Nutrition and the Millennium Development Goals

After a recent visit to South Africa, Swaziland and Mozambique, I feel that it is necessary for me to expand on this subject.

Close to a billion people suffer from hunger, and malnutrition has implications for all of the UN Millennium Development Goals.

But if we are serious about improving nutrition, at a minimum we need to:

• Remunerate producers on nutritional content, rather than yield. Deep ploughing, monoculture and artificial fertilisers have conspired to reduce the nutritional content of our food. A growing plant takes up to 60 minerals from the soil. Fertilisers put three back – N, P & K.
• Eat fresh, local and seasonal. ‘Dig for Victory’ was the successful wartime mantra that called for everyone in Britain to keep an allotment. In Southern Africa, rural people used to grow a little maize (plus sorghum, millet, ground nuts, pumpkin, sweet potato and cabbage), pound it locally (whole grain) and eat it as part of a balanced diet that included wild spinach, hibiscus shoots and guavas. 
• Stop refining grain. In Southern Africa, refined maize has become the staple food. The milling process removes the husk (roughage), the membrane (vitamins) and the germ (omega fats, vitamins and minerals). What is left (empty calories) is sold for human consumption. We forget that it was polished rice that caused the fatal disease, beriberi (thiamine deficiency), and that it was the introduction of the National Loaf (wholegrain) in wartime Britain that helped to ensure that, by the end of the war, the UK was healthier than it had ever been. Nearly 70 years on, it is disconcerting to read in the British Food Journal, Volume 44, 4 of 1942: 

The unanimous verdict of those who are best qualified to express an opinion supports the conclusion that adequate nutrition is the prime requirement for the physical well-being of mankind. It is deplorable, therefore, that so little has been done hitherto in the sphere of national welfare to support the findings of science in favour of the more adequate loaf which has been so powerfully advocated for years. It is no exaggeration to state that the ‘white loaf’ has been a real impediment to an improvement in the hygienic development of the growing child, more especially those of the poorer section of the community for whom bread is the main food. As the much impoverished wheat of the ‘white loaf’ is a matter for considerable national concern, it is an anomaly that it should be permitted, seeing that similar impoverishments of natural foodstuffs (such as the watering of milk) have long been punishable by law.

•  Ban trans fats. We used to be taught that margarine was healthier than butter. I am referring here to the margarine of the day, which still abounds in many parts of the world. We now know that this trans fat is vastly inferior to butter and extremely dangerous to health. 
• Seriously reduce our consumption of sugar, high fructose corn syrup, fat and salt. In rural Africa, diabetes, high blood pressure and ischaemic heart disease used to be extremely rare. They have now reached epidemic proportions, and sugar (fructose), saturated fat and salt are the culprits. We should traffic light label all processed foods. The FSA in the UK supports this. 
• Stop filling the bellies of hungry children in the third world with refined cereal (CSB) or products that are high in fat and sugar (Plumpy’Nut). Plumpy’Nut contains powdered milk (30%), sugar (28%), peanut butter (25%), cottonseed oil (15%) and vitamins and minerals (as chemical isolates). The dangers of high levels of sugar and fat are now so well understood that the UK Government bans all advertising to young children of such products. André Briend, its creator, states that Plumpy’Nut does contain a lot of sugar and fat, but argues that it is designed for short term use in severe acute malnutrition (SAM). I accept that Plumpy’Nut has a place in such emergency situations, but this is not how it is being promoted. 
• Stop believing that mid upper arm circumference (MUAC) and body mass index (BMI) are useful measures of nutritional status. MUAC correlates with risk of death in SAM, but increases in BMI or MUAC in the moderately malnourished tell us nothing about nutritional status, unless we believe that fatter kids are healthier kids. 
• Stop believing that we can correct micronutrient deficiencies by adding these to food in the form of chemical isolates, courtesy of the pharmaceutical industry. GAIN has been doing this in South Africa for years and has not addressed the problem. 

The typical shopping basket in Southern Africa today contains refined maize meal, refined white/brown bread, white sugar, cooking oil and traditional margarine. People everywhere need a diet that is based on whole grains. It should be low in fat and sugar. It should contain all the vitamins and minerals that would ideally be sourced from fruit and vegetables in a form that is bioavailable.

Geoff Douglas, CEO – Health Empowerment Through Nutrition

Cholesterol Confusion

I recently spotted an article in a magazine which stated that doctors have finally decided that eggs are good for us, and that the old adage ‘Go to work on an egg’ might actually be good advice. And why was this ever in doubt? The problem is that eggs are rich in cholesterol, along with shellfish and other exciting foods, and cholesterol is bad for us, isn’t it?

