Women and Health Learning Package Developed by The Network: TUFH Women and Health Taskforce Second edition, September 2006 docx

NUTRITION AND WOMEN’S HEALTH Global Overview Today it is well recognised that in developing countries, women are one of the most vulnerable population groups in terms of their health an

NUTRITION AND WOMEN’S HEALTH

Women and Health Learning Package Developed by The Network: TUFH Women and Health Taskforce

Second edition, September 2006

Support for the production of the Women and Health Learning Package (WHLP) has been provided

by The Network: Towards Unity for Health (The Network: TUFH), Global Health through Education, Training and Service (GHETS), and the Global Knowledge Partnership Copies of this and other WHLP modules and related materials are available on The Network: TUFH website at http://www.the-networktufh.org/publications_resources/trainingmodules.asp or by contacting GHETS

by email at info@ghets.org, or by fax at +1 (508) 448-8346

About the authors

Pilar Torre Medina-Mora, MPH

Full Professor, Department of Health Care, Division of Biological and Health Sciences

Universidad Autónoma Metropolitana-Xochimilco

Mexico City, Mexico

Pilar Torre, a nutritionist, graduated from the Faculty of Nutrition, Ibero-American University, Mexico, and holds a masters degree from the National Institute of Public Health, Cuernavaca, Mexico She began work at the Metropolitan Autonomous University, Xochimilco Campus (UAM-X) in 1992, and has been a full professor since 2000 Before entering the UAM, she worked at the Ministry of Health and at the National Institute of Nutrition, Mexico Her academic interests include infant and child nutrition, breastfeeding practices, and women’s health and nutrition She was the coordinator of the Research Unit on Health and Society, and she teaches subjects related to infant and maternal health and nutrition She also collaborated in the design of a new curriculum proposal to train nutrition professionals at the UAM-X Pilar Torre served as an external advisor to UNICEF, from 1982

to 1986, and to the High Commissioner of United Nations for Refugees from 1989 to1992, in the implementation of emergency programs for Guatemalan refugees in the south-eastern region of Mexico She collaborates with a Mexican NGO dedicated to the improvement of the nutritional status of indigenous children and women, in the state of Chiapas, Mexico, since 1994 She has been a member of The Network: TUFH Taskforce on Women and Health since 2004 E-mail: ptorre@correo.xoc.uam.mx

Deyanira González de León Aguirre, MD, MPH

Full Professor, Department of Health Care, Division of Biological and Health Sciences

Universidad Autónoma Metropolitana-Xochimilco

Mexico City, Mexico

Deyanira González de León graduated from the Faculty of Medicine, National Autonomous University of Mexico, and holds a master’s degree from the Institute of Health Development, Havana, Cuba She began work at the Metropolitan Autonomous University, Xochimilco Campus (UAM-X) in 1981, and has been a full professor since 1992 Her academic interests

include health promotion and education, gender studies, and women’s sexual and reproductive health She was the coordinator of the Research Unit on Education and Health, and is currently responsible for the project “Abortion Care in Mexico: Physicians’ Attitudes towards Abortion” She also conducted a project on women and medicine in Mexico, and has collaborated in other research projects at the UAM-X She teaches subjects related to women’s sexual and reproductive health in both undergraduate and graduate university programs, and collaborated in the design of a new curriculum proposal to train nutrition professionals at the UAM-X Deyanira González de León served as an external advisor from 2001-2002 to Ipas Mexico, a non-profit agency working to improve women’s lives by focusing on reproductive health She has been a member of The Network: TUFH Women and Health Taskforce since 2002, and previously served on the Taskforce Management Committee (2004-2005) E-mail: deyagla@yahoo.com.mx and dgonzal@correo.xoc.uam.mx

Fernando Mora Carrasco, MD, PhD

Full Professor, Department of Health Care, Division of Biological and Health Sciences

