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TESTE DEIN WISSEN

Your fellow students from your previous bachelor program, asks you what Public Health Nutrition is.

  • Describe the main principles of a PHN
  • Explain the main competence areas a PHN should cover
  • What kind of competences do you think a PHN should cover 
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Main principles

  • PHN focuses on the promotion of good health through nutrition and the primary prevention of nutrition related illness in the population
  • PHN is where population health and nutrition interact or overlap
  • Public Health refers to nutritional aspects of public health, which is the science and art od promoting and protecting health and well-being, preventing ill health and prolonging life
  • Public health nutrition is about (3 A’s)
    • Knowledge relating nutrition to health and disease
    • Assess the nutrition situation and Analyze the drivers of the challenges
    • Evidence-informed policy development and implementation (Action)

 

Main competence areas

  • Practices Nutrition assessment, monitoring and surveillance
  • Knows how Nutrition education, Food & Nutrition Systems, Public Health Systems and Nutrition science work 
  • In-depth nutritional knowledge
  • Understanding of the food system 
  • Knowledge of effective program planning and interventions
  • Understanding of food policy
  • Ability to work with all other sectors

 

Competences a PHN should cover

  • Knows about other areas of research --> biological- / environmental- / behavioral- / social science, economics, and politics 
  • Does know how to communicate, lead, manage and how to be professional
  • Can analyze papers, scientific research, etc. 
  • Assess and identify nutritional challenges 
  • Analyse and monitor 
  • Plan, develop and evaluate effective interventions 
  • Collaborate 
  • Build capacity 
    • Community capacity and social capital to engage in, identify and build solutions to nutrition problems and issues
    • Organizational capacity and systems to facilitate and coordinate effective public health nutrition action
  • Communicate about determinants of nutrition problems, policy impacts, intervention effectiveness
  • Advocate for food and nutrition related policy and government support to protect and promote health
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Explain what the Global Burden of Disease-project is, what DALYs are and explain some of the main findings from the project


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GBD-Project:

  • A systematic, scientific effort to quantify the health loss due to diseases, injuries, and risk factors by age, sex, and geographies for specific points in time
  • Most comprehensive worldwide observational epidemiological study to date
  • The GBD give answer to
    • What are the world’s health problems? 
    • Who do they hurt?
    • How much?
    • Where?
    • Why?
  • The world’s largest catalog of health data (data from 204 countries)
  • Uses data from multiple sources
  • PH normally only takes mortality indicators into account to map population health --> GBD also accounts diseases that cause disabilities and pain during life (non-fatal health outcomes)
  • Reveal the burden of mental disorders
  • burden of non-communicable diseases and injuries in low- and middle income countries
  • Comparative Risk assessment (CRA) as a continuation of the GBD project: challenge is to estimate the influence of risk factirs to disease burden
  • Why Risk factor?: Risk factors are possible to prevent
  • How much of the disease burden can be avoided if you take away a certain risk factor?

 

DALYs

  • Disability-adjusted life year
  • Measure on the disease burden that describes ill health in the population by combining information about both mortality and disability
  • Quantifies burden of diseases, injuries and risk factors expressed as cumulative numbers of years lost due to ill health in the population by combining information about both mortality and disability
  • Based on years of life lost from premature death (YLLs = Years of life lost) and years lived in less than full health (YLDs = Years lived with disability, disease) --> DALY = YLL + YLD 


Main findings

  • Rapid progress in life expectancy 
  • Among age groups, the under-5 age group experienced huge reductions in mortality between 1950 and 2017, while adults have made much less progress, particularly adult males
  • DALYs (1990-2017):
    • Decrease in communicable diseases and neonatal disorders --> Vaccines, better hygiene, medicine, treatment, education 
    • Increase in NCDs --> people are getting older, changing of traditional diet to a more western diet, more stationary work / lifestyle than before 
  • Causes of death  
    • Early death from enteric infections, respiratory infections and tuberculosis, maternal and neonatal disorders dropped
    • Common diseases (NCDs as CVDs and cancer) are a common cause for mortality now
    • An unintended consequence of increased access to health care globally is increases in mortality from diseases and disorders linked to antibiotic resistance
  • Many of the leading causes of disability --> low back pain, headaches, and depression, diabetes 
  • Smoking and high systolic blood pressure are global leading risk factors causing early death and disability
  • Intake of healthy foods was lower than the optimal intake in all regions (with a few exceptions)
  • Intake of unhealthy foods was higher than the optimal intake in many regions
    • Sugar-sweetened beverages and salt: Higher in all regions
    • Red and processed meat: Higher in several regions


 

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TESTE DEIN WISSEN

Unhealthy diet is one of the most important risk factors for developing NCDs, such as cardiovascular diseases (CVD). Which are the most important dietary factors affecting the development of CVD? Explain the effect of saturated fatty acids (SFA) versus polyunsaturated fatty acids (PUFA) on risk of developing CVD at the different levels of evidence (cohorts, RCTs, mechanistic studies). What is the percentage reduction in cholesterol levels likely to obtain by exchanging 5E% of SFA with PUFA, and what is the expected risk reduction in developing CVD after a 10% reduction in total cholesterol levels? What are the most important sources of fat in a western diet, including sources of SFA and PUFA?

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NCDs

  • chronic diseases
  • don't pass from one person to another
  • tend to be of long duration
  • are a result of the combination of genetic, physiological, environmental and behavioural factors


Cardio Vascular Disease (CVD)
  • Leading cause of death and disabilities worldwide --> 32 % of all deaths globally (2019)
  • >3/4 of CVD deaths take place in low- and middle-income countries
  • Globally 1 in 10 people aged 30-70 die from CVD 
  • Group of disorders that include:
    • Coronary heart disease
    • Deep vein thrombosis and pulmonary embolism
    • Peripheral arterial disease


  • CVD Result of Atherosclerosis = Disorder of circulatory system, affecting large and medium size arteries
    --> Narrowed blood vessels lumen because of lipid-containing plaques raised and thickened from vascular luminal walls
    --> Lifelong process 
  • Driven by Hypercholesterolemia (Circulating LDL) and endothelial dysfunction
  • It is important to detect CVD as early as possible so that the management with counselling and medicines can begin


Role of cholesterol

  • Reduction in LDL-cholesterol reduce the risk of CVD

  • Atherosclerotic plaques is driven by hypercholesterolemia

  • Excess LDL infiltrates the blood vessel’s intimal layer

  • LDL can be oxidized (oxLDL) which leads to oxidative stress that causes inflammation

  • OxLDL is taken up by macrophages and they build a foam cell

  • Lipid core with fibrous cover --> atherosclerotic plaque

  • Chronic low-grade inflammation --> atherosclerosis --> CVD

  • Plaques grow over many years and can develop large lipid-rich necrotic cores, making them unstable 
  • The rupture of an atherosclerotic plaque causes a blood clot (thrombosis)


--> Non-modifiable risk factors: Genes, Gender, Age
--> Modifiable risk factors: Tobacco, Physical inactivity, Overweight and obesity, Alcohol, Unhealthy diet (saturated fat)


Dietary factors: dietary fats and fiber intake

  • Reduction of SFA intake and replacement with PUFAs --> Reduction of cholesterol levels --> Reduction of CHD mortality
    • SFA: increase blood cholesterol levels, especially LDL-Cholesterol
  • Cholesterol levels in blood is one of the most important markers
  • increasing intakes of PUFA are of greater benefit for cardiovascular health than further reduction of SFA intake
  • soluble fiber can inhibit absorption of cholesterol, inhibit reabsorption of bile acids and reduce hepatic cholesterol synthesis
     

--> unhealthy eating patterns support the development of CVD

  • Excessive intake of sodium and processed foods
  • High intake of SFA and a low intake in PUFA
  • Added sugars
  • Unhealthy fats (high SFA and low PUFA)
  • Low intake of fruit and vegetables, whole grains, fiber, legumes, fish, and nuts
  • Global recommended fat intake: similar worldwide



WHO: Risk of developing NCDs is lowered by reducing saturated fats < 10% of total energy intake and trans fats <1 % and replacing both with unsaturated fats

 

effect of saturated fatty acids (SFA) versus polyunsaturated fatty acids (PUFA)
  • Meta Study: 5% lower energy intake from SFAs and a concomitant higher intake of PUFAs showed a significant invers association between PUFAs and risk of coronary events 
  • Randomized crossover trial 

    • Replacement of SFA with PUFA for 3 days 
    • Beneficial effect on serum cholesterol (8%), but not glycemic regulation 
  • Cohort Study Uppsala Longitudinal Study of Adult Men (ULSAM)

    • The amount of linoleic acid in the serum was associated with a protective effect from CVD deaths with a risk reduction of ca. 15% --> exchanging 5E% of SFA with linoleic acids leads to a 13% reduced risk of CHD-death 
  • Mechanistic studies 

    • effects of PUFA  the lipid metabolism

 

Percentages of reduction in cholesterol levels likely to attain when changing SFA with PUFA

  • Cohort and RCTs show that increase in PUFA intake reduce level of cholesterol and risk of CVD
  • Exchanging 5 E% SFA with PUFA leads to a 10 % reduction in total- and LDL-cholesterol
  • 10 % reduction in LDL-cholesterol reduces risk for CVD with 27% (dependent on age) --> the lower the age the more effective the risk reduction when reducing the total cholesterol level

 

most important sources of fat in a western diet, including sources of SFA and PUFA

  • SFA
    • Dairy products
    • Added fats and oils from animal sources
    • Meat and meat products
    • Highly processed food 


  • PUFA
    • Added fats and oils --> plant-based margarine, or fish-based
    • Cereals and cereal product
    • Meat and meat products
    • Avocado
    • Salmon
    • Nuts and Seeds (Walnut, almond, pumpkin)
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Why is obesity a risk factor for developing NCDs? What is the difference between subcutaneous and visceral/abdominal adipose tissue, and how do the different adipose tissues affect metabolic regulation? Explain the connection between adipose tissue and development of type 2 diabetes (T2D). Give examples of food that will reduce the risk of T2D.

