Drug rehabilitation

From Wikipedia, the free encyclopedia

 

Drug Rehabilitation
ICD-9-CM	94.64

Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and cease substance abuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused, especially by extreme abuse.

Treatment includes medication for depression or other disorders, counseling by experts and sharing of experience with other addicts.

Psychological dependency

Psychological dependency is addressed in many drug rehabilitation programs by attempting to teach the patient new methods of interacting in a drug-free environment. In particular, patients are generally encouraged, or possibly even required, to not associate with peers who still use the addictive substance. Twelve-step programs encourage addicts not only to stop using alcohol or other drugs, but to examine and change habits related to their addictions. Many programs emphasize that recovery is a permanent process without culmination. For legal drugs such as alcohol, complete abstention—rather than attempts at moderation, which may lead to relapse—is also emphasized ("One is too many, and a thousand is never enough.") 

Whether moderation is achievable by those with a history of abuse remains a controversial point, but is generally considered unsustainable.

Types of treatment

The brain’s chemical structure is impacted by drugs of abuse and these changes are present long after an individual stops using. This change in brain structure increases the risk of relapse, making treatment an important part of the rehabilitation process.

Various types of programs offer help in drug rehabilitation, including: residential treatment (in-patient/ out-patient), local support groups, extended care centers, recovery or sober houses, addiction counselling, mental health, and medical care. Some rehab centers offer age- and gender-specific programs. 

In a survey of treatment providers from three separate institutions (the National Association of Alcoholism and Drug Abuse Counselors, Rational Recovery Systems and the Society of Psychologists in Addictive Behaviors) measuring the treatment provider's responses on the Spiritual Belief Scale (a scale measuring belief in the four spiritual characteristics Alcoholics Anonymous identified by Ernest Kurtz); the scores were found to explain 41% of the variance in the treatment provider's responses on the Addiction Belief Scale (a scale measuring adherence to the disease model or the free-will model addiction).

Scientific research since 1970 shows that effective treatment addresses the multiple needs of the patient rather than treating addiction alone. In addition, medically assisted drug detoxification or alcohol detoxification alone is ineffective as a treatment for addiction. The National Institute on Drug Abuse (NIDA) recommends detoxification followed by both medication (where applicable) and behavioral therapy, followed by relapse prevention. According to NIDA, effective treatment must address medical and mental health services as well as follow-up options, such as community or family-based recovery support systems. Whatever the methodology, patient motivation is an important factor in treatment success. 

For individuals addicted to prescription drugs, treatments tend to be similar to those who are addicted to drugs affecting the same brain systems. Medication like methadone and buprenorphine can be used to treat addiction to prescription opiates, and behavioral therapies can be used to treat addiction to prescription stimulants, benzodiazepines, and other drugs.

Types of behavioral therapy include:

• Cognitive-behavioral therapy, which seeks to help patients to recognize, avoid and cope with situations in which they are most likely to relapse.
• Multidimensional family therapy, which is designed to support recovery of the patient by improving family functioning.
• Motivational interviewing, which is designed to increase patient motivation to change behavior and enter treatment.
• Motivational incentives, which uses positive reinforcement to encourage abstinence from the addictive substance.
• EEG Biofeedback augmented treatment improves abstinence rates of 12-step, faith-based and medically assisted addiction for cocaine, methamphetamine, alcoholism and opioid addictions.

Treatment can be a long process and the duration is dependent upon the patient’s needs and history of abuse. Research has shown that most patients need at least three months of treatment and longer duration's are associated with better outcomes.

Medications

Certain opioid medications such as methadone and more recently buprenorphine (In America, "Subutex" and "Suboxone") are widely used to treat addiction and dependence on other opioids such as heroin, morphine or oxycodone. Methadone and buprenorphine are maintenance therapies intended to reduce cravings for opiates, thereby reducing illegal drug use, and the risks associated with it, such as disease, arrest, incarceration, and death, in line with the philosophy of harm reduction. Both drugs may be used as maintenance medications (taken for an indefinite period of time), or used as detoxification aids. All available studies collected in the 2005 Australian National Evaluation of Pharmacotherapies for Opioid Dependence suggest that maintenance treatment is preferable, with very high rates (79–100%) of relapse within three months of detoxification from levo-α-acetylmethadol (LAAM), buprenorphine, and methadone.