Oh dear, oh dear. When I was a biochemistry student in the 1960s, I had to write a lengthy essay on the difference between a cholesterol lowering diet and a low cholesterol diet, and to discuss the health importance of each.

 We knew then – 50 years ago – that a cholesterol lowering diet was one that was low in saturated fat (animal fat) and contained a higher proportion of polyunsaturated fat (vegetable oil), and that a low cholesterol diet was of no significance to health because our blood cholesterol level is not influenced by the cholesterol in our diet. So, it has taken 50 years for this to permeate down to some of the nutritional gurus, and many of us have denied ourselves healthy food because it might contain a smidgeon of cholesterol.

Of course, some more pernicious myths have been debunked over time. Any doctor my age would have been taught that margarine was healthier than butter. I am referring here to the margarine of the day, which still abounds in many parts of the world. Of course we now know that this trans fat is vastly inferior to butter and extremely dangerous to health. Do I hear any apologies? Has it been withdrawn from the market? Sadly, no.

Is it any wonder that the general public is confused and sceptical?

Nutrition and the Millennium Development Goals – Let’s get real

It is well worth reading the recent statement from the UN Standing Committee on Nutrition.

It is true that close to a billion people still suffer from hunger. It is also true that malnutrition has implications for all eight of the Millennium Development Goals.

The problem I have with the recommendations is that they include nebulous statements like:

‘Scale-up and adapt direct nutrition interventions that have proven effective. It is urgent to build on existing efforts and experience, to review and disseminate good practices and to ensure integration of relevant sectoral interventions’.

What on earth does this mean?

If we are serious about improving nutrition, at a minimum we need to:

• Remunerate producers on the nutritional content of the food they produce. Currently they are remunerated on the yield.
• Eat fresh, eat local and eat seasonal. Home grown is best.
• Stop refining grain.
• Ban trans fats.
• Seriously reduce our consumption of sugar, high fructose corn syrup, fat and salt.
• Traffic light label all processed foods. The Food Standards Agency in the UK supports this. The European Commission, most manufacturers and many supermarket chains reject it. I can guess why.
• Stop filling the bellies of hungry children in the third world with corn soya blend (refined cereal), Plumpy’Nut (high fat, high sugar) or XanGo Meal Pack (non dairy creamer).
• Stop using mid upper arm circumference (MUAC) and body mass index (BMI) as a measure of nutritional status – unless we believe that fatter kids are healthier kids.
• Stop believing that we can correct micronutrient deficiencies by adding these to food in the form of chemical isolates, courtesy of the pharmaceutical industry.

Unfortunately, these basic measures involve trampling on the toes of vested interest, so are unlikely ever to be implemented.

Now is the time to tax sugar

In the current global economic recession, governments are looking for ways to increase income and reduce expenditure. They need look no further than sugar. Our love affair with sugar is an addiction and it is killing us. No one needs it.

Sugar (sucrose) is a disaccharide made up of two monosaccharides – glucose and fructose – in equal proportions. Many people believe that sucrose is healthy because it is a natural substance, and infer that fructose is even healthier because it is found in fruit.

Let’s begin by dispelling these myths. Firstly, there are many natural substances that are toxic, and some are extremely toxic. It is true that fruit contains fructose, but when we eat fruit – rather than fruit juices – the amount of fructose we consume is modest.

Whereas every cell in the human body can use glucose as an energy source, only one organ can handle fructose – the liver. This fact alone should alert us to its ‘foreign’ nature. And what does the liver do with all the surplus fructose? Well – surprise, surprise – it turns it all into fat. This is then shipped off to other parts of the body for storage.

So, fructose makes us fat? It does indeed, but the bad news doesn’t end there. When consumed in excess, fructose also causes an increase in:

• Blood fat levels – triglycerides, total blood cholesterol and LDL (bad) cholesterol
• The prevalence of type 2 diabetes
• The prevalence of high blood pressure
• The prevalence of abnormal blood clotting and heart disease

Today, the average US citizen consumes 20 teaspoons of added sugars per day. For teenage males the figure is 34 teaspoons. This equates to some 25% of total calorie intake – ‘empty calories’ that not only fail to provide food value, but actually rob the body of essential nutrients. 70% of the consumed sugars come from manufactured foods, where the label may describe them as corn sweeteners, dextrose, glucose, honey or high fructose corn syrup. Whatever the source of the sweetener, it is no longer associated with the naturally occurring vitamins and minerals found in the original plant source.