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Adipose Tissue

  • Adipose tissue = A type of specialized connective tissue whose main functions are to store the energy, protect the organs and contribute to the endocrine profile of the body
  • Types: Depending on location --> Subcutaneous fat (located between the skin and the abdominal muscles) and visceral fat (under the abdominal muscles, in the abdomen) 
  • Function: 
    • Energy storing (very large amount of energy with little volume and weight as TAG)
    • hormone production (adipokines)
    • thermal isolation (white adipose tissue)
    • thermogenesis (brown adipose tissue: high in Mitochondria --> Use Fat Oxidation for energy production; mostly present mostly in newborns and infants)
    • mechanical protection
    • Store cholesterol and Vitamins D and E


Effect on metabolic regulation 

--> Visceral

  • Effect on metabolic regulation--> Visceral
  • Endocrine tissue/organ
  • Low insulin sensitivity
  • Influencing production of cholesterol by releasing free fatty acids into the bloodstream and liver
  • Makes proteins cytokines --> triggers low-level inflammation = risk factor for heart disease and other chronic conditions
  • Produces a precursor to angiotensin = protein that causes blood vessels to constrict and blood pressure to rise
  • Ectopic fat deposition: Fat also stored in Liver, Heart and Skeletal muscle --> Metabolic dysregulation of adipose tissue --> Altered metabolism and altered release of adipokines --> Lipid Overflow --> Ectopic fat: Increase in Muscle fat / epicardial fat / liver fat and altered functions --> Insulin Resistance and Dyslipidemia 

 

--> Subcutaneous

  • “Healthy” adipose tissue
  • No Ectopic Fat: Low muscle fat / low epicardial fat / low liver fat and normal functions --> Normal metabolic profile

 

Adipose tissue is an endocrine organ


 

Diabetes and T2DM

  • The majority of T2DM patients live in low- and middle-income countries
  • With T2DM there is an increased risk of premature death, CVD, nephropathy, neuropathy and retinopathy
  • T2DM is closely linked to the epidemic of obesity
  • Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose
    • Pancreas does not produce enough insulin or
    • The cells cannot utilize the produced insulin due to IR
  • In T2DM the body produces too little insulin and/or is unable to respond to it
  • Risk factors are
    • Advancing age
    • Obesity --> BMI is the single most important risk factor 
    • Poor diet
    • Family history of T2D
    • Physical inactivity
    • Ethnicity
    • Increased blood glucose levels


Normal regulation of blood glucose levels

  • regulated by insulin and glucagon
  • Insulin is produced in the pancreatic ß-cells
  • Food intake increases the blood glucose --> insulin is released by the ß-cells which stimulates the glycogen formation as well as the glucose uptake from the blood and leads to a lower blood sugar
  • If the blood sugar is low in between meals --> Glucagon is released which stimulates the glycogen breakdown and leads to an blood sugar rise


Glycemic dysregulation in T2DM

  • Cells don’t react to insulin that is released by the pancreas
  • The pancreas gets thereby the signaling to produce even more because the glucose is still in the bloodstream which leads to a high blood sugar 
  • insulin resistance 


food that will reduce the risk of T2D

  • Consuming more PUFA in place of saturated fats e.g. Avocado, salmon, nuts and seeds instead of highly processed foods and read meat 
    • Improves insulin sensitivity in the long term
    • Could be because PUFA reduces inflammation and thus improves insulin sensitivity while SFA increases inflammation  
    • High intake of total fat (> 37 % of energy intake) reduces insulin sensitivity regardless of fat quality
    • Fat quality can lead to changes in the gut microbiota and thereby the production of SCFA
    • Fiber-rich foods e.g. whole grain bread or pasta, oats, vegetables
    • High intake of fiber is associated with reduced prevalence of T2DM in the nurses health studies I and II
    • Beta-glucan (soluble dietary fiber) has been shown to improve glycemia
    • Bacterial fermentation of beta glucan in the gut causes production of short chain fatty acids that may affect metabolic status of the host (human)
    • SCFA are taken up into the blood stream where they can bind to receptors and affect incretin hormones, reduce inflammation and also impact gluconeogenesis in the liver (building of glucose in the liver)
  • Low Calorie food or at least not over the --> Prevention of Obesity e.g. food that are high in volume and have a low energy density like lean white meat, vegetables, salad
  • Other factors to reduce the risk or delay the onset of T2DM
    • Regular physical activity
    • Maintaining a healthy body weight
    • Avoiding tobacco
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TESTE DEIN WISSEN

What is the difference between dietary guidelines and nutrient recommendations? What characterizes the two different kinds of recommendations and how are they used? 


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Nutrient recommendations:

  • focus on preventing deficiency diseases and the prevention of diet related NCDs
  • State recommended intake of energy, macro- and micronutrients for groups of healthy people over a longer period of time
  • Formulated as Dietary Reference Values, DRV, which is the term used both in the EU, as published by EFSA and in the Nordic Nutrition Recommendations, NNR (US: Dietary Reference Intakes)
  • Vary by age, sex and physiological state (e.g., pregnancy, lactation)
  • Can be used to compose diets at the group level and to assess nutrient intake of individuals and groups. However, nutrient recommendations are equal to nutrient requirements in individuals and cannot be used to estimate nutritional status
  • Objective: Population meets needs for essential nutrients to maintain physiological functions and avoid toxic intakes


Food-based dietary guidelines

  • Provide more concrete recommendations for how diet and food groups can be put together to contribute to good health, reduce the risk of obesity and NCDs and ensure adequate intake of nutrients
  • intended to establish a basis for public food and nutrition, health and agricultural policies and nutrition education programmes to foster healthy eating habits and lifestyles
  • provide advice on foods, food groups and dietary patterns to provide the required nutrients to the general public to promote overall health and prevent chronic diseases
  • a lot of countries use food guides as a graphic representation if the guidelines


What are the recommendations based on?

  • Both based on systematic methodology that summarizes the totality of the available knowledge, across different study types
  • Systematic literature reviews and meta-analysis are used to summarize the entirety of existing research --> Predefined plan for how studies are to be identified, evaluated and summarized
  • Dietary guidelines are central in nutrition - we need to know what the optimal diet is at various life stages in order to be able to assess whether people are eating healthily

 

How are they used?

  • National dietary guidelines offer guidance to both individuals, policy makers, researchers and the food industry
  • Often shaped into messages/advice/recommendations communicated to general population to help people make the right food choices
  • typically propose a set if recommendations in terms of foods, food groups and dietary patterns to provide the required nutrients to promote overall health and prevent chronic diseases
  • Provide a way for monitoring the healthiness of the food intake of the population --> monitor how the situation changes --> form the basis for national food and nutrition policies --> plan strategies and programs to improve the situation and target the most vulnerable groups
  • Used by the food industry to guide them in making and promoting healthier food products
  • need to be integrated in national food, agricultural, education and/or health policies and programmes and involve a wide range of stakeholders (government, NGOs, mass media ...)
  • are needed because
    • the majority of countries face a serious burden of two or three forms of malnutrition: undernutrition, micronutrient deficiencies, obesity and diet-related diseases (T2DM, CVD, Cancer)
    • they can serve to guide a wide range of food and nutrition, health, agriculture and nutrition education policies and programmes 
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Explain what food-based dietary guidelines are. What are some of the most important weaknesses with dietary guidelines?

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What are FBDG?

  • Food-based dietary guidelines (also known as dietary guidelines) are intended to establish a basis for public food and nutrition, health and agricultural policies and nutrition education programs to foster healthy eating habits and lifestyles
  • Guidelines are intended to influence consumer behavior and inform a range of national food, nutrition, and health policies and programs
  • They provide advice on foods, food groups and dietary patterns to provide the required nutrients to the general public to promote overall health and prevent chronic diseases
  • Type of evidence used to inform FBDG include: assessment of food and nutrient intakes, food supplies, prevalence and public health importance of diet-related health and nutrition outcomes, cultural preferences etc.
  • FBDGs can be either on a national or regional level 
  • Most common 3-group combination: starchy staples, fruit and vegetables, protein foods
  • Most countries with FBDG publish food guides, often in the form of food pyramids and food plates, which are used for consumer education

 

Why more focus on FBDG

  • Easier for people to relate to food than to nutrients --> We eat food not nutrients
  • Graphic presentation makes the FBDG-information accessible also for people who are not familiar with the (national) language in which they are presented
  • One food delivers more than one nutrient
  • Obesity and NCDs biggest disease burden mainly driven by intake of foods and not nutrition
  • Increasing knowledge base about how diet is associated with NCDs --> Summarize knowledge in systematic way
  • Increasing focus on “food matrix” --> not just nutrients and individual components but food as such 
  • Increasing focus on impact processing on health (ultra-processed food)

 

Why is it challenging to study relationship between diet and health?

  • Long latency period: cumulative exposure over many years or relatively short exposure many years before diagnosis --> impossible and unethical with RCTs 
  • Complex web of causes for NCDs: Diet, genetics, occupation, psychosocial factors, infectious diseases. Physical activity etc. --> High risk of confounding factor / bias
  • The conditions are (mostly) not reversible 
  • Cohort studies (mostly measured on the beginning), Observation study

 

Why is it challenging to study relationship between diet and cause of NCDs?

