Healthy nutrition: a global challenge / by Hiroshi Nakajima

HEAL THY NUTRITION a global challenge by Hiroshi Nakajima Director-General of the World Health Organization ]Freedom from hunger and malnutrition, essential to the enjoyment of the highest attainable standard of health, is among the fundamental rights of every human being. What is more, there can be no sound social and economic develop- ment without adequate food and nutrition. This is the message I hear over and over again from world lead- ers as they strive to meet the needs of their people. This is not the same as saying that people in rich countries necessarily have a better chance of being properly nourished than do people in poorer 2 countries. As readers will discover throughout this issue of World Health, there is much more to achieving healthy nutritional status than can be conveyed by such simplistic labels as "developed" and "developing" where countries and people are concerned. By nutritional status we mean a characteristic common to us all that can be measured and monitored through a combination of charts, scales, rulers and-sometimes- laboratory tests. There is some truth, of course, in the axiom that "we are what we eat", but nutritional status depends on considerably more than diet. It is best understood as the . result of the Nobody can be truly free unless they are free from hunger and malnutrition. complex interaction between our health at any given moment, the food we eat, and our surrounding physical, social and economic environment. It reflects not only the quality and quan- tity of food but also shows to what extent our bodies can transform it into the nutrients that will protect our health and permit us to function to the best advantage. Because the environment and its impact vary so greatly from individual to individual, there can be no "stand- ard" answer to the problem of malnu- trition. And since no single strategy to combat it will produce the same results in every case, the approach to prevent- ing and overcoming malnutrition has to be tailored to fit the circumstances. Bearing in mind this important prin- ciple, I would like to share with readers some reflections on the twofold chal- lenge that we face today, starting with a brief overview of how nutrition has "evolved" over the years. Nutrition and the sweep of history If we look back in history, we can see more clearly that a major shift is taking place in mankind's approach to the main factors-poor diet and ill- health-that have traditionally accounted for most malnutrition. With the possible exception of foodbome diseases, most people have been blithely unaware over the centuries that what they eat might be hazardous to their health. The human species survived hand-to-mouth on whatever it could manage to hunt, gather, harvest or hoard. Anthropological studies show that the diet which fuelled most of human evolution was low in fat and very low in sugar, but high in fibre and other complex carbohydrates. Some 200 years ago, when the industrial revolution brought radical improvements in methods of food production, processing, storage and distribution, people living in high- income countries found they could stop worrying about the threat of occasional hunger and could start · indulging in preferred foods. Only ·during the past few decades, as people have benefited from greater control of infectious diseases and better access to food, have research findings confirmed the well-founded suspicion that dietary preferences may influence the onset of several major chronic diseases. These include coronary heart disease, stroke, various cancers, dia- betes mellitus, gastrointestinal dis- W ORLD HEALTH. Ju ly-August 1991 orders, and various bone and joint diseases. Although many dietary factors have been investigated, those most frequently linked to such diseases figure prominently in the so-called "affluent" diet, a pattern of eating typified by the high consumption of energy-dense foods of animal origin and of foods processed or prepared with added fat, sugar and salt. A two-pronged approach For these reasons, if we are to promote healthy nutrition for all we must take simultaneous action on two quite different, if overlapping, fronts. Many less-favoured nations remain handicapped by a formidable array of development constraints. These include a rapidly increasing popu- lation, unproductive agriculture, environmental degradation, inade- quate roads and other means of communication, limited health service coverage, and-all too often-civil strife. Among the harmful conse- Hiroshi Nakajima, M.D., Ph.D. quences is the tragedy of many mil- lions of thin and stunted children who do not have enough protein and energy in their diets, who suffer from cretinism and other permanent brain damage because their diets and those of their parents are deficient in iodine, or who go blind or even die for lack of vitamin A. It is in just such environ- ments that diarrhoea! diseases, fre- quently compounded by seasonal or chronic food shortages, take their heavtest toll in terms of malnutrition, ill-health and premature death. To reverse this situation is among today's most urgent priorities in the field of development. W ORLD HEALTH, Ju ly -Au gust 1991 At the same time, there has been a significant drop in the prevalence of infectious diseases, while food avail- ability and the quality of diets have improved for population groups all over the world. The result in many countries has been a sharp reduction in infant and child mortality and longer adult life expectancy. These and related factors have paved the way for a dramatic expansion of a different type of nutrition crisis: diet-related chronic disorders are now flourishing in environments where, not so long ago, infectious diseases were seen as the greatest menace to health. Chronic disorders are fast becoming major killers in low- and medium-income countries. Ironically, their prevalence is especially high among the urban poor who pursue the unhealthy dietary habits and life-styles that, until recently, were considered to be the exclusive province of affluent groups. Such life-styles include unbalanced nutrient intake, lack of exercise, smoking, and alcohol and substance abuse. One type of malnutrition is being exchanged for or-worse still--being superimposed upon another, with no net gain for human health in the process. Labels like rich/poor and developed/ developing, by themselves, provide little insight into what causes malnutrition and how it can be over- come. The fact is, wherever we reside, it is the way we live, what we eat, and how we interact with our environment that determine our nutritional status. Whatever the cultural influences