Universidad Autónoma Metropolitana-Xochimilco

Mexico City, Mexico

After studying medicine at the University of Chile and Microbiology at the University of Illinois (1952-1962) Fernando Mora moved to Cuba, where he collaborated until 1969 in the development of medical education and biomedical research From 1969 until 1974 he was professor at the Faculty of Medicine of the National Autonomous University of Mexico Since 1974 he has been a full professor at the Metropolitan Autonomous University, Xochimilco Campus, where he has been Director of the Division of Biological and Health Sciences and Coordinator of the Program in Medicine, among other responsibilities He has been an invited professor at the medical schools of Brown University and University of California at San Francisco, in the USA, and the University of Helsinki, in Denmark He has collaborated with the WHO and PAHO as a temporary advisor on different aspects of health sciences education, and helped in the creation of medical schools in Georgetown, Guyana, and Managua, Nicaragua He has participated in The Network: TUFH since its beginning in

1979, and with GHETS also from its conception in 2002 He has been chairman of the Network: TUFH, and is currently vice-president of the GHETS Board of Directors E-mail:

fmora@correo.xoc.uam.mx and fmora5@yahoo.com

NUTRITION AND WOMEN’S HEALTH

Global Overview

Today it is well recognised that in developing countries, women are one of the most vulnerable population groups in terms of their health and nutritional status Different socioeconomic and cultural factors generate unfavourable nutritional outcomes for many women, and this may in turn seriously affect their health and overall quality of life

Women’s nutritional conditions differ widely among and within countries Such conditions are worst in the less-developed regions and countries of the world, where poverty, social disparities, discrimination, and different kinds of malnutrition affect large populations The nutritional and health status of women may be severely impaired in societies where the political and cultural context allows extreme conditions of subordination, as well as in those countries where the threat of hunger persists because of political conflicts, migration, environmental degradation, or natural disasters On the other hand, not all women who live in developing countries experience nutritional problems in the same way, and such problems do not have the same impact on all women Economic and social inequalities have a strong correlation with the differences in the nutritional status among women in these countries Poor women in general, with limited or no access to nutritious food, education, employment

or adequate health care, are more vulnerable to nutritional deficiencies In developed countries, women in lower income groups may also be affected by nutritional deficiencies because of economic disparities and lack of social protection

During the last decades, global organizations and women’s rights advocates have called on governments to recognise the multiple determinants of women’s health, and there has been a growing consensus about the need to integrate and widen health services to respond to a broad variety of problems affecting them Nutrition is a fundamental pillar of women’s well-being, and women’s right to full and equal access to health care, including adequate nutrition during pregnancy and lactation, has been recognised at many international conferences, including the 1979 Convention on the Elimination of All Forms of Discrimination against Women, the 1987 International Conference on Safe Motherhood, the 1990 World Summit for Children, the 1994 International Conference on Population and Development, the 1995 Fourth World Conference on Women, and the 2000 Millennium Goals Declaration, to name just a few

Experts have made recommendations to incorporate nutrition as an essential component of primary health care, stressing that programs to deal with women’s nutritional problems must

be based on a life cycle approach The nutritional needs of women substantially change during the different stages of their lives A life cycle approach allows a better recognition of specific nutritional needs at every stage of women’s lives, as well as a more comprehensive understanding of the cumulative effects of poor nutrition on women’s health

In many countries, the nutritional deficiencies that affect thousands of women are still neglected Most of the strategies to respond to women’s nutritional needs—such as micronutrient dietary supplementation programs, health education activities, and delivery of medical services—have been mainly focused on pregnant and lactating women, giving little

or no attention to women in other moments of their lives

There is no doubt that the protection of women during pregnancy and lactation must be one

of the major priorities of health systems and social policies The effect of women’s nutritional status on pregnancy outcomes is particularly strong, and adequate maternal nutrition is closely related to the survival and well-being of babies and children However, not all women are mothers, and their nutritional and health needs go far beyond motherhood and reproduction

Women of all ages in developing countries face elevated risks of nutritional deficiencies Therefore much more attention should be paid to the nutritional needs of girls, adolescents and young women, in order to strengthen their overall health, protect them from the cumulative effects of poor nutrition, and prevent problems later in life In fact, the health problems of many women in late adulthood and old age are mostly chronic and often associated with previous nutritional deficiencies