  • Diet varies from day to day, with seasons and changes over time --> difficult to give detailed and correct description of diet (Recall bias)
  • Difficult to measure usual food intake (bias related to dietary assessment methods)
  • In Cohort studies, diet often measured only at beginning --> do nor capture later changes
  • New foods on market --> need to continuously update food composition tables accordingly (is home-made bread better than brought?)
  • Food intake is difficult to blind / control

 

Why is it challenging to study diet as cause of illness?

  • Most people in western eat relatively well, extreme intake is unusual --> difficult to see clear effects / differences
  • When intake of food increases, one eats less of something else --> Effect because you ate less meat, or you ate more lentils? 
  • Diet consists of many factors --> difficult to distinguish what is factor influencing health
  • Challenges with good data on nutrient content in food 

 

Future frontiers

  • Sustainability of diets is not addressed in most current FBDGs --> becomes an more and more important and should therefore be included (meat consumption, regional and seasonal fruits and veggies, food waste)
    • Nordic Nutrition Recommendations plan to focus more on that in the next release 2022
  • Greater attention in some FBDGs could be paid to socioeconomic equity and inclusion of indigenous groups 
  • greater attention to nutrition transition and the rise in consumption of ultra-processed/junk foods (e.g. with the note: food to limit)
  • weaknesses
    • can be influenced by the industry e.g. lobbying
    • portions are very variable
    • dosnt take preferences into account
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TESTE DEIN WISSEN

What is Bourdieu's contribution to our understanding in social differences in health? 


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TESTE DEIN WISSEN
  • Each individual occupy a position in society according to its capital (economic, social and cultural capital)
    • Economic: money and material assets
    • Social: aggregate of actual or potential resources connected to stable networks of acquaintances —> advantages that grow out of networks 
    • Cultural: knowledge that exists in three different forms; incorporated dispositions (embodied or reflective), objectivized (books, tools, kitchen supplies etc.) and institutionalized (education degrees)
  • Economic and social capital are linked to cultural capital by the access they provide to education and social networks (e.g. tuition and club-membership fees)
  • cultural capital determines accumulation and development of economic and social capital; for instance, education may give access to better-paid jobs, and shared norms and values are necessary to enter certain social networks
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TESTE DEIN WISSEN

The Oslo schools are introducing free-meals for kids from 8th to 10th grade. Response to this initiative has been varying and particularly kids from 10th grade do not participate much to the free-meals. What can influence participation to school meals and what would you do to promote higher participation?


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  • Eating in the school-canteen might be considered as “uncool” by the older kids as only the younger ones eat in the school
  • Food is not tasty and the variety is not good enough
  • Friends might influence the decision to eat in the school canteen
  • Acceptance/Participation is influenced by:
    • Food quality, often school canteens offer fatty and unhealthy food that is not freshly prepared (cook and chill) and it therefor does not look appealing to the students --> in my school older students were allowed to leave the school in lunch break and would rather get some food at another place outside the school
    • Nutritional knowledge that the students get to know in their classes
    • Participation of teachers on the lunch in the canteen
    • Breaks are too short for eating in the canteen --> long waiting times
    • especially older children have a busier schedule  
    • Hectic, noise, too little space --> not a nice atmosphere to eat in
    • Not that much variation in food choices --> especially older children had the same options over a long time 
    • Unfriendly staff

 

Promote higher participation

  • More and healthier food choices, preferably freshly cooked
  • Easy process to order or preorder food 
  • Enough time in the lunch-break to eat 
  • Nice atmosphere with appealing premises
  • Furniture, Ceiling and wall elements for noise reduction
  • Teachers should participate at the lunch to be a role model for students participation
  • Friendly staff in the canteen
  • Giving students the possibility to give feedback which is then acted upon where possible
  • two or more meals to chose from (not only a vegetarian option)
  • Food habits are formed at a young age --> if the free meals are offered from a young age it becomes a routine; maybe forbid young children to leave the school grounds during lunch break to form habits)
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Discuss what food systems models are and how they can be used to analyze and act on challenges related to food, diet and nutrition


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Food Systems

  • A food system gathers all the elements (environment, people, inputs, processes, infrastructures, institutions etc.) and activities that relate to the production processing, distribution, preparation and consumption of food, and the output of these activities, including socio-economic and environmental outcomes --> everybody and everything involved in bringing food from farm to fork
  • Sustainable food system: ensures food security and nutrition for all in such a way that the economic, social and environmental bases to generate food security and nutrition of future generations are not compromised 
  • Constituent elements of food systems
    • Food supply chains: Production systems, storage and distribution, processing and packaging, retail and markets, (waste management?)
    • Food environments: physical, economic, political and socio-cultural context in which consumers engage with the food system to make their decisions about acquiring, preparing and consuming food
    • Consumer behavior: decisions made by consumers, at the household or individual level, on what food to acquire, store, prepare, cook and eat, and on the allocation of food within the household (including gender repartition and feeding of children)
    • Diets
    • Nutrition and Health outcomes
  • Food systems are highly interconnected, any intervention or policy that addresses one part of the system will affect other parts
  • Food systems depend on the environment and natural resources, but food system activities can degrade and impair these resources
  • Drivers
    • Biophysical and environmental drivers
    • Innovation, technology and infrastructure drivers
    • Political and economic drivers
    • Socio-cultural drivers
    • Demographic drivers
  • Who influences and engages with food systems?
    • Farmers, livestock producers and fishers
    • Private sector: affects food production, pricing and affordability, consumer attitudes and perceptions, and public policy; businesses are involved in every stage of the FSC
    • Governments: In some countries, governments directly manage and even participate in food production, while in other countries, the state regulates and facilitates the activities of food systems through policy; influence both private sector and consumers
    • Civil society: non-governmental organizations may operate at the local or global level to support positive nutrition, health, and environmental outcomes

 

  • It’s important to know what is included in the model to take action and make changes in different drivers/constituent elements --> there is not only one way to change the situation, by changing different elements one can reach goals in different ways and everyone fits in a different way to a different country
  • Because of the interaction it is often not enough to change just one part --> it is often necessary to make changes on different levels
  • Food system models can help to identify challenges and help solve them


--> traditional food system

  • Traditional food systems are associated with the highest prevalence of undernutrition
  • people generally live in rural areas
  • dietary diversity can be low partly because people rely mainly on locally grown, fished, herded, hunted or gathered foods and often lack appropriate infrastructure to access distant market
  • People tend to grow much of their own food and buy food from local daily and weekly wet markets, and from kiosks
  • markets primarily sell fresh foods, but may also sell some packaged foods
  • kiosks sell staples, such as cooking oil and sugar, as well as packaged foods and convenience foods, such as instant noodles and snack foods
  • Foods are often not monitored for quality and safety
  • Many people’s diets primarily consist of staple grains such as maize, rice and wheat, and do not contain sufficient amounts of protein and micronutrients --> often high stunting rates and micronutrient deficiencies

 

--> mixed food system

  • Higher proportion of people living in peri-urban areas and having greater income than in traditional food systems
  • Wider range of “food entry points” 
  • Access to supermarkets is available but may be limited especially in low income areas
  • More access to prepared meals eaten outside the home
  • people tend to have access to diverse foods, leading to sufficient calorie and protein intakes 
  • Better nutritional status, as well as advances in water provision, sanitation, hygiene and other medical services, lead to lower incidences of, and mortality from, infectious diseases as well as well as less undernutrition
  • hygiene and other medical services, lead to lower incidences of, and mortality from, infectious diseases. With the availability and popularity of processed foods, there is increased intake of saturated and trans fats and sugar 
  • Some dietary changes result in these systems in an increasing incidence of overweight and obesity and lead to an increased incidence of, and morbidity from, NCDs such as cardiovascular disease and diabetes. While life expectancy increases due to the decrease in infectious diseases, morbidity increases due to the rise in NCDs 

 

--> modern food system

  • higher proportion of people tend to live in urban areas and have greater incomes and an overwhelming number of food choices 
  • consumers often live far from where their food is produced
  • through technological an infrastructural advances (including distribution and exchange/trade), a wide variety of foods is accessible to consumers all year long
  • consumers have options as to where they procure their foods 
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In country X there is a high prevalence of undernutrition (a high proportion of children are stunted) and in country Y there is a high prevalence of overweight and obesity. Explain how you can use a food systems model to analyze the causes of these situations.