at work in a given milieu, all governments are challenged to develop policies that will make healthy choices the easy choices for their populations where good nutrition is concerned. As this issue of World Health will amply illustrate, healthy nutritional status is by no means the monopoly of rich coun- tries, any more than malnutrition is somehow the prerogative of poor ones. Let us try to see healthy nutrition in its fullest dimension. Only then can we best identify and influence the multiple factors--ecological, social, economic and political-that determine nutri- tional status. It is in this spirit that WHO and the United Nations Food and Agriculture Organization (FAO) will organize an international conference on nutrition next year. For the first time in history, governments acting in an international forum will be asked to · think beyond the still-present problems of hunger and survival and to focus squarely on healthy nutrition, both as an essential component of the devel- opment process and as one of its most important outcomes. Cover: '"An apple a day keeps the doctor awpy.'" Popu lar wisdom says it all : .more fruit and vegetables and less ani.{'l'lal fat will keep you healthy Drawing by Peter Dav.ies IX ISSN 0043-8502 World Health is the official illustrated magazine oft he World Health Organizption. Editor: Ei lif Liisberg. M .D. Deputy Editor: Christiane Viedma Art Editor: Peter Davies .News Page Editor: Philippe Stroot World Health appears six. times a year in English. French. Portuguese. Russian and Sp;m\sh. and four times a year in Arabic and FarsL The German editio.n is obtainable front German Green Cross. Schuhmarkt 4. 3550 Marburg. Germany. Articles and photographs not copyrighted may be reproduced provided cred it is given to the World Health Organization. Signed .articles do not neces$ari ly reflect WH O's views. The designations employed and thE) pr€lsentation of mate.rial published in World Health do not il)'lply the expression of any opinion w hatsoever on the part of the Organization concE)rning the legal stotus of any country. territory or other orea or of its authorities. or concerning the delimitation of its frontiers or boundaries, Contents Healthy nutrition: a global challenge by Hiroshi Nakajima . . . . . . . . . 2-4 New concepts of a balanced diet by W Philip T James . . . . . . . 5-8 A fair share for all by Adolfo Chavez . . . . . . . . . . . 9-10 Food aid in action interview with Peter L. Pellet .11-13 Politics and nutrition in Africa by Tumsifu N. Maletnlema .. . 14-15 Ideas for action . . .. ... . . . . 16-17 Foodborne illness: a growing problem by Mohammed Abdussalam and Dieter Grossklaus . .. .. . . . 18-19 Not all change is good by Abdulrahman 0 Musaiger .20-22 Fat animals - fat humans by Michael A Crawford . . . . . . 23-25 Saving sight in Nepal by Chet Raj Pant .. . •.. . . . .. .. 26-27 Diet in the cities by Dinesh P Sinha ...... ... . 28-29 News page . . . .... .... . . . . . 30-31 3 a global challenge Alongside the obvious problems of famine and sUrvival, a new "food crisis" looms: how can we balance our diet to ensure a long and healthy life? The means for making major improvements in human well-being everywhere in the world are already in our grasp. Our scientific knowledge is adequate, the technology has proved to be effective, and we have accumu- lated enough practical experience in its application. The implications are immense and call for broad, intensive and sustained efforts to increase public awareness of the relationship between food, environment and health. What is now needed is the political will and commitment to ensure that the appro- priate level of human and financial resources is consistently available to apply these remedies. That will and that commitment will ultimately enable us to meet the global nutrition chal- lenge. • H. Hiroshi Nakajima, M.D., Ph.D. 4 0. ~teoporosis, sometime• s called "brittle bones", is caused by . the loss of bone density in elderly people, 2particularly women, and leads to fractures tHat are often spontaneous.· For reasons that are not yet clear, the number of fractures of the hip in elderly people is rapidly growing; even reaching epidemic levels in many developed countries. ln:,the USA itis estimated that, by the age of 90, one third of women and one sixth ''of men will suffer a fracture of the ... hip, .that in "12% to 20% of these cases the fracture or its compli- cations will prove fatal, and that half ofthose who sunlive will need long- term nursing care. Bone density increases throughout . .the skeleton during infancy and ado- lescence, before tlevelling out at the age "of 20. Then · it starts to diminish after the menopause in women, a[ld around the age of 55 in men, though more slowly with increasing age. In the industrialized countries; ,women lose about 1 5% Of their · bone mass during the ten years following menopause. Middle-aged people whose bone density lies at the lower level of the nor.m will suffer more rapidly from osteoporosis as they grow older; by contrast, people \Nith m a high bone.density will have a good chance of never suffering from·• this illness. So it is very important to ensure from an early age that bone formation is encouraged, particularly by giving children a good supply of calcium during the growing period. , Six major factors play a determin- ing role in bone density. These ·are: .a ~hortage of .,. estrogens (ahd this explains the bone loss in women .• at the 'time ()f .the menopause); physical inactivity; smoking, drinkirlg alcohol. and taking ' certB,in drugs; and not Open~ "physical jerks" in Cuba. Regular·.exercise helps t.o overcome osteoporosis. enough calcium in the diet. So it is possible to prevent .. , osteoporosis, fi[st of all by ensuring that infants and adolescents receive an adequate s,upplyu of .calcium, by taking plenty of 'eXercise 'throughout one's life, and by abstaining from smoking or drinking too much alcohol. In some women, the process of bone loss is rapid, reaching 0.5-2% per year after the start of the meno- pause. Such women should therefore consider having hormonal treatmenl As the world's population ages, osteoporosis reaches epidemic pro- portions. in conjunction wi,!h supplementary calcium. Certain links have been ooted between the loss of bone mass and a high consumption of proteins and salt, .as well as high concentrations of .uoride in the drinking water; these factors would help to explain the geographical variations in the inci- dence of "osteoporosis. But since the aging of the population is such a w i d e.s p re a d p h e n o m e n o n- particularly in developing countries- osteoporosis is becoming a serious publici health problem for the whole pl~pet.