According to the National Institute on Drug Abuse (NIDA), patients stabilized on adequate, sustained doses of methadone or buprenorphine can keep their jobs, avoid crime and violence, and reduce their exposure to HIV and Hepatitis C by stopping or reducing injection drug use and drug-related high risk sexual behavior. Naltrexone is a long-acting opioid antagonist with few side effects. It is usually prescribed in outpatient medical conditions. Naltrexone blocks the euphoric effects of alcohol and opiates. Naltrexone cuts relapse risk during the first three months by about 36%. However, it is far less effective in helping patients maintain abstinence or retaining them in the drug-treatment system (retention rates average 12% at 90 days for naltrexone, average 57% at 90 days for buprenorphine, average 61% at 90 days for methadone).

Ibogaine is a hallucinogenic drug promoted by certain fringe groups to interrupt both physical dependence and psychological craving to a broad range of drugs including narcotics, stimulants, alcohol, and nicotine. To date, there have never been any controlled studies showing it to be effective, and it is not accepted as a treatment by physicians, pharmacists, or addictionologist. There have also been several deaths related to ibogaine use, which causes tachycardia and long QT syndrome. The drug is an illegal Schedule I controlled substance in the United States, and the foreign facilities in which it is administered from tend to have little oversight, and range from motel rooms to one moderately-sized rehabilitation center.

A few antidepressants have been proven to be helpful in the context of smoking cessation/nicotine addiction, these medications include bupropion and nortriptyline. Bupropion inhibits the re-uptake of nor-epinephrine and dopamine and has been FDA approved for smoking cessation, while nortriptyline is a tricyclic antidepressant which has been used to aid in smoking cessation it has not been FDA approved for this indication.

Acamprosate, disulfiram and topiramate (a novel anticonvulsant sulphonated sugar) are also used to treat alcohol addiction. Acamprosate has shown effectiveness for patients with severe dependence, helping them to maintain abstinence for several weeks, even months. Disulfiram (also called Antabuse) produces a very unpleasant reaction when drinking alcohol that includes flushing, nausea and palpitations. It is more effective for patients with high motivation and some addicts use it only for high-risk situations. Patients who wish to continue drinking or may be likely to relapse, should not take disulfiram as it can result in the disulfiram-alcohol reaction mentioned previously, which is very serious and can even be fatal.

Nitrous oxide, also sometimes known as laughing gas, is a legally available gas used for purposes that include anesthesia during certain dental and surgical procedures, as well as food preparation and the fueling of rocket and racing engines. Substance abusers also sometimes use the gas as an inhalant. Like all other inhalants, it's popular because it provides consciousness-altering effects while allowing users to avoid some of the legal issues surrounding illicit or illegal drugs of abuse. Abuse of nitrous oxide can produce significant short-term and long-term damage to human health, including a form of oxygen starvation, called hypoxia, brain damage, and a serious vitamin B12 deficiency that can lead to nerve damage.

Although dangerous and addictive in its own right, nitrous oxide has been shown to be an effective treatment for a number of addictions.

Residential treatment

In-patient residential treatment for alcohol abuse is usually quite expensive without proper insurance. Most American programs follow a traditional 28–30 day program length. The length is based solely upon providers' experience. During the 1940's, clients stayed about one week to get over the physical changes, another week to understand the program, and another week or two to become stable. 70% to 80% of American residential alcohol treatment programs provide 12-step support services. These include, but are not limited to AA, Narcotics Anonymous, Cocaine Anonymous and Al-Anon. One recent study suggests the importance of family participation in residential treatment patient retention, finding "increased program completion rate for those with a family member or significant other involved in a seven-day family program".

Experimental treatment

The Nature of Things, a CBC Television program by David Suzuki, explored an experimental drug treatment by Dr. Gabor Maté in which the substance Ayahuasca was used to treat addicts in Vancouver.

Recovery

The definition of recovery remains divided and subjective in drug rehabilitation, as there are no set standards for measuring recovery. The Betty Ford Institute defined recovery as achieving complete abstinence as well as personal well-being while other studies have considered "near abstinence" as a definition. The wide range of meanings has complicated the process of choosing rehabilitation programs.

Criminal justice

Drug rehabilitation is sometimes part of the criminal justice system. People convicted of minor drug offenses may be sentenced to rehabilitation instead of prison, and those convicted of driving while intoxicated are sometimes required to attend Alcoholics Anonymous meetings. There are a great number of ways to address an alternative sentence in a drug possession or DUI case; increasingly, American courts are willing to explore outside-the-box methods for delivering this service. There have been lawsuits filed, and won, regarding the requirement of attending Alcoholics Anonymous and other twelve-step meetings as being inconsistent with the Establishment Clause of the First Amendment of the U.S. Constitution, mandating separation of church and state.