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Food Sytems

  • A food system gathers all the elements (environment, people, inputs, processes, infrastructures, institutions etc.) and activities that relate to the production processing, distribution, preparation and consumption of food, and the output of these activities, including socio-economic and environmental outcomes --> everybody and everything involved in bringing food from farm to fork
  • Sustainable food system: ensures food security and nutrition for all in such a way that the economic, social and environmental bases to generate food security and nutrition of future generations are not compromised 
  • Constituent elements of food systems
    • Food supply chains: Production systems, storage and distribution, processing and packaging, retail and markets, (waste management?)
    • Food environments: physical, economic, political and socio-cultural context in which consumers engage with the food system to make their decisions about acquiring, preparing and consuming food
    • Consumer behavior: decisions made by consumers, at the household or individual level, on what food to acquire, store, prepare, cook and eat, and on the allocation of food within the household (including gender repartition and feeding of children)
    • Diets
    • Nutrition and Health outcomes
  • Food systems are highly interconnected, any intervention or policy that addresses one part of the system will affect other parts
  • Food systems depend on the environment and natural resources, but food system activities can degrade and impair these resources
  • Drivers
    • Biophysical and environmental drivers
    • Innovation, technology and infrastructure drivers
    • Political and economic drivers
    • Socio-cultural drivers
    • Demographic drivers
  • Who influences and engages with food systems?
    • Farmers, livestock producers and fishers
    • Private sector: affects food production, pricing and affordability, consumer attitudes and perceptions, and public policy; businesses are involved in every stage of the FSC
    • Governments: In some countries, governments directly manage and even participate in food production, while in other countries, the state regulates and facilitates the activities of food systems through policy; influence both private sector and consumers
    • Civil society: non-governmental organizations may operate at the local or global level to support positive nutrition, health, and environmental outcomes

 

traditional food system

  • Traditional food systems are associated with the highest prevalence of undernutrition
  • people generally live in rural areas
  • dietary diversity can be low partly because people rely mainly on locally grown, fished, herded, hunted or gathered foods and often lack appropriate infrastructure to access distant market
  • People tend to grow much of their own food and buy food from local daily and weekly wet markets, and from kiosks
  • markets primarily sell fresh foods, but may also sell some packaged foods
  • kiosks sell staples, such as cooking oil and sugar, as well as packaged foods and convenience foods, such as instant noodles and snack foods
  • Foods are often not monitored for quality and safety
  • Many people’s diets primarily consist of staple grains such as maize, rice and wheat, and do not contain sufficient amounts of protein and micronutrients  often high stunting rates and micronutrient deficiencies

 

--> mixed food system

  • Higher proportion of people living in peri-urban areas and having greater income than in traditional food systems
  • Wider range of “food entry points” 
  • Access to supermarkets is available but may be limited especially in low income areas
  • More access to prepared meals eaten outside the home
  • people tend to have access to diverse foods, leading to sufficient calorie and protein intakes 
  • Better nutritional status, as well as advances in water provision, sanitation, hygiene and other medical services, lead to lower incidences of, and mortality from, infectious diseases as well as well as less undernutrition
  • hygiene and other medical services, lead to lower incidences of, and mortality from, infectious diseases. With the availability and popularity of processed foods, there is increased intake of saturated and trans fats and sugar 
  • Some dietary changes result in these systems in an increasing incidence of overweight and obesity and lead to an increased incidence of, and morbidity from, NCDs such as cardiovascular disease and diabetes. While life expectancy increases due to the decrease in infectious diseases, morbidity increases due to the rise in NCDs 

 

--> modern food system

  • higher proportion of people tend to live in urban areas and have greater incomes and an overwhelming number of food choices 
  • consumers often live far from where their food is produced
  • through technological an infrastructural advances (including distribution and exchange/trade), a wide variety of foods is accessible to consumers all year long
  • consumers have options as to where they procure their foods 
  • many options for prepared meals eaten outside the home, such as fast casual and fine dining restaurants and gourmet food trucks 
  • wide range in food prices, with fresh produce being more expensive than most packaged foods 
  • relative costs compared with staples is lower than the traditional food systems
  • Strong regulations and means of implementation enable a strict control of food quality and safety 
  • the abundance of food, especially highly-processed food, is associated with increased risk of overweight, obesity and NCDs 
  • increases in income and education are likely to make people more aware of the relationship between diet, nutrition and health. People in these systems also tend to have increased access to, and quality of, medical care, including the prevention and management of NCDs

 

Country X: undernutrition 

  • this country has a traditional food system 
  • Malnutrition is inadequate dietary intake to individuals’ needs and undernutrition (dietary energy deficiency) is one form of it
  • Dietary energy: kcal from proteins, carbohydrates and fats
  • Indigenous peoples are generally among the most vulnerable to different forms of malnutrition because of: marginalization; extreme poverty; violations of their inherent rights to their traditionally occupied or used lands, territories and resources; environmental and ecosystem degradation; and decline in their traditional food sources
  • Health consequences: increased risk or morbidity and mortality

 

Country Y: overweight

This country is either a country with a modern food system or with a mixed system (traditional to modern)

-->  example PIC

  • Nutrition transition because of globalization and increasing international trade (trade agreements): import of nutritionally poor, energy dense and inexpensive food is increasing
  • Apart from political and economic drivers (globalization, disposable income of the urban population and Low costs) Consumer behavior (that pacific islanders lack the awareness of the consequences of poor nutrition), changes in the food supply chain (decreasing access to land for growing food,) and demographic drivers (rapidly growing population) are reasons for the increase
  • Change in consumer behavior has an influence on the individual health --> modern/western diet is associated with higher prevalence of the metabolic syndrome
  • Another important driver are biophysical and environmental drivers, as climate change has a mayor influence on the PIC food system --> affects the agriculture on the PIC
Lösung ausblenden
TESTE DEIN WISSEN

Provide 3 examples of frameworks/theories for understanding social inequalities in health. Please use the framework/theory to explain why social inequalities in health may arise.  

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TESTE DEIN WISSEN

 Social inequalities in health

  • systemic differences in health outcomes that arise from social conditions in which people are born, grow, work, and age
  • have significant social and economic costs to society
  • inequities
    • differences caused by uneven distribution of resources
    • avoidable 
    • unjust and unfair
    • for example: a social group difference in health, such as those based on race or religion 


Theorie, examples

  • Material factors: 
    • availability of/access to sanitary facilities
    • people with higher socioeconomic backgrounds and higher income are able to afford sufficient health care when needed and are also able to ensure nutrition that meets the recommended supply of macro and micro nutrients
  • Geography: access to sufficient health care
  • Health behavior: 
    • low income and therefore more likely to buy/consume cheap but high processed foods
    • if the mother of an unborn child smokes and drinks alcohol during pregnancy or is not able to feed herself according to recommendations, the child might suffer from diseases
  • Geography, Space: air pollution that exacerbates asthma symptoms would be an example of a health risk that is distributed across space. Proximity to landfills, crime clusters, and health clinics are other examples of spatially patterned health risks and protective factors
  • Geography, Place: Many government run programs and policies that affect health, such as food assistance programs or tax policies, are specific to administrative units and operate uniformly within their boundaries. As a result, the health impacts of a wide range of programs and policies do not depend on residents’ precise physical location, but rather on membership in a given political or administrative unit
  • Selection: people who value physical activity may be more likely to move to walkable areas, while sedentary individuals might choose to live in auto-dependent suburbs
  • Selection: relationship between SES and health as a product of selection by arguing that genetically superior individuals are more likely to have good health and high IQ, therefore explaining why highly educated, high income individuals are generally healthier


  • Bordieu: reach high level of health literacy (critical or even communicative): better ability to learn how to understand information and apply informtion to changing situations or even critically analyze this information to gain greater control over life events and self management
    • people with higher socioeconomic status have better abilities to gain higher levels of health literacy and therefore inequalities in health may arise --> they are able to better apply information they got to know by reading or in communication to their food choices and are able to follow prescription plans better as well as seek a doctor when needed

 

Theories for inequalities in health 

  • Material factor  
    • food, shelter, pollution, and other physical risks and resources (income) 
  • Psychosocial factors, discrimination
    • social exclusion, discrimination, stress, low social support, and other psychological reactions to social experiences
  • Health behavior: diet, physical activity, alcohol consumption, smoking etc.
  • Geography: place vs. space 
    • space: exposure to spatially distributed health risks and protective factors will change according to an individual’s precise location
    • place: membership in political or administrative units, such as school districts, cities, or states
  • Selection
    • people have a tendency to sort themselves into neighborhoods, social groups, and other clusters
    • also sometimes proposed as an explanation for educational, occupational, and even racial/ethnic differences in health
  • Context vs. composition
    • Context: influence a neighborhood or other type of higher level unit has on people
    • Consumption: reflective of the characteristics of individuals comprised by the neighborhood or other setting
  • Biological response to stress
  • Life long, cumulative effect of negative factors starting at birth or pregnancy




WHO Framework of social determinants of health

--> Structural determinants

  • Socio-economic and political context people live in  Governance, social and public policies, social and cultural values placed on health issues 
  • All these can lead to inequal distribution of material and monetary resources that can change a persons socio-economic position 
  • Socio-economic position: education, occupation, income, gender, ethnicity and social class
  • Structural determinants operate through a set of intermediary determinants 

 

--> Intermediary determinants 

  • Impact someones exposure, vulnerability and outcomes to factors influencing their health 
  • This includes Material Circumstances (Money to buy good house, food, cloth, income and work environment), Psychosocial factors (Relationships, stress), Behaviours, Biological Factors 

 

 

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TESTE DEIN WISSEN

Reflect on how the COVID-19 pandemic may have increased social inequalities in diet and health.

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TESTE DEIN WISSEN
  • Restriction of food supply chains leads to inadequate food and medical supply of some areas (closed borders and less international flights)
  • medical care cannot always be guaranteed due to the overload of the health system
  • economic impact of COVID19 
    • higher prices for fruits, veggies and dietary products
    • It’s even harder for people in poorer regions like Asia, Afrika or the Pacific to afford a healthy diet 
    • negative impact on the food security and availability of sufficient nutrition for all, and for mothers and children in particular
  • People with lower economic status leave in smaller houses and with a lot of people in one house —> social distancing and quarantining is hard for them 
  • People with better paid jobs/higher degrees could work from home while e.g. people working in health care or supermarkets needed to work in the field and therefore have a higher risk of infection (excluding doctor’s)
  • Children of lower socio-economic status had lower access to education because there was not always enough resources for all family member to work from home and they sometimes also got less support from family members 
  • Rich families can afford tutoring for their children to even out the worse education during COVID 
  • lack of decent work opportunities has led to a worsening of inequality, as poorer families with dwindling incomes further alter their diets to choose cheaper, less nutritious foods
  • rations e.g. in migration camps become smaller
  • aid programmes are harder to perform, a lot of helpers were taken back to their home countries in the beginning of the crisis and humanitarian help/projects were neglected
  • inequal access to vaccine (COVID19); besonders betroffen: poor regions
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Q:

Your fellow students from your previous bachelor program, asks you what Public Health Nutrition is.