Research has suggested a link between nutritional deficiencies in early (including prenatal) life, and the development of chronic diseases—cardiovascular disease, diabetes mellitus, hypertension, stroke, cancer, and osteoporosis, among others—some decades later (World Health Organization 2000a, 2000b; Jacoby 2004) A possible link between early nutritional deficiencies and obesity has also been suggested, and it remains an area of ongoing research (Pan American Health Organization 2003) These associations are especially relevant for women, since they generally live longer than men, and therefore the complications and disabilities that result from these kinds of diseases are much more common among elderly women

Undernutrition affects large populations of boys and girls in developing countries Its major determinant is poverty, which usually combines with other important factors like poor breastfeeding practices and inadequate complementary foods for babies, as well as lack of basic health care, safe water and sanitation Globally, about 150 million children under five years are undernourished, which comprises 27% of the world’s population in this age group Twelve million of these children die every year, and protein-energy malnutrition is implicated in more than 55% of all these deaths Undernourished children are much more likely to get sick and die from common infectious diseases Chronic protein-energy malnutrition leads to growth retardation and stunting and may severely impair mental and cognitive abilities Undernutrition and a variety of micronutrient deficiencies—iron, calcium, iodine, and vitamins A and D, for example—often start before birth and may continue throughout life (United Nations Children’s Fund 1998; World Health Organization 2000a) The impact of undernutrition on young girls has received special attention In many parts of the world, poverty often interacts with sociocultural factors that make girls and adult women less favoured than men Female infants and children commonly receive less medical care and also less and lower-quality food than male children In a number of countries in the developing world, these discriminatory attitudes result not only in higher rates of protein-energy malnutrition among girls but also in an excess of mortality among them (Gómez 1993; United Nations Children’s Fund 1998, 1999)

Undernourished girls are likely to reach adolescence in disadvantaged physical conditions, and this may in turn have severe implications for their overall health, in particular when they experience early pregnancies Stunted and/or anaemic adolescent mothers are more likely to have complications during childbirth and the postpartum period, as well as to give birth to premature and low-weight babies Closely-spaced pregnancies and repeated childbearing,

along with heavy physical work, poor diets, discrimination and inadequate health care, may severely undermine the nutritional status of many women, with consequences for both them and for the health and nutrition of the next generation (World Health Organization 1997, 2000a; United Nations Population Fund 1997, 2000) Global data indicate that at the end of the 20th century, an estimated 450 million adult women in developing countries were stunted

as a result of chronic protein-energy malnutrition during infancy and childhood (The World Bank 1997)

Nutritional deficiencies during pregnancy usually lead to intrauterine growth retardation, which is one of the main causes of foetal and infant undernutrition in developing countries Every year, 30 million newborns, or 23% of 126 million births per year, are affected by intrauterine growth retardation; by contrast, in developed countries the rate is only about 2% (World Health Organization 2000a) A significant proportion of infant mortality, in particular within the first month of life, is also attributable to poor maternal health and nutrition during pregnancy and the immediate postpartum period (United Nations Children’s Fund 1999) Specific micronutrient deficiencies may affect maternal and foetal health Iodine deficiency during pregnancy may cause foetal brain damage and mental retardation in infants Vitamin

A deficiency increases the risk in pregnant women of infection and anaemia, may cause blindness during pregnancy and early lactation, and has been associated to an elevated risk of HIV mother-to-child transmission Folate deficiency may cause severe foetal neural tube defects like anencephaly and spina bifida Iron deficiency weakens the maternal body, impairs intrauterine growth and increases the risk of both maternal and foetal morbidity and mortality (World Health Organization 2000a)