If you live outside the US, don’t feel smug. Other countries are catching up fast.

So serious is this health problem that urgent consideration should be given to taxing sugar in the same way we tax alcohol and tobacco. Activists wax lyrical on the issue of tobacco and liquor advertising, and argue that tobacco products should be kept out of sight in supermarkets. For the sake of our children’s health and longevity, we should be applying these ideas to any food and drink that contains added sugar.

I was chatting with a ‘nutritionist’ in South Africa, who made the observation that many of the indigenous people were listless and lacking in energy. He felt that any nutritional supplement should be rich in fat and sugar, because these are the foods that provide energy. He was dismayed when I argued that most of the people he was referring to were drowning in fat and sugar. Any listlessness was almost certainly due to a lack of essential micronutrients – vitamins and minerals.

If you want more science – see Appleton

If you want a lecture – see Lustig

Micronutrients must have Bioefficacy

In their SciDev.Net article, Thorne-Lyman and Fawzi highlight the links between malnutrition and infectious disease. I agree with their assessment that micronutrient interventions offer a low-cost, yet underfunded, strategy for preventing and treating infectious disease, and that it is ‘time to turn knowledge into action’.

The underlying problem is that people have moved away from their traditional diets, while a combination of environmental degradation, modern agricultural practices and food processing removes essential nutrients from our food. The malnourished are being fed refined foods, fortified with vitamins and minerals in the form of chemical isolates.

In southern Africa, a traditional nutrient-rich diet would include home-grown millet and sorghum, hand-gathered herbs, roots and fruits, as well as groundnuts, sweet potato, pumpkin, cabbage and a moderate intake of free range meat, eggs and milk. The staples today are refined maize meal, bread (mostly refined) and white sugar – all of which provide ‘empty calories’ – together with cooking oil and traditional margarine packed with extremely unhealthy trans-fats.

The consequences for nutrition are severe. In Mozambique, 95 per cent of children under five suffer from iron deficiency. A National Food Consumption Survey in 1999 found that South African children were deficient in iron, zinc, vitamin A and most of the B vitamins. Is it any wonder that immunity is impaired and there is an escalating prevalence of infectious disease?

To address micronutrient deficiencies, especially in the most vulnerable, South Africa began a food fortification programme in 2004, adding iron, zinc, vitamin A, B vitamins and folic acid to all maize and wheat flour. But, five years on, the project was judged a resounding failure. Apart from a modest improvement in folic acid status, the prevalence of vitamin A, zinc and iron deficiencies in children had all increased.

Hurrell evaluated wheat flour iron fortification programs in 78 countries, and concluded that most are likely to be ineffective. He argues that legislation needs updating in many countries so that flour is fortified with adequate levels of the recommended iron compounds. This ignores that fact that most legislation in this area has been framed on the advice of international agencies, and in their latest advice, the WHO states, ‘The selection of the type and quantity of vitamins and minerals to add to flour, either as a voluntary standard or a mandatory requirement, lies with national decision makers in each country and therefore the choice of compounds – as well as quantities – should be viewed in the context of each country’s situation’. This is not helpful.

Part of the problem in South Africa is that fortification is based on adult food portions. Children, who are more vulnerable, eat less and so need more highly fortified food. Another problem is that cooking can destroy the vitamins. But, most importantly, it is because chemical isolates have a significantly lower bioefficacy than whole foods. Fortifying or supplementing a defective diet with micronutrients in the form of chemical isolates is now commonplace, despite a plethora of scientific evidence that they are poorly absorbed, rarely act in the body in the way intended and, in some cases, may even be toxic.

Take, for example, the essential mineral and antioxidant, selenium. Where there is deficiency, bread or salt is often fortified with sodium selenate or selenite. But this is unlikely to have the desired benefit because these salts are toxic and poorly absorbed – and the little that is absorbed does not act as an antioxidant. It is a mad world that bans mineral water contaminated with sodium selenite – an industrial pollutant – and then puts it in bread!

The key to success in micronutrient fortification or supplementation lies in the form of micronutrient used. For the past 18 months, Health Empowerment Through Nutrition (HETN) has been working with the South African National Tuberculosis Association to provide tuberculosis patients and their families with an inexpensive and effective daily nutritional supplement. The supplement – e’Pap – costs just 18 South African Rand (US$2.38) per person per month. It is wholegrain (maize and soya), pre-cooked, and contains the recommended daily allowance of 28 important micronutrients, in a form that enhances bioefficacy, all in a small meal portion.