  • Describe the main principles of a PHN
  • Explain the main competence areas a PHN should cover
  • What kind of competences do you think a PHN should cover 
A:

Main principles

  • PHN focuses on the promotion of good health through nutrition and the primary prevention of nutrition related illness in the population
  • PHN is where population health and nutrition interact or overlap
  • Public Health refers to nutritional aspects of public health, which is the science and art od promoting and protecting health and well-being, preventing ill health and prolonging life
  • Public health nutrition is about (3 A’s)
    • Knowledge relating nutrition to health and disease
    • Assess the nutrition situation and Analyze the drivers of the challenges
    • Evidence-informed policy development and implementation (Action)

 

Main competence areas

  • Practices Nutrition assessment, monitoring and surveillance
  • Knows how Nutrition education, Food & Nutrition Systems, Public Health Systems and Nutrition science work 
  • In-depth nutritional knowledge
  • Understanding of the food system 
  • Knowledge of effective program planning and interventions
  • Understanding of food policy
  • Ability to work with all other sectors

 

Competences a PHN should cover

  • Knows about other areas of research --> biological- / environmental- / behavioral- / social science, economics, and politics 
  • Does know how to communicate, lead, manage and how to be professional
  • Can analyze papers, scientific research, etc. 
  • Assess and identify nutritional challenges 
  • Analyse and monitor 
  • Plan, develop and evaluate effective interventions 
  • Collaborate 
  • Build capacity 
    • Community capacity and social capital to engage in, identify and build solutions to nutrition problems and issues
    • Organizational capacity and systems to facilitate and coordinate effective public health nutrition action
  • Communicate about determinants of nutrition problems, policy impacts, intervention effectiveness
  • Advocate for food and nutrition related policy and government support to protect and promote health
Q:

Explain what the Global Burden of Disease-project is, what DALYs are and explain some of the main findings from the project


A:

GBD-Project:

  • A systematic, scientific effort to quantify the health loss due to diseases, injuries, and risk factors by age, sex, and geographies for specific points in time
  • Most comprehensive worldwide observational epidemiological study to date
  • The GBD give answer to
    • What are the world’s health problems? 
    • Who do they hurt?
    • How much?
    • Where?
    • Why?
  • The world’s largest catalog of health data (data from 204 countries)
  • Uses data from multiple sources
  • PH normally only takes mortality indicators into account to map population health --> GBD also accounts diseases that cause disabilities and pain during life (non-fatal health outcomes)
  • Reveal the burden of mental disorders
  • burden of non-communicable diseases and injuries in low- and middle income countries
  • Comparative Risk assessment (CRA) as a continuation of the GBD project: challenge is to estimate the influence of risk factirs to disease burden
  • Why Risk factor?: Risk factors are possible to prevent
  • How much of the disease burden can be avoided if you take away a certain risk factor?

 

DALYs

  • Disability-adjusted life year
  • Measure on the disease burden that describes ill health in the population by combining information about both mortality and disability
  • Quantifies burden of diseases, injuries and risk factors expressed as cumulative numbers of years lost due to ill health in the population by combining information about both mortality and disability
  • Based on years of life lost from premature death (YLLs = Years of life lost) and years lived in less than full health (YLDs = Years lived with disability, disease) --> DALY = YLL + YLD 


Main findings

  • Rapid progress in life expectancy 
  • Among age groups, the under-5 age group experienced huge reductions in mortality between 1950 and 2017, while adults have made much less progress, particularly adult males
  • DALYs (1990-2017):
    • Decrease in communicable diseases and neonatal disorders --> Vaccines, better hygiene, medicine, treatment, education 
    • Increase in NCDs --> people are getting older, changing of traditional diet to a more western diet, more stationary work / lifestyle than before 
  • Causes of death  
    • Early death from enteric infections, respiratory infections and tuberculosis, maternal and neonatal disorders dropped
    • Common diseases (NCDs as CVDs and cancer) are a common cause for mortality now
    • An unintended consequence of increased access to health care globally is increases in mortality from diseases and disorders linked to antibiotic resistance
  • Many of the leading causes of disability --> low back pain, headaches, and depression, diabetes 
  • Smoking and high systolic blood pressure are global leading risk factors causing early death and disability
  • Intake of healthy foods was lower than the optimal intake in all regions (with a few exceptions)
  • Intake of unhealthy foods was higher than the optimal intake in many regions
    • Sugar-sweetened beverages and salt: Higher in all regions
    • Red and processed meat: Higher in several regions


 

Q:

Unhealthy diet is one of the most important risk factors for developing NCDs, such as cardiovascular diseases (CVD). Which are the most important dietary factors affecting the development of CVD? Explain the effect of saturated fatty acids (SFA) versus polyunsaturated fatty acids (PUFA) on risk of developing CVD at the different levels of evidence (cohorts, RCTs, mechanistic studies). What is the percentage reduction in cholesterol levels likely to obtain by exchanging 5E% of SFA with PUFA, and what is the expected risk reduction in developing CVD after a 10% reduction in total cholesterol levels? What are the most important sources of fat in a western diet, including sources of SFA and PUFA?

A:

NCDs

  • chronic diseases
  • don't pass from one person to another
  • tend to be of long duration
  • are a result of the combination of genetic, physiological, environmental and behavioural factors


Cardio Vascular Disease (CVD)
  • Leading cause of death and disabilities worldwide --> 32 % of all deaths globally (2019)
  • >3/4 of CVD deaths take place in low- and middle-income countries
  • Globally 1 in 10 people aged 30-70 die from CVD 
  • Group of disorders that include:
    • Coronary heart disease
    • Deep vein thrombosis and pulmonary embolism
    • Peripheral arterial disease


  • CVD Result of Atherosclerosis = Disorder of circulatory system, affecting large and medium size arteries
    --> Narrowed blood vessels lumen because of lipid-containing plaques raised and thickened from vascular luminal walls
    --> Lifelong process 
  • Driven by Hypercholesterolemia (Circulating LDL) and endothelial dysfunction
  • It is important to detect CVD as early as possible so that the management with counselling and medicines can begin


Role of cholesterol

  • Reduction in LDL-cholesterol reduce the risk of CVD

  • Atherosclerotic plaques is driven by hypercholesterolemia

  • Excess LDL infiltrates the blood vessel’s intimal layer

  • LDL can be oxidized (oxLDL) which leads to oxidative stress that causes inflammation

  • OxLDL is taken up by macrophages and they build a foam cell

  • Lipid core with fibrous cover --> atherosclerotic plaque

  • Chronic low-grade inflammation --> atherosclerosis --> CVD

  • Plaques grow over many years and can develop large lipid-rich necrotic cores, making them unstable 
  • The rupture of an atherosclerotic plaque causes a blood clot (thrombosis)


--> Non-modifiable risk factors: Genes, Gender, Age
--> Modifiable risk factors: Tobacco, Physical inactivity, Overweight and obesity, Alcohol, Unhealthy diet (saturated fat)


Dietary factors: dietary fats and fiber intake

  • Reduction of SFA intake and replacement with PUFAs --> Reduction of cholesterol levels --> Reduction of CHD mortality
    • SFA: increase blood cholesterol levels, especially LDL-Cholesterol
  • Cholesterol levels in blood is one of the most important markers
  • increasing intakes of PUFA are of greater benefit for cardiovascular health than further reduction of SFA intake
  • soluble fiber can inhibit absorption of cholesterol, inhibit reabsorption of bile acids and reduce hepatic cholesterol synthesis
     

--> unhealthy eating patterns support the development of CVD

  • Excessive intake of sodium and processed foods
  • High intake of SFA and a low intake in PUFA
  • Added sugars
  • Unhealthy fats (high SFA and low PUFA)
  • Low intake of fruit and vegetables, whole grains, fiber, legumes, fish, and nuts
  • Global recommended fat intake: similar worldwide



WHO: Risk of developing NCDs is lowered by reducing saturated fats < 10% of total energy intake and trans fats <1 % and replacing both with unsaturated fats

 

effect of saturated fatty acids (SFA) versus polyunsaturated fatty acids (PUFA)
  • Meta Study: 5% lower energy intake from SFAs and a concomitant higher intake of PUFAs showed a significant invers association between PUFAs and risk of coronary events 
  • Randomized crossover trial 

    • Replacement of SFA with PUFA for 3 days 
    • Beneficial effect on serum cholesterol (8%), but not glycemic regulation 
  • Cohort Study Uppsala Longitudinal Study of Adult Men (ULSAM)

    • The amount of linoleic acid in the serum was associated with a protective effect from CVD deaths with a risk reduction of ca. 15% --> exchanging 5E% of SFA with linoleic acids leads to a 13% reduced risk of CHD-death 
  • Mechanistic studies 

    • effects of PUFA  the lipid metabolism

 

Percentages of reduction in cholesterol levels likely to attain when changing SFA with PUFA

  • Cohort and RCTs show that increase in PUFA intake reduce level of cholesterol and risk of CVD
  • Exchanging 5 E% SFA with PUFA leads to a 10 % reduction in total- and LDL-cholesterol
  • 10 % reduction in LDL-cholesterol reduces risk for CVD with 27% (dependent on age) --> the lower the age the more effective the risk reduction when reducing the total cholesterol level

 

most important sources of fat in a western diet, including sources of SFA and PUFA

  • SFA
    • Dairy products
    • Added fats and oils from animal sources
    • Meat and meat products
    • Highly processed food 


  • PUFA
    • Added fats and oils --> plant-based margarine, or fish-based
    • Cereals and cereal product
    • Meat and meat products
    • Avocado
    • Salmon
    • Nuts and Seeds (Walnut, almond, pumpkin)
Q:

Why is obesity a risk factor for developing NCDs? What is the difference between subcutaneous and visceral/abdominal adipose tissue, and how do the different adipose tissues affect metabolic regulation? Explain the connection between adipose tissue and development of type 2 diabetes (T2D). Give examples of food that will reduce the risk of T2D.

