Jones & Bartlett Learning Health Blog

    Teaching about Undernutrition

    Posted by Cassie Peterson on Jun 26, 2013 10:10:44 AM

    Richard Skolnik – Author of Global Health 101

    Some topics are more important than others and nutrition is certainly one of them. Of the almost 7 million childhood deaths globally every year, about 45% can be attributed to undernutrition. In addition, about 26% of the under five children in the world are stunted. For the world as a whole, six of the top ten risk factors for Disability Adjusted Life Years (DALYs) are nutrition-related. For the poorest countries in the world, three of the four top risk factors for DALYs are nutrition related, including childhood underweight, sub-optimal breastfeeding, and iron deficiency.

    The world has increasingly understood these facts, as well as those concerning the growth of obesity and other dietary risks, and a world conference on nutrition “Sustaining Political Commitments to Scaling Up Nutrition” was held recently. Related to this, a number of organizations, including UNICEF and The Lancet recently published major reports on nutrition.

    Those of us who teach Global Health face a number of questions about how to handle nutrition in our global health courses at what is an increasingly exciting time to address nutrition in the classroom. Some of the most important questions related to teaching about nutrition in a broad based Global Health course include:

    • Should I handle nutrition as one topic, including undernutrition and overnutrition? Or, should I treat undernutrition in one part of the course, closely linked with maternal and child health, and then teach about overnutrition as part of the sessions on noncommunicable diseases?  In addition, how much should I address “food policy” issues?
    • Are there clear and concise materials that can introduce students in a comprehensive manner to the critical nutrition issues that countries face, especially low- and middle-income countries?
    • Are there accessible materials that cover the latest scientific findings and evidence about nutrition, particularly as it applies to the health of women and children in low- and middle-income countries?
    • How can I maximize student learning about undernutrition?

    Given that my undergraduate introductory course focuses on the health of the poor in low- and middle-income countries, I treat undernutrition as a separate course topic, aligned largely with the sessions on maternal and child health. I treat diseases related to other nutritional concerns as part of the course coverage of noncommunicable diseases. Although I treat nutrition in many ways as part of a “continuum,” I find it much easier for the students to master an understanding of key nutritional concerns when they are linked with the problems for which they are risk factors. I do not dwell much on food policy, largely because it is a very complicated topic that requires an understanding of agricultural and economic issues that go substantially beyond what I can cover or what I expect most undergrads to be able to master in a single session.

    For the first few years I taught Global Health, I regularly looked for a clear and concise overview of the most important nutrition issues affecting low- and middle-income countries and tied with the death of so many children. Unfortunately, I found very few examples of these kinds of materials at the time, other than the chapter on nutrition in International Health, edited by Merson, Black, and Mills, (now in a third edition called Global Health, Diseases, Systems, Program, and Policies), and the two chapters dealing with nutrition in the Disease Control Priorities in Developing Countries, Second Edition.

    Thus, I included a major chapter on nutrition in my first and second editions – Essentials of Global Health/Global Health 101. I try in my nutrition chapter to provide an accessible overview of the role of key nutrients, the nutritional state of the world, critical nutrition issues affecting low- and middle-income countries, and how those issues can be addressed in the most cost-effective ways. I also include in the chapter a number of “case studies.”

    To introduce my students to undernutrition, I ask them to start with the nutrition chapter of my book. However, I also ask them to read a piece that we commissioned when I worked with Population Reference Bureau (PRB). This is called “Malnutrition is Still a Major Contributor of Child Deaths” and was prepared by James Levinson, an eminent nutrition specialist then at Tufts University, and Lucy Bassett, then one of Professor Levinson’s graduate students. Although the piece is from 2007, I still find it an excellent overview that is scientific - yet easy to read.

    In addition to my chapter and the Levinson/Bassett piece, I ask my students to read the Executive Summary of “Repositioning Nutrition as Central to Development”, a World Bank policy document from 2006.

    I also ask them to read carefully the latest Lancet Series on maternal and child health. The previous series was from 2008, but I now ask them to read the 2013 series.

    Save the Children published a report in 2012 that most undergraduate students will find both valuable and quite easy to follow, called A Life Free from Hunger, Tackling Child Malnutrition.

    In addition, UNICEF has just released an important document on nutrition with which I also want my students to be familiar: Improving Child Nutrition: The achievable imperative for global progress.

    When teaching graduate students about nutrition in a single session of my graduate Global Health course, I generally assign The Lancet Series, plus a range of journal articles that cover important findings on major topics in undernutrition.

    My classes are very “policy oriented” and I generally run my undergraduate nutrition session by posing as the Minister of Finance of a poor country and asking the students to design during our session a new child nutrition policy. To do this, I lead them through the following questions:

    • What are the key nutrition problems?
    • Which populations are most affected by these problems?
    • What are the most important risk factors for these problems?
    • Why should our country care about undernutrition?
    • What can we do in the most cost-effective ways to address our concerns for undernutrition?

    I also ask the students, as described in other blogs, to prepare their first policy brief for me on undernutrition in a low- or middle income country of their choice.

    Ms. Selen Uman reviewed a draft of this blog.

    Richard Skolnik is a Lecturer at the Yale School of Public Health, where he teaches global health courses at the undergraduate and graduate levels. Richard was previously an Instructor in Global Health at The George Washington University, the Vice President for International Programs at the Population Reference Bureau, and the Executive Director of the Harvard School of Public Health PEPFAR program. Richard worked at the World Bank from 1976 to 2001, last serving as the Director for Health and Education for South Asia. Richard is the author of Global Health 101, a comprehensive, introductory text on global health.

    Topics: Richard Skolnik, Global health

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