the actual causes of symptoms and their mechanisms need to be established to improve condition diagnosis and management. Complicating matters is the issue of poly-avoidance, with more than 50% of wheat avoiders also avoiding dairy foods, and we need to establish whether the behaviours share a common aetiology. We also need to clarify whether consumers are making other self-prescribed dietary changes, either in response to their symptoms or in the belief that they are improving their personal health.
[Comment] Offline: Let’s celebrate rhetoric-based development
“We are now no more than rent boys in the neoliberal takeover of health, nutrition, and development.” The words of one professor of global health last week. He was angry about what has become the most politically charged annual event in global health—the UN General Assembly in New York, a kind of Davos for real people. This year was historic, and not only because Pope Francis shamed heads of state into thinking about someone other than themselves. It was also historic because it signified a turning point in international diplomacy.
News briefs
The BMJ questions e-cigarettes endorsement
The BMJ has questioned the decision by Public Health England — (mission statement: “We protect and improve the nation’s health and wellbeing, and reduce health inequalities”) — to endorse the use of e-cigarettes as an aid to quitting smoking. In a report released at the end of August PHE concluded that e-cigs were “95% less harmful” than conventional cigarettes and described them as a potential “game changer” in tobacco control. In The BMJ Professor Martin McKee and Professor Simon Capewell said the available evidence, including a recent Cochrane review, did not show clearly that e-cigs were as effective as established quitting aids. “We might also expect that the prominently featured ‘95% less harmful’ figure was based on a detailed review of evidence, supplemented by modelling”, wrote McKee and Capewell. “In fact, it comes from a single [sponsored] meeting of 12 people.” The sponsors included a CEO with previous funding from British American Tobacco. One of the 12 was a chief scientific advisor with declared funding from an e-cigarette manufacturer, and Philip Morris International. “None of these links or limitations are discussed in the PHE report”, McKee and Capewell wrote.
Dramatic rise in antibiotic use globally
Nature reports that “antibiotic use is growing steadily worldwide, driven mainly by rising demand in low- and middle-income countries”, citing the latest report from the Center for Disease Dynamics, Economics and Policy. The organisation used a review of data from scientific literature, and national and regional surveillance systems to calculate and map the rate of antibiotic resistance for 12 types of bacteria in 39 countries, and trends in antibiotic use in 69 countries over the past 10 years or longer. “Global antibiotic consumption grew by 30% between 2000 and 2010. This growth is driven mostly by countries such as South Africa and India, where antibiotics are widely available over the counter and sanitation in some areas is poor.” The report also found that the use of antibiotics in livestock is growing worldwide, particularly in China, which used about 15 000 tonnes of antibiotics for this purpose in 2010, and is projected to double its consumption by 2030.
Child mortality under six million for first time
A new World Health Organization report says deaths among children aged 5 years and under worldwide have more than halved over the last 25 years, falling from 12.7 million a year in 1990 to 5.9 million in 2015. “While progress has been substantial, a 53% drop in child mortality is far short of the Millennium Development Goal, where countries agreed to reduce child mortality between 1990 and 2015 by two-thirds.” Around 16 000 children under 5 still die every day, most from diseases that are readily preventable or treatable, says the report. Around 50% of global deaths among the under 5s occur in sub-Saharan Africa, while 30% occur in southern Asia. Approximately 45% of deaths among the under 5s occur in the first 28 days of life. One million infants die on the day they are born, and nearly 2 million during the first week following birth. Leading causes of death in this group include complications during labour, premature birth, pneumonia, sepsis, diarrhea and malaria. Most of the remaining deaths among the under 5s are tied to undernutrition.
Static electricity next frontline in malaria control
Dutch researchers have come up with a way of improving the efficacy of mosquito nets using static electricity, according to a report in The Economist. With the WHO reporting a 60% drop in deaths caused by malaria since 2000, In2Care, a Dutch mosquito-control firm, is finding a way to deliver insecticides embedded in mosquito nets more effectively to the target insect. “Current mosquito nets are woven from fibres impregnated throughout with an insecticide”, The Economist reports. “This permits them to be washed and used for years without loss of potency. But it also means this potency is not as great as it could be, because the insecticide is released only slowly by the fibres. Using static electricity, by contrast, means all of the insecticide is held on the surface of a net’s fibres. Much larger doses can thus be transferred to an insect which blunders into the net. In addition, a wide range of insecticides — and even, possibly, the spores of a fungus harmless to people but lethal to mosquitoes — can be applied to the fibres.”
[Editorial] Coca-Cola’s funding of health research and partnerships
In a bid to increase transparency, Coca-Cola has disclosed spending US$118·6 million in the past 5 years on scientific research and health and wellbeing partnerships. In a list of organisations funded by Coca-Cola, published on Sept 22, they reveal several influential medical organisations that have received funding, including the American Cancer Society, which received roughly $2 million, the American College of Cardiology, which received roughly $3·1 million, and the Academy of Nutrition and Dietetics, as detailed in an article published on Sept 22 in The New York Times.