A:

Adipose Tissue

  • Adipose tissue = A type of specialized connective tissue whose main functions are to store the energy, protect the organs and contribute to the endocrine profile of the body
  • Types: Depending on location --> Subcutaneous fat (located between the skin and the abdominal muscles) and visceral fat (under the abdominal muscles, in the abdomen) 
  • Function: 
    • Energy storing (very large amount of energy with little volume and weight as TAG)
    • hormone production (adipokines)
    • thermal isolation (white adipose tissue)
    • thermogenesis (brown adipose tissue: high in Mitochondria --> Use Fat Oxidation for energy production; mostly present mostly in newborns and infants)
    • mechanical protection
    • Store cholesterol and Vitamins D and E


Effect on metabolic regulation 

--> Visceral

  • Effect on metabolic regulation--> Visceral
  • Endocrine tissue/organ
  • Low insulin sensitivity
  • Influencing production of cholesterol by releasing free fatty acids into the bloodstream and liver
  • Makes proteins cytokines --> triggers low-level inflammation = risk factor for heart disease and other chronic conditions
  • Produces a precursor to angiotensin = protein that causes blood vessels to constrict and blood pressure to rise
  • Ectopic fat deposition: Fat also stored in Liver, Heart and Skeletal muscle --> Metabolic dysregulation of adipose tissue --> Altered metabolism and altered release of adipokines --> Lipid Overflow --> Ectopic fat: Increase in Muscle fat / epicardial fat / liver fat and altered functions --> Insulin Resistance and Dyslipidemia 

 

--> Subcutaneous

  • “Healthy” adipose tissue
  • No Ectopic Fat: Low muscle fat / low epicardial fat / low liver fat and normal functions --> Normal metabolic profile

 

Adipose tissue is an endocrine organ


 

Diabetes and T2DM

  • The majority of T2DM patients live in low- and middle-income countries
  • With T2DM there is an increased risk of premature death, CVD, nephropathy, neuropathy and retinopathy
  • T2DM is closely linked to the epidemic of obesity
  • Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose
    • Pancreas does not produce enough insulin or
    • The cells cannot utilize the produced insulin due to IR
  • In T2DM the body produces too little insulin and/or is unable to respond to it
  • Risk factors are
    • Advancing age
    • Obesity --> BMI is the single most important risk factor 
    • Poor diet
    • Family history of T2D
    • Physical inactivity
    • Ethnicity
    • Increased blood glucose levels


Normal regulation of blood glucose levels

  • regulated by insulin and glucagon
  • Insulin is produced in the pancreatic ß-cells
  • Food intake increases the blood glucose --> insulin is released by the ß-cells which stimulates the glycogen formation as well as the glucose uptake from the blood and leads to a lower blood sugar
  • If the blood sugar is low in between meals --> Glucagon is released which stimulates the glycogen breakdown and leads to an blood sugar rise


Glycemic dysregulation in T2DM

  • Cells don’t react to insulin that is released by the pancreas
  • The pancreas gets thereby the signaling to produce even more because the glucose is still in the bloodstream which leads to a high blood sugar 
  • insulin resistance 


food that will reduce the risk of T2D

  • Consuming more PUFA in place of saturated fats e.g. Avocado, salmon, nuts and seeds instead of highly processed foods and read meat 
    • Improves insulin sensitivity in the long term
    • Could be because PUFA reduces inflammation and thus improves insulin sensitivity while SFA increases inflammation  
    • High intake of total fat (> 37 % of energy intake) reduces insulin sensitivity regardless of fat quality
    • Fat quality can lead to changes in the gut microbiota and thereby the production of SCFA
    • Fiber-rich foods e.g. whole grain bread or pasta, oats, vegetables
    • High intake of fiber is associated with reduced prevalence of T2DM in the nurses health studies I and II
    • Beta-glucan (soluble dietary fiber) has been shown to improve glycemia
    • Bacterial fermentation of beta glucan in the gut causes production of short chain fatty acids that may affect metabolic status of the host (human)
    • SCFA are taken up into the blood stream where they can bind to receptors and affect incretin hormones, reduce inflammation and also impact gluconeogenesis in the liver (building of glucose in the liver)
  • Low Calorie food or at least not over the --> Prevention of Obesity e.g. food that are high in volume and have a low energy density like lean white meat, vegetables, salad
  • Other factors to reduce the risk or delay the onset of T2DM
    • Regular physical activity
    • Maintaining a healthy body weight
    • Avoiding tobacco
Q:

What is the difference between dietary guidelines and nutrient recommendations? What characterizes the two different kinds of recommendations and how are they used? 


A:

Nutrient recommendations:

  • focus on preventing deficiency diseases and the prevention of diet related NCDs
  • State recommended intake of energy, macro- and micronutrients for groups of healthy people over a longer period of time
  • Formulated as Dietary Reference Values, DRV, which is the term used both in the EU, as published by EFSA and in the Nordic Nutrition Recommendations, NNR (US: Dietary Reference Intakes)
  • Vary by age, sex and physiological state (e.g., pregnancy, lactation)
  • Can be used to compose diets at the group level and to assess nutrient intake of individuals and groups. However, nutrient recommendations are equal to nutrient requirements in individuals and cannot be used to estimate nutritional status
  • Objective: Population meets needs for essential nutrients to maintain physiological functions and avoid toxic intakes


Food-based dietary guidelines

  • Provide more concrete recommendations for how diet and food groups can be put together to contribute to good health, reduce the risk of obesity and NCDs and ensure adequate intake of nutrients
  • intended to establish a basis for public food and nutrition, health and agricultural policies and nutrition education programmes to foster healthy eating habits and lifestyles
  • provide advice on foods, food groups and dietary patterns to provide the required nutrients to the general public to promote overall health and prevent chronic diseases
  • a lot of countries use food guides as a graphic representation if the guidelines


What are the recommendations based on?

  • Both based on systematic methodology that summarizes the totality of the available knowledge, across different study types
  • Systematic literature reviews and meta-analysis are used to summarize the entirety of existing research --> Predefined plan for how studies are to be identified, evaluated and summarized
  • Dietary guidelines are central in nutrition - we need to know what the optimal diet is at various life stages in order to be able to assess whether people are eating healthily

 

How are they used?

  • National dietary guidelines offer guidance to both individuals, policy makers, researchers and the food industry
  • Often shaped into messages/advice/recommendations communicated to general population to help people make the right food choices
  • typically propose a set if recommendations in terms of foods, food groups and dietary patterns to provide the required nutrients to promote overall health and prevent chronic diseases
  • Provide a way for monitoring the healthiness of the food intake of the population --> monitor how the situation changes --> form the basis for national food and nutrition policies --> plan strategies and programs to improve the situation and target the most vulnerable groups
  • Used by the food industry to guide them in making and promoting healthier food products
  • need to be integrated in national food, agricultural, education and/or health policies and programmes and involve a wide range of stakeholders (government, NGOs, mass media ...)
  • are needed because
    • the majority of countries face a serious burden of two or three forms of malnutrition: undernutrition, micronutrient deficiencies, obesity and diet-related diseases (T2DM, CVD, Cancer)
    • they can serve to guide a wide range of food and nutrition, health, agriculture and nutrition education policies and programmes 
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Q:

Explain what food-based dietary guidelines are. What are some of the most important weaknesses with dietary guidelines?

A:

What are FBDG?

  • Food-based dietary guidelines (also known as dietary guidelines) are intended to establish a basis for public food and nutrition, health and agricultural policies and nutrition education programs to foster healthy eating habits and lifestyles
  • Guidelines are intended to influence consumer behavior and inform a range of national food, nutrition, and health policies and programs
  • They provide advice on foods, food groups and dietary patterns to provide the required nutrients to the general public to promote overall health and prevent chronic diseases
  • Type of evidence used to inform FBDG include: assessment of food and nutrient intakes, food supplies, prevalence and public health importance of diet-related health and nutrition outcomes, cultural preferences etc.
  • FBDGs can be either on a national or regional level 
  • Most common 3-group combination: starchy staples, fruit and vegetables, protein foods
  • Most countries with FBDG publish food guides, often in the form of food pyramids and food plates, which are used for consumer education

 

Why more focus on FBDG

  • Easier for people to relate to food than to nutrients --> We eat food not nutrients
  • Graphic presentation makes the FBDG-information accessible also for people who are not familiar with the (national) language in which they are presented
  • One food delivers more than one nutrient
  • Obesity and NCDs biggest disease burden mainly driven by intake of foods and not nutrition
  • Increasing knowledge base about how diet is associated with NCDs --> Summarize knowledge in systematic way
  • Increasing focus on “food matrix” --> not just nutrients and individual components but food as such 
  • Increasing focus on impact processing on health (ultra-processed food)

 

Why is it challenging to study relationship between diet and health?

  • Long latency period: cumulative exposure over many years or relatively short exposure many years before diagnosis --> impossible and unethical with RCTs 
  • Complex web of causes for NCDs: Diet, genetics, occupation, psychosocial factors, infectious diseases. Physical activity etc. --> High risk of confounding factor / bias
  • The conditions are (mostly) not reversible 
  • Cohort studies (mostly measured on the beginning), Observation study

 

Why is it challenging to study relationship between diet and cause of NCDs?