Recipients’ general health and wellbeing have improved dramatically. Tuberculosis cure rates have risen by 39 per cent. Now HETN is embarking on a longitudinal study with the University of the Witwatersrand to confirm these anecdotal findings and evaluate other non-invasive indicators of nutritional status.

It is now widely accepted that the Millennium Development Goals have failed to achieve the initiation of sufficient numbers of HIV positive people on anti-retroviral medications. Africa continues to experience a rampant HIV epidemic with its associated negative social and economic impact. Antiretroviral medications should remain the major focus of treatment initiatives, but a growing body of evidence of the adjunctive role of good nutrition is being ignored.

Micronutrient supplements can and do make a real contribution to alleviating the burden of infectious disease but only if they are formulated to ensure bioefficacy. Despite this, I am not aware of any global effort to reach a consensus on appropriate micronutrient supplementation in the adjunctive management of chronic health problems.

Sadly, confusion and vested interest reign.

Dearth of Nutrition at AIDS Impact Conference

I recently attended the AIDS Impact Conference in Gaborone, Botswana, where HETN was presenting a poster.

Very few presenters even mentioned the subject of nutrition. When we raised it, there was interest, but the consensus seemed to be:

• (From the scientists) – Yes, nutrition is important, but it is complex, so we would rather concentrate on things we can understand.
• (From the agencies) – Yes, nutrition is important, but it is complex and we cannot get into ‘feeding the world’.

One of the plenary speakers, Dr Gita Ramjee of the Medical Research Council, gave an excellent presentation on all possible biomedical interventions, with their strengths and weaknesses. She questioned whether the randomised control trial was always an appropriate assessment tool, but she never mentioned the role of micronutrients.

No one I spoke to had even heard of the importance of selenium.

In 1979, Chinese scientists reported that selenium had been linked to Keshan disease, an endemic juvenile cardiomyopathy (disease of heart muscle) found in the Keshan district of China. This often fatal disease has since has been found elsewhere (including New Zealand and Finland) where soil selenium levels are low.

However, certain epidemiological features of the disease could not be explained solely on the basis of inadequate selenium. Fluctuations in the seasonal incidence suggested the involvement of an infectious agent.

Indeed, a coxsackie virus isolated from a Keshan disease victim caused more heart muscle damage when inoculated into selenium-deficient mice than when given to selenium-replete mice. Vitamin E status had a similar effect on viral virulence.
 
Keshan disease seems to be the result of several interacting factors, including a dominant nutritional deficiency (selenium), other nutritional deficiencies (vitamin E and polyunsaturated fatty acids) and an infectious agent (virus).

Turning to HIV infection, the estimated adult prevalence rate (2007) in Bolivia was 0.2. In Senegal it was 1.0. These two countries have the highest naturally occurring soil selenium levels in the world. Comparable figures for South Africa and Swaziland, where soil selenium levels are very low, were 18.1 and 26.1 respectively. Finland had low soil selenium levels, but has been adding selenium to fertilisers since 1984. There, the estimated adult HIV prevalence rate (2007) was 0.1, whereas in neighbouring Russia and Estonia it was 1.1 and 1.3 respectively.

Kupka studied the relationship between death from AIDS and plasma selenium levels in pregnant women in Tanzania. Blood was collected from 949 pregnant women and saved for 5.7 years, by which time 306 of them had died. Statistical analysis showed that the lower the original plasma selenium level, the more likely the woman was to die of AIDS. The relationship was statistically significant.

Has selenium been shown to benefit AIDS patients? Yes. Randomised controlled trials in Nigeria (Odonukwe) and in the US (Hurwitz) have shown significant benefit.

Both these studies used selenium rich yeast. Many selenium studies show little benefit, but I have talked elsewhere about the importance of form. Where there is deficiency, it has become commonplace to fortify bread or salt with sodium selenate or selenite. This is unlikely to have the desired benefit because these salts are toxic, poorly absorbed, and the little that is absorbed does not act as an antioxidant. It is a mad world that bans mineral water that is contaminated with sodium selenite – an industrial pollutant – and then puts it in the bread! Selenomethionine is better absorbed and has some antioxidant properties. In contrast, selenium rich yeast is non-toxic, well absorbed and has powerful antioxidant properties. One would expect this, as yeast is a natural food and the selenium in it is complexed with natural carrier proteins.