In some cases, individuals can be court ordered to drug rehabilitation by the state through legislation like the Marchman Act.

Counseling

Traditional addiction treatment is based primarily on counseling.

Counselors help individuals with identifying behaviors and problems related to their addiction. It can be done on an individual basis, but it's more common to find it in a group setting and can include crisis counseling, weekly or daily counseling, and drop-in counseling supports. Counselors are trained to develop recovery programs that help to reestablish healthy behaviors and provide coping strategies whenever a situation of risk happens. It's very common to see them also work with family members who are affected by the addictions of the individual, or in a community to prevent addiction and educate the public. Counselors should be able to recognize how addiction affects the whole person and those around him or her. Counseling is also related to "Intervention"; a process in which the addict's family and loved ones request help from a professional to get an individual into drug treatment. 

This process begins with a professionals' first goal: breaking down denial of the person with the addiction. Denial implies lack of willingness from the patients or fear to confront the true nature of the addiction and to take any action to improve their lives, instead of continuing the destructive behavior. Once this has been achieved, the counselor coordinates with the addict's family to support them on getting the individual to drug rehabilitation immediately, with concern and care for this person. Otherwise, this person will be asked to leave and expect no support of any kind until going into drug rehabilitation or alcoholism treatment. An intervention can also be conducted in the workplace environment with colleagues instead of family. 

One approach with limited applicability is the sober coach. In this approach, the client is serviced by the provider(s) in his or her home and workplace—for any efficacy, around-the-clock—who functions much like a nanny to guide or control the patient's behavior.

Twelve-step programs

The disease model of addiction has long contended the maladaptive patterns of alcohol and substance use displays addicted individuals are the result of a lifelong disease that is biological in origin and exacerbated by environmental contingencies. This conceptualization renders the individual essentially powerless over his or her problematic behaviors and unable to remain sober by himself or herself, much as individuals with a terminal illness being unable to fight the disease by themselves without medication. Behavioral treatment, therefore, necessarily requires individuals to admit their addiction, renounce their former lifestyle, and seek a supportive social network who can help them remain sober. Such approaches are the quintessential features of Twelve-step programs, originally published in the book Alcoholics Anonymous in 1939. These approaches have met considerable amounts of criticism, coming from opponents who disapprove of the spiritual-religious orientation on both psychological and legal grounds. Opponents also contend that it lacks valid scientific evidence for claims of efficacy. However, there is survey-based research that suggests there is a correlation between attendance and alcohol sobriety. Different results have been reached for other drugs, with the twelve steps being less beneficial for addicts to illicit substances, and least beneficial to those addicted to the physiologically and psychologically addicting opioids, for which maintenance therapies are the gold standard of care.

SMART Recovery

SMART Recovery was founded by Joe Gerstein in 1994 by basing REBT as a foundation. It gives importance to the human agency in overcoming addiction and focuses on self-empowerment and self-reliance. It does not subscribe to disease theory and powerlessness. The group meetings involve open discussions, questioning decisions and forming corrective measures through assertive exercises. It does not involve a lifetime membership concept, but people can opt to attend meetings, and choose not to after gaining recovery. Objectives of the SMART Recovery programs are:

• Building and Maintaining Motivation,
• Coping with Urges,
• Managing Thoughts, Feelings, and Behaviors,
• Living a Balanced Life.

This is considered to be similar to other self-help groups who work within mutual aid concepts.

Client-centered approaches

In his influential book, Client-Centered Therapy, in which he presented the client-centered approach to therapeutic change, psychologist Carl Rogers proposed there are three necessary and sufficient conditions for personal change: unconditional positive regard, accurate empathy, and genuineness. Rogers believed the presence of these three items, in the therapeutic relationship, could help an individual overcome any troublesome issue, including but not limited to alcohol abuse. To this end, a 1957 study compared the relative effectiveness of three different psychotherapies in treating alcoholics who had been committed to a state hospital for sixty days: a therapy based on two-factor learning theory, client-centered therapy, and psychoanalytic therapy. Though the authors expected the two-factor theory to be the most effective, it actually proved to be deleterious in the outcome. Surprisingly, client-centered therapy proved most effective. It has been argued, however, these findings may be attributable to the profound difference in therapist outlook between the two-factor and client-centered approaches, rather than to client-centered techniques. The authors note two-factor theory involves stark disapproval of the clients' "irrational behavior" (p. 350); this notably negative outlook could explain the results. 