  • Diet varies from day to day, with seasons and changes over time --> difficult to give detailed and correct description of diet (Recall bias)
  • Difficult to measure usual food intake (bias related to dietary assessment methods)
  • In Cohort studies, diet often measured only at beginning --> do nor capture later changes
  • New foods on market --> need to continuously update food composition tables accordingly (is home-made bread better than brought?)
  • Food intake is difficult to blind / control

 

Why is it challenging to study diet as cause of illness?

  • Most people in western eat relatively well, extreme intake is unusual --> difficult to see clear effects / differences
  • When intake of food increases, one eats less of something else --> Effect because you ate less meat, or you ate more lentils? 
  • Diet consists of many factors --> difficult to distinguish what is factor influencing health
  • Challenges with good data on nutrient content in food 

 

Future frontiers

  • Sustainability of diets is not addressed in most current FBDGs --> becomes an more and more important and should therefore be included (meat consumption, regional and seasonal fruits and veggies, food waste)
    • Nordic Nutrition Recommendations plan to focus more on that in the next release 2022
  • Greater attention in some FBDGs could be paid to socioeconomic equity and inclusion of indigenous groups 
  • greater attention to nutrition transition and the rise in consumption of ultra-processed/junk foods (e.g. with the note: food to limit)
  • weaknesses
    • can be influenced by the industry e.g. lobbying
    • portions are very variable
    • dosnt take preferences into account
Q:

What is Bourdieu's contribution to our understanding in social differences in health? 


A:
  • Each individual occupy a position in society according to its capital (economic, social and cultural capital)
    • Economic: money and material assets
    • Social: aggregate of actual or potential resources connected to stable networks of acquaintances —> advantages that grow out of networks 
    • Cultural: knowledge that exists in three different forms; incorporated dispositions (embodied or reflective), objectivized (books, tools, kitchen supplies etc.) and institutionalized (education degrees)
  • Economic and social capital are linked to cultural capital by the access they provide to education and social networks (e.g. tuition and club-membership fees)
  • cultural capital determines accumulation and development of economic and social capital; for instance, education may give access to better-paid jobs, and shared norms and values are necessary to enter certain social networks
Q:

The Oslo schools are introducing free-meals for kids from 8th to 10th grade. Response to this initiative has been varying and particularly kids from 10th grade do not participate much to the free-meals. What can influence participation to school meals and what would you do to promote higher participation?


A:
  • Eating in the school-canteen might be considered as “uncool” by the older kids as only the younger ones eat in the school
  • Food is not tasty and the variety is not good enough
  • Friends might influence the decision to eat in the school canteen
  • Acceptance/Participation is influenced by:
    • Food quality, often school canteens offer fatty and unhealthy food that is not freshly prepared (cook and chill) and it therefor does not look appealing to the students --> in my school older students were allowed to leave the school in lunch break and would rather get some food at another place outside the school
    • Nutritional knowledge that the students get to know in their classes
    • Participation of teachers on the lunch in the canteen
    • Breaks are too short for eating in the canteen --> long waiting times
    • especially older children have a busier schedule  
    • Hectic, noise, too little space --> not a nice atmosphere to eat in
    • Not that much variation in food choices --> especially older children had the same options over a long time 
    • Unfriendly staff

 

Promote higher participation

  • More and healthier food choices, preferably freshly cooked
  • Easy process to order or preorder food 
  • Enough time in the lunch-break to eat 
  • Nice atmosphere with appealing premises
  • Furniture, Ceiling and wall elements for noise reduction
  • Teachers should participate at the lunch to be a role model for students participation
  • Friendly staff in the canteen
  • Giving students the possibility to give feedback which is then acted upon where possible
  • two or more meals to chose from (not only a vegetarian option)
  • Food habits are formed at a young age --> if the free meals are offered from a young age it becomes a routine; maybe forbid young children to leave the school grounds during lunch break to form habits)
Q:

Discuss what food systems models are and how they can be used to analyze and act on challenges related to food, diet and nutrition


A:

Food Systems

  • A food system gathers all the elements (environment, people, inputs, processes, infrastructures, institutions etc.) and activities that relate to the production processing, distribution, preparation and consumption of food, and the output of these activities, including socio-economic and environmental outcomes --> everybody and everything involved in bringing food from farm to fork
  • Sustainable food system: ensures food security and nutrition for all in such a way that the economic, social and environmental bases to generate food security and nutrition of future generations are not compromised 
  • Constituent elements of food systems
    • Food supply chains: Production systems, storage and distribution, processing and packaging, retail and markets, (waste management?)
    • Food environments: physical, economic, political and socio-cultural context in which consumers engage with the food system to make their decisions about acquiring, preparing and consuming food
    • Consumer behavior: decisions made by consumers, at the household or individual level, on what food to acquire, store, prepare, cook and eat, and on the allocation of food within the household (including gender repartition and feeding of children)
    • Diets
    • Nutrition and Health outcomes
  • Food systems are highly interconnected, any intervention or policy that addresses one part of the system will affect other parts
  • Food systems depend on the environment and natural resources, but food system activities can degrade and impair these resources
  • Drivers
    • Biophysical and environmental drivers
    • Innovation, technology and infrastructure drivers
    • Political and economic drivers
    • Socio-cultural drivers
    • Demographic drivers
  • Who influences and engages with food systems?
    • Farmers, livestock producers and fishers
    • Private sector: affects food production, pricing and affordability, consumer attitudes and perceptions, and public policy; businesses are involved in every stage of the FSC
    • Governments: In some countries, governments directly manage and even participate in food production, while in other countries, the state regulates and facilitates the activities of food systems through policy; influence both private sector and consumers
    • Civil society: non-governmental organizations may operate at the local or global level to support positive nutrition, health, and environmental outcomes

 

  • It’s important to know what is included in the model to take action and make changes in different drivers/constituent elements --> there is not only one way to change the situation, by changing different elements one can reach goals in different ways and everyone fits in a different way to a different country
  • Because of the interaction it is often not enough to change just one part --> it is often necessary to make changes on different levels
  • Food system models can help to identify challenges and help solve them


--> traditional food system

  • Traditional food systems are associated with the highest prevalence of undernutrition
  • people generally live in rural areas
  • dietary diversity can be low partly because people rely mainly on locally grown, fished, herded, hunted or gathered foods and often lack appropriate infrastructure to access distant market
  • People tend to grow much of their own food and buy food from local daily and weekly wet markets, and from kiosks
  • markets primarily sell fresh foods, but may also sell some packaged foods
  • kiosks sell staples, such as cooking oil and sugar, as well as packaged foods and convenience foods, such as instant noodles and snack foods
  • Foods are often not monitored for quality and safety
  • Many people’s diets primarily consist of staple grains such as maize, rice and wheat, and do not contain sufficient amounts of protein and micronutrients --> often high stunting rates and micronutrient deficiencies

 

--> mixed food system

  • Higher proportion of people living in peri-urban areas and having greater income than in traditional food systems
  • Wider range of “food entry points” 
  • Access to supermarkets is available but may be limited especially in low income areas
  • More access to prepared meals eaten outside the home
  • people tend to have access to diverse foods, leading to sufficient calorie and protein intakes 
  • Better nutritional status, as well as advances in water provision, sanitation, hygiene and other medical services, lead to lower incidences of, and mortality from, infectious diseases as well as well as less undernutrition
  • hygiene and other medical services, lead to lower incidences of, and mortality from, infectious diseases. With the availability and popularity of processed foods, there is increased intake of saturated and trans fats and sugar 
  • Some dietary changes result in these systems in an increasing incidence of overweight and obesity and lead to an increased incidence of, and morbidity from, NCDs such as cardiovascular disease and diabetes. While life expectancy increases due to the decrease in infectious diseases, morbidity increases due to the rise in NCDs 

 

--> modern food system

  • higher proportion of people tend to live in urban areas and have greater incomes and an overwhelming number of food choices 
  • consumers often live far from where their food is produced
  • through technological an infrastructural advances (including distribution and exchange/trade), a wide variety of foods is accessible to consumers all year long
  • consumers have options as to where they procure their foods 
Q:

In country X there is a high prevalence of undernutrition (a high proportion of children are stunted) and in country Y there is a high prevalence of overweight and obesity. Explain how you can use a food systems model to analyze the causes of these situations.