Anaemia is one of the most common nutritional problems affecting women in developing countries, where iron deficiency usually combines with other micronutrient deficiencies such

as folate and vitamin B In addition, the diet of the poorest populations is often monotonous and mainly based on staple foods, which are low in iron and contain absorption inhibitors Other important factors involved in the occurrence of anaemia include malaria and hookworm infestations, chronic infections such as HIV, and congenital conditions like sickle cell disease, among others Available data indicate that in developing countries the prevalence rates of anaemia among women of reproductive age are extremely elevated (see table 1) In pregnant women the rates vary from 40-60%, and among other women from 20-40% In developed countries, many women are also affected by anaemia, but the prevalence rates are lower (World Health Organization 1992, 2000a; Rush 2000)

The poor nutritional status of women in developing countries has been associated with maternal mortality Maternal deaths do not result from malnutrition alone, however, but mainly from a lack of access to obstetric care and from previous conditions that may be aggravated by poor nutrition For example, maternal deaths caused by obstructed labour are more common in malnourished adolescents and young women with a short stature and small pelvic size; and deaths resulting from haemorrhage during childbirth and the immediate postpartum period may be associated with severe anaemia (Rush 2000)

Obesity and overweight are also among the most relevant nutritional problems of women worldwide The obesity epidemic has rapidly been increasing around the world over recent decades, affecting virtually all social and age groups in both developed and developing countries An estimated 200 million adults worldwide were obese in 1995, a number which had risen to 300 million by 2000 In addition, more than 17 million children under five years

were overweight (World Health Organization 2000a, 2000b) Child obesity is associated with many health problems, and it has been observed that the most important long-term consequence of childhood and adolescent obesity is its persistence into adulthood (Pan American Health Organization 2003)

In a number of developing countries, obesity currently affects all income groups of adult men and women, but it is rapidly increasing among poor urban populations The increase in obesity in these countries is attributed to the conjunction of complex societal factors, such as urbanization, economic growth and modernization, globalisation of food markets, and changes in diet and physical activity patterns In many cities of the developing world, diet has become higher in fats, refined sugars and processed foods, and the consumption of relatively cheaper but higher-calorie, lower-nutrient foods has been progressively adopted by poor populations These changes in diet patterns combine with a more sedentary life and a marked decreased of physical activity among urban populations (Pan American Health Organization 2003; Jacoby 2004)

Obesity is a chronic disease, and its consequences include an elevated risk of premature death and a variety of serious health problems such as heart disease, hypertension and stroke, diabetes, cancer, osteoarthritis, and accidents, among others (World Health Organization

1997, 2000a) An estimated 35 million deaths from chronic diseases were expected to occur worldwide in 2005, with 80% of them in low-income and middle-income developing countries Along with tobacco smoking and physical inactivity, obesity is responsible for many of these deaths among adults aged 30-69 years (Strong et al 2005) Obesity is also associated with nonfatal but debilitating conditions like sleep apnoea, low back pain, skin diseases, and infertility, which reduce the overall quality of life in overweight and obese persons and are often the primary reason for consultation with health services (World Health Organization 1997, 2000a) In addition, obesity may seriously impair mental health by causing anxiety, depression or eating disorders; obese persons are often stigmatised as weak-willed, lazy and unhygienic in their personal habits, because of generalised negative attitudes towards obesity and dominant perceptions about body image (Pan American Health Organization 2003)

Surveys from both developed and developing countries have shown that obesity rates are in general higher in women, although overweight is more frequent in men (see table 2) Obesity presents a major risk for the health and well-being of women Currently, all health consequences of obesity described above affect many women in both developed and developing countries, but obesity may also have specific negative effects on reproductive health

It has been documented, for example, that high maternal pre-pregnancy weight and excessive weight gain during pregnancy are often associated with adverse pregnancy outcomes, including greater risks of gestational diabetes, childbirth complications, caesarean sections, hypertension and pre-eclampsia, and post-partum obesity Women with severe (morbid) obesity are more likely to experience even poorer outcomes such as stillbirths or neonatal deaths Studies have shown that obesity is frequently associated with hormonal and menstrual disorders, as well as with polycystic ovary syndrome, infertility, and higher risks of endometrial, ovarian, cervical, and breast cancer It has also been reported that obesity may reduce the effectiveness of some hormonal contraceptives, and implies technical difficulties for inserting intrauterine devices and for performing surgical sterilisation or abortions (World Health Organization 1997; Lederman 2001; Grims & Shields 2005)