In my naivety, I thought that the scientific method was about noticing something, developing a hypothesis and testing it. There is certainly much to notice about HIV prevalence and selenium status.

Sadly, there seems little interest. This is indeed strange. AIDS is about immune deficiency. The commonest cause of immune deficiency is micronutrient deficiency. Surely any AIDS intervention should start with ensuring that populations are micronutrient replete?

HETN’s poster was about TB, which kills more adults than any other infectious disease, and is often found with HIV. Ensuring that patients are micronutrient replete improves TB cure rates by 39% and only costs £1.50 per month. So cost is not the issue – but perhaps it explains the lack of interest?

Geoff Douglas

CEO – Health Empowerment Through Nutrition

More of the Same!

I have been looking at the recent plethora of authoritative reports on Nutritional Support for People Living with HIV/AIDS (PLWHA) or TB or Famine. They come from the International Agencies. They are all lengthy. They are full of scientific citations.

 They all agree that malnutrition is widespread throughout the world, with devastating impact on the global economy.

They all support the notion of a balanced diet, but fail to mention that:

• People in Africa have limited access to a balanced diet
• Most people make poor food choices
• Farming methods have depleted the soil and the food of essential micronutrients
• Food processing, such as grain milling, removes essential micronutrients.

They usually support the use of multivitamins, but quickly add that systematic reviews of micronutrient supplementation conclude that there is no convincing evidence that these reduce morbidity or mortality in people living with HIV/AIDS. What they fail to mention is that:

• The trials that have been done concentrate on single supplement intervention, or supplementation with a small group of micronutrients. Neither can be expected to correct the type of nutrient deficiency seen in HIV/AIDS
• The problem is compounded by the fact that the dose of supplement is often not physiological and the form of supplement is often not considered
• Much of the research is done in the West where baseline nutrition is higher.

The truth is that:

• People have moved away from their traditional foods, whilst modern agricultural practices and food processing remove essential nutrients from the food chain
• Many communities are experiencing health problems not seen by their grandparents who often lived in greater poverty
• Science has had limited success in providing solutions to this problem and there is confusion as to what represents good nutrition.
• On the advice of GAIN and the Micronutrient Initiative, the malnourished are being fed refined foods, with added vitamins and minerals in the form of chemical isolates – despite evidence of their limited bio-availability.
  • In South Africa, iron, zinc and vitamin A deficiency is widespread. Their maize and wheat flour fortification programme has not addressed these deficiencies. This is not surprising:
  • The electrolytic iron used has a bio-availability of less than 2%
  • Phytates in maize further reduce this
  • The electrolytic zinc used competes with the iron for absorption
  • Electrolytic iron oxidizes the vitamin A
  • The added vitamins are denatured and destroyed by cooking.

In order to have any chance of health, human beings need whole foods with bio-available vitamins and minerals. Where access to fruit and vegetables is limited, wholegrain cereals need to be fortified with vitamins and minerals in a bio-available form. Neither of these terms is ever used in these authoritative reports.

 The scientific community has paid little attention to the crucial issue of nutrient form. Most scientific papers do not mention it. Some examples:

• Iron. Chelated Iron is better absorbed and less toxic than ferrous sulphate.
• Calcium. Research has shown that 30mg of Calcium rich yeast is better absorbed than 300mg of Calcium Carbonate.
• Selenium. Selenium is an essential trace element – required for an extensive range of biochemical functions – mediated by some 20 selenoproteins that play a key role in antioxidant systems, thyroid hormone metabolism, immune function and reproduction.
  • Where there is deficiency, it has become commonplace to fortify bread or salt with sodium selenate or selenite. But this is unlikely to have the desired benefit because these salts are toxic, poorly absorbed, and the little that is absorbed does not act as an antioxidant. South Africa bans the sale of mineral water if it is contaminated with sodium selenite – an industrial pollutant – but permits its use in bread!
  • Selenomethionine is better absorbed and has some antioxidant properties, whereas selenium rich yeast is non-toxic, well absorbed and has powerful antioxidant properties. One would expect this as yeast is a natural food and the selenium in it is complexed with natural carrier proteins.
• Vitamin C. We need our vitamins and minerals as food or in a food form. When the discoverer of Vitamin C, Szent-Györgyi, tried his crystalline ascorbic acid on patients with scurvy, he expected a strong reaction – but it did nothing. The concentrated whole foods he used in his research were far more effective. He attributed this to complex food factors, such as bioflavonoids, present in the food.

Oh dear, oh dear!