A:

Food Sytems

  • A food system gathers all the elements (environment, people, inputs, processes, infrastructures, institutions etc.) and activities that relate to the production processing, distribution, preparation and consumption of food, and the output of these activities, including socio-economic and environmental outcomes --> everybody and everything involved in bringing food from farm to fork
  • Sustainable food system: ensures food security and nutrition for all in such a way that the economic, social and environmental bases to generate food security and nutrition of future generations are not compromised 
  • Constituent elements of food systems
    • Food supply chains: Production systems, storage and distribution, processing and packaging, retail and markets, (waste management?)
    • Food environments: physical, economic, political and socio-cultural context in which consumers engage with the food system to make their decisions about acquiring, preparing and consuming food
    • Consumer behavior: decisions made by consumers, at the household or individual level, on what food to acquire, store, prepare, cook and eat, and on the allocation of food within the household (including gender repartition and feeding of children)
    • Diets
    • Nutrition and Health outcomes
  • Food systems are highly interconnected, any intervention or policy that addresses one part of the system will affect other parts
  • Food systems depend on the environment and natural resources, but food system activities can degrade and impair these resources
  • Drivers
    • Biophysical and environmental drivers
    • Innovation, technology and infrastructure drivers
    • Political and economic drivers
    • Socio-cultural drivers
    • Demographic drivers
  • Who influences and engages with food systems?
    • Farmers, livestock producers and fishers
    • Private sector: affects food production, pricing and affordability, consumer attitudes and perceptions, and public policy; businesses are involved in every stage of the FSC
    • Governments: In some countries, governments directly manage and even participate in food production, while in other countries, the state regulates and facilitates the activities of food systems through policy; influence both private sector and consumers
    • Civil society: non-governmental organizations may operate at the local or global level to support positive nutrition, health, and environmental outcomes

 

traditional food system

  • Traditional food systems are associated with the highest prevalence of undernutrition
  • people generally live in rural areas
  • dietary diversity can be low partly because people rely mainly on locally grown, fished, herded, hunted or gathered foods and often lack appropriate infrastructure to access distant market
  • People tend to grow much of their own food and buy food from local daily and weekly wet markets, and from kiosks
  • markets primarily sell fresh foods, but may also sell some packaged foods
  • kiosks sell staples, such as cooking oil and sugar, as well as packaged foods and convenience foods, such as instant noodles and snack foods
  • Foods are often not monitored for quality and safety
  • Many people’s diets primarily consist of staple grains such as maize, rice and wheat, and do not contain sufficient amounts of protein and micronutrients  often high stunting rates and micronutrient deficiencies

 

--> mixed food system

  • Higher proportion of people living in peri-urban areas and having greater income than in traditional food systems
  • Wider range of “food entry points” 
  • Access to supermarkets is available but may be limited especially in low income areas
  • More access to prepared meals eaten outside the home
  • people tend to have access to diverse foods, leading to sufficient calorie and protein intakes 
  • Better nutritional status, as well as advances in water provision, sanitation, hygiene and other medical services, lead to lower incidences of, and mortality from, infectious diseases as well as well as less undernutrition
  • hygiene and other medical services, lead to lower incidences of, and mortality from, infectious diseases. With the availability and popularity of processed foods, there is increased intake of saturated and trans fats and sugar 
  • Some dietary changes result in these systems in an increasing incidence of overweight and obesity and lead to an increased incidence of, and morbidity from, NCDs such as cardiovascular disease and diabetes. While life expectancy increases due to the decrease in infectious diseases, morbidity increases due to the rise in NCDs 

 

--> modern food system

  • higher proportion of people tend to live in urban areas and have greater incomes and an overwhelming number of food choices 
  • consumers often live far from where their food is produced
  • through technological an infrastructural advances (including distribution and exchange/trade), a wide variety of foods is accessible to consumers all year long
  • consumers have options as to where they procure their foods 
  • many options for prepared meals eaten outside the home, such as fast casual and fine dining restaurants and gourmet food trucks 
  • wide range in food prices, with fresh produce being more expensive than most packaged foods 
  • relative costs compared with staples is lower than the traditional food systems
  • Strong regulations and means of implementation enable a strict control of food quality and safety 
  • the abundance of food, especially highly-processed food, is associated with increased risk of overweight, obesity and NCDs 
  • increases in income and education are likely to make people more aware of the relationship between diet, nutrition and health. People in these systems also tend to have increased access to, and quality of, medical care, including the prevention and management of NCDs

 

Country X: undernutrition 

  • this country has a traditional food system 
  • Malnutrition is inadequate dietary intake to individuals’ needs and undernutrition (dietary energy deficiency) is one form of it
  • Dietary energy: kcal from proteins, carbohydrates and fats
  • Indigenous peoples are generally among the most vulnerable to different forms of malnutrition because of: marginalization; extreme poverty; violations of their inherent rights to their traditionally occupied or used lands, territories and resources; environmental and ecosystem degradation; and decline in their traditional food sources
  • Health consequences: increased risk or morbidity and mortality

 

Country Y: overweight

This country is either a country with a modern food system or with a mixed system (traditional to modern)

-->  example PIC

  • Nutrition transition because of globalization and increasing international trade (trade agreements): import of nutritionally poor, energy dense and inexpensive food is increasing
  • Apart from political and economic drivers (globalization, disposable income of the urban population and Low costs) Consumer behavior (that pacific islanders lack the awareness of the consequences of poor nutrition), changes in the food supply chain (decreasing access to land for growing food,) and demographic drivers (rapidly growing population) are reasons for the increase
  • Change in consumer behavior has an influence on the individual health --> modern/western diet is associated with higher prevalence of the metabolic syndrome
  • Another important driver are biophysical and environmental drivers, as climate change has a mayor influence on the PIC food system --> affects the agriculture on the PIC
Q:

Provide 3 examples of frameworks/theories for understanding social inequalities in health. Please use the framework/theory to explain why social inequalities in health may arise.  

A:

 Social inequalities in health

  • systemic differences in health outcomes that arise from social conditions in which people are born, grow, work, and age
  • have significant social and economic costs to society
  • inequities
    • differences caused by uneven distribution of resources
    • avoidable 
    • unjust and unfair
    • for example: a social group difference in health, such as those based on race or religion 


Theorie, examples

  • Material factors: 
    • availability of/access to sanitary facilities
    • people with higher socioeconomic backgrounds and higher income are able to afford sufficient health care when needed and are also able to ensure nutrition that meets the recommended supply of macro and micro nutrients
  • Geography: access to sufficient health care
  • Health behavior: 
    • low income and therefore more likely to buy/consume cheap but high processed foods
    • if the mother of an unborn child smokes and drinks alcohol during pregnancy or is not able to feed herself according to recommendations, the child might suffer from diseases
  • Geography, Space: air pollution that exacerbates asthma symptoms would be an example of a health risk that is distributed across space. Proximity to landfills, crime clusters, and health clinics are other examples of spatially patterned health risks and protective factors
  • Geography, Place: Many government run programs and policies that affect health, such as food assistance programs or tax policies, are specific to administrative units and operate uniformly within their boundaries. As a result, the health impacts of a wide range of programs and policies do not depend on residents’ precise physical location, but rather on membership in a given political or administrative unit
  • Selection: people who value physical activity may be more likely to move to walkable areas, while sedentary individuals might choose to live in auto-dependent suburbs
  • Selection: relationship between SES and health as a product of selection by arguing that genetically superior individuals are more likely to have good health and high IQ, therefore explaining why highly educated, high income individuals are generally healthier


  • Bordieu: reach high level of health literacy (critical or even communicative): better ability to learn how to understand information and apply informtion to changing situations or even critically analyze this information to gain greater control over life events and self management
    • people with higher socioeconomic status have better abilities to gain higher levels of health literacy and therefore inequalities in health may arise --> they are able to better apply information they got to know by reading or in communication to their food choices and are able to follow prescription plans better as well as seek a doctor when needed

 

Theories for inequalities in health 

  • Material factor  
    • food, shelter, pollution, and other physical risks and resources (income) 
  • Psychosocial factors, discrimination
    • social exclusion, discrimination, stress, low social support, and other psychological reactions to social experiences
  • Health behavior: diet, physical activity, alcohol consumption, smoking etc.
  • Geography: place vs. space 
    • space: exposure to spatially distributed health risks and protective factors will change according to an individual’s precise location
    • place: membership in political or administrative units, such as school districts, cities, or states
  • Selection
    • people have a tendency to sort themselves into neighborhoods, social groups, and other clusters
    • also sometimes proposed as an explanation for educational, occupational, and even racial/ethnic differences in health
  • Context vs. composition
    • Context: influence a neighborhood or other type of higher level unit has on people
    • Consumption: reflective of the characteristics of individuals comprised by the neighborhood or other setting
  • Biological response to stress
  • Life long, cumulative effect of negative factors starting at birth or pregnancy




WHO Framework of social determinants of health

--> Structural determinants

  • Socio-economic and political context people live in  Governance, social and public policies, social and cultural values placed on health issues 
  • All these can lead to inequal distribution of material and monetary resources that can change a persons socio-economic position 
  • Socio-economic position: education, occupation, income, gender, ethnicity and social class
  • Structural determinants operate through a set of intermediary determinants 

 

--> Intermediary determinants 

  • Impact someones exposure, vulnerability and outcomes to factors influencing their health 
  • This includes Material Circumstances (Money to buy good house, food, cloth, income and work environment), Psychosocial factors (Relationships, stress), Behaviours, Biological Factors 

 

 

Q:

Reflect on how the COVID-19 pandemic may have increased social inequalities in diet and health.

A:
  • Restriction of food supply chains leads to inadequate food and medical supply of some areas (closed borders and less international flights)
  • medical care cannot always be guaranteed due to the overload of the health system
  • economic impact of COVID19 
    • higher prices for fruits, veggies and dietary products
    • It’s even harder for people in poorer regions like Asia, Afrika or the Pacific to afford a healthy diet 
    • negative impact on the food security and availability of sufficient nutrition for all, and for mothers and children in particular
  • People with lower economic status leave in smaller houses and with a lot of people in one house —> social distancing and quarantining is hard for them 
  • People with better paid jobs/higher degrees could work from home while e.g. people working in health care or supermarkets needed to work in the field and therefore have a higher risk of infection (excluding doctor’s)
  • Children of lower socio-economic status had lower access to education because there was not always enough resources for all family member to work from home and they sometimes also got less support from family members 
  • Rich families can afford tutoring for their children to even out the worse education during COVID 
  • lack of decent work opportunities has led to a worsening of inequality, as poorer families with dwindling incomes further alter their diets to choose cheaper, less nutritious foods
  • rations e.g. in migration camps become smaller
  • aid programmes are harder to perform, a lot of helpers were taken back to their home countries in the beginning of the crisis and humanitarian help/projects were neglected
  • inequal access to vaccine (COVID19); besonders betroffen: poor regions
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