In many countries, professional education for physicians and nurses has little emphasis on nutrition It is common that when nutritional topics are presented to students the problems and solutions show serious restrictions In the particular case of women, curricular contents are usually selected from a narrow perspective about their health and nutritional needs Currently, the nutritional problems affecting women in the developing world present important challenges for health systems and social policies and should receive more attention

in university programs

Regional Overview: Mexico

The current nutritional and health profiles of the Mexican population reflect notable failures

in the field of social policies Protein-energy malnutrition and infectious diseases are still relevant public health matters among poor rural and urban populations, and they remain common causes of death during infancy and childhood, and even later in life By contrast, overweight and obesity affect a large proportion of the adult urban population and are rapidly increasing among young children and lower income groups; over the last decades, the high prevalence rates of obesity have been a major factor in the increase of chronic diseases, which today constitute the leading causes of general mortality in the country

A general profile of the Mexican population is presented in Table 3 It is important to note that the information contained in this table, as well as in this section, may not give an adequate overview of the social reality prevailing in the country, since average data cannot reflect extensive social inequalities and a wide dispersion of income and ethnicity

Available information shows that the nutritional status of Mexican women differs widely within the country, according to geographical regions, urban and rural areas, and income groups Nutritional deficiencies, anaemia and stunting, for example, are more common in poor women who live in the less-developed regions of the country, in rural and indigenous communities or in marginal urban areas On the other hand, overweight and obesity currently affect women of all income groups, but rates are higher in the more economically advanced regions and big cities Available information also shows that women’s nutritional needs seem

to remain far too low on the national agenda of health priorities

The prevalence rates of anaemia among pregnant and nonpregnant women increased between

1988 and 1999 (table 4) In 1999, an estimated 21% of all women aged 12-49 were anaemic (27.8% of pregnant women and 20.8% for nonpregnant women) Among all nonpregnant women, the rate of anaemia was higher (about 25%) in indigenous minorities (Shamah et al 2003) As a result of the cumulative effects of undernutrition, many adult women had short statures, with an average height of 1.52m for those in reproductive age Specific micronutrient deficiencies affected many women; 40% of nonpregnant women had iron and vitamin C deficiencies, and 5% were deficient in vitamin A and folate (Rivera & Sepúlveda 2003)

According to information about the nutritional status of children under five years, collected in

1999 at the national level, the percentages of boys and girls affected by undernutrition were very similar For example, 8% of boys and 7% of girls had low weight according to their age, and the prevalence of stunting was of 18% and 17%, respectively (Instituto Nacional de Salud Pública 2001) Mortality statistics indicate that deaths attributed to protein-energy

malnutrition and other nutritional deficiencies decreased between 1990 and 2003 However, data presented in Table 5 show that the percentages of deaths because of this cause are slightly higher in women during childhood, early adolescence and even old age (Instituto Nacional de Estadística, Geografía e Informática 2003) In addition, protein-energy malnutrition and nutritional anaemia were among the twenty primary causes of general mortality in women in 2003 (Secretaría de Salud 2005)

Overweight and obesity among women have been dramatically increasing over the last decades (Table 6) At the national level, more than 56% of women of reproductive age were overweight or obese in 1999 (Rivera and Sepúlveda 2003) In Mexico City, where more than one fifth of the country’s total population is concentrated, the prevalence rates of overweight and obesity among low-income adults—both men and women—sharply increased within the period 1995-2002 (table 7); more than 65% of women and 52% of men were overweight or obese in 2002, and the prevalence rates of obesity were higher in women than men (Instituto Nacional de Nutrición 1995, 2003)

Four diet-related chronic diseases—diabetes, heart disease, stroke and hypertension—were the leading causes of general mortality among women in 2003, accounting for more than 36%

of total female deaths (Secretaría de Salud 2005) Breast cancer, which is strongly associated with overweight and obesity, is also a frequent cause of death among Mexican women This kind of cancer has had a marked ascending trend during the last decades; an estimated 706 women died because of breast cancer in 1970, while in 2002 the number of annual deaths had increased to 3860 On the other hand, diet-related chronic diseases are clearly associated with premature deaths among women In 2002, diabetes, breast cancer, stroke, and heart disease accounted for more than one-fifth of the total deaths in women of reproductive age (Secretaría de Salud 2004)

APPENDIX

Table 1: Estimated prevalence of anaemia in women by region, around 1988*

women (%)

Non pregnant women

(%)

All women (%)

Source: World Health Organization, 1992 The prevalence of anaemia in women: a tabulation of

available information Geneva: WHO (WHO/MCH/MSM/92.2)

*Figures may not add up exactly to total due to rounding

** Japan, Australia and New Zealand were excluded from the regional estimates but are

included in the total for developed countries

*** Data collected before political changes USSR: former Union of Soviet Socialist Republics

Table 2: Prevalence of obesity among women and men in selected countries, 1989-1996

Age (years)

Men (%)

Women (%)

United States of America 1994 20-74 20.0 25.0

Source: World Health Organization, 1998 Obesity: preventing and managing the global epidemic Geneva: WHO Pan American Health Organization, 2003 Obesity in the Americas: the challenge to promote healthy nutrition and active living Washington, DC: PAHO

* Low socio-economic level

** Black population, Cape Peninsula

Table 3: General profile of the Mexican population, around 2004

Total population (millions), 2004 Projected population 2050 Average population growth rate (%), 2000-2005 Urban population (%), 2003

Urban growth rate, 2000-2005 Total fertility rate, 2000-2005 Life expectancy of women, 2001 Life expectancy of men, 2001 Births per 1,000 women aged 15-19 Births with skilled attendants (%) Contraceptive prevalence All methods

Modern methods Maternal mortality ratio per 100,000 live births Infant mortality rate per 1,000 live births Under-five years mortality

Boys Girls HIV prevalence rate (%, 15-49) Men

Women Primary enrolment (gross) Males

Females

% of males and females reaching grade 5 Males

Females Secondary enrolment (gross) Males

Females

% of illiterate (aged 15 and over) Males

Females GNI per capita, 2002 Public health expenditures (% of GDP) Primary education expenditures (% of GDP per capita) Energy consumption (per capita)

% of population with access to safe water

104.9 140.2 1.5

76 1.8 2.50 76.4 70.4

88

Source: United Nations Population Fund, 2004 State of world population 2004

The Cairo consensus at ten: Population, reproductive health and the global

effort to end poverty New York: UNFPA

Table 4: Prevalence of anaemia among Mexican women of reproductive age (12-49 years), 1988 and 1999

Description

1988 (%)

1999 (%)

Source: Shamah, T et al., 2003 Anemia en mujeres mexicanas: un problema de salud

pública Salud Pública de México, Vol 45, suplemento 4

Table 5: Percentage of direct deaths attributed to protein-energy malnutrition and

other nutritional deficiencies, by sex and selected age groups, Mexico 2003

deaths (all causes)

% of total deaths due to nutritional deficiencies

Source: Instituto Nacional de Estadística, Geografía e Informática, 2003 Estadísticas de mortalidad México: INEGI

Table 6: Prevalence of overweight and obesity among Mexican women of reproductive age (12-49 years), 1988 and 1999

Description

1988 (%)

1999 (%)

Source: Rivera, Juan; Sepúlveda, Jaime, 2003 Conclusiones de la Encuesta Nacional de Nutrición

Salud Pública de México, Vol 45, suplemento 4

Table 7: Nutritional status* among low income adult men and women in Mexico City,

* According to Body Mass Index (BMI)

Source: Instituto Nacional de la Nutrición, 1995 Encuesta Urbana de Alimentación en la Zona

Metropolitana de la Ciudad de México 1995 México: INNSZ Instituto Nacional de Nutrición,

2003 Encuesta Urbana de Alimentación en la Zona Metropolitana de la Ciudad de México

2002 México: INCMNSZ