A variation of Rogers' approach has been developed in which clients are directly responsible for determining the goals and objectives of the treatment. Known as Client-Directed Outcome-Informed therapy (CDOI), this approach has been utilized by several drug treatment programs, such as Arizona's Department of Health Services.

Psychoanalysis

Psychoanalysis, a psychotherapeutic approach to behavior change developed by Sigmund Freud and modified by his followers, has also offered an explanation of substance abuse. This orientation suggests the main cause of the addiction syndrome is the unconscious need to entertain and to enact various kinds of homosexual and perverse fantasies, and at the same time to avoid taking responsibility for this. It is hypothesized specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. The addiction syndrome is also hypothesized to be associated with life trajectories that have occurred within the context of teratogenic processes, the phases of which include social, cultural and political factors, encapsulation, traumatophobia, and masturbation as a form of self-soothing. Such an approach lies in stark contrast to the approaches of social cognitive theory to addiction—and indeed, to behavior in general—which holds human beings to regulate and control their own environmental and cognitive environments, and are not merely driven by internal, driving impulses. Additionally, homosexual content is not implicated as a necessary feature in addiction.

Relapse prevention

An influential cognitive-behavioral approach to addiction recovery and therapy has been Alan Marlatt's (1985) Relapse Prevention approach. Marlatt describes four psycho-social processes relevant to the addiction and relapse processes: self-efficacy, outcome expectancy, attributions of causality, and decision-making processes. Self-efficacy refers to one's ability to deal competently and effectively with high-risk, relapse-provoking situations. Outcome expectancy refer to an individual's expectations about the psychoactive effects of an addictive substance. Attributions of causality refer to an individual's pattern of beliefs that relapse to drug use is a result of internal, or rather external, transient causes (e.g., allowing oneself to make exceptions when faced with what are judged to be unusual circumstances). Finally, decision-making processes are implicated in the relapse process as well. Substance use is the result of multiple decisions whose collective effects result in a consumption of the intoxicant. Furthermore, Marlatt stresses some decisions—referred to as apparently irrelevant decisions—may seem inconsequential to relapse, but may actually have downstream implications that place the user in a high-risk situation.

For example: As a result of heavy traffic, a recovering alcoholic may decide one afternoon to exit the highway and travel on side roads. This will result in the creation of a high-risk situation when he realizes he is inadvertently driving by his old favorite bar. If this individual is able to employ successful coping strategies, such as distracting himself from his cravings by turning on his favorite music, then he will avoid the relapse risk (PATH 1) and heighten his efficacy for future abstinence. If, however, he lacks coping mechanisms—for instance, he may begin ruminating on his cravings (PATH 2)—then his efficacy for abstinence will decrease, his expectations of positive outcomes will increase, and he may experience a lapse—an isolated return to substance intoxication. So doing results in what Marlatt refers to as the Abstinence Violation Effect, characterized by guilt for having gotten intoxicated and low efficacy for future abstinence in similar tempting situations. This is a dangerous pathway, Marlatt proposes, to full-blown relapse.

Cognitive therapy

An additional cognitively-based model of substance abuse recovery has been offered by Aaron Beck, the father of cognitive therapy and championed in his 1993 book Cognitive Therapy of Substance Abuse. This therapy rests upon the assumption addicted individuals possess core beliefs, often not accessible to immediate consciousness (unless the patient is also depressed). These core beliefs, such as "I am undesirable," activate a system of addictive beliefs that result in imagined anticipatory benefits of substance use and, consequentially, craving. Once craving has been activated, permissive beliefs ("I can handle getting high just this one more time") are facilitated. Once a permissive set of beliefs have been activated, then the individual will activate drug-seeking and drug-ingesting behaviors. The cognitive therapist's job is to uncover this underlying system of beliefs, analyze it with the patient, and thereby demonstrate its dysfunctional. As with any cognitive-behavioral therapy, homework assignments and behavioral exercises serve to solidify what is learned and discussed during treatment.

Emotion regulation and mindfulness

A growing literature is demonstrating the importance of emotion regulation in the treatment of substance abuse. Considering that nicotine and other psychoactive substances such as cocaine activate similar psycho-pharmacological pathways, an emotion regulation approach may be applicable to a wide array of substance abuse. Proposed models of affect-driven tobacco use have focused on negative reinforcement as the primary driving force for addiction; according to such theories, tobacco is used because it helps one escape from the undesirable effects of nicotine withdrawal or other negative moods. Acceptance and commitment therapy (ACT), is showing evidence that it is effective in treating substance abuse, including the treatment of poly-substance abuse and cigarette smoking. Mindfulness programs that encourage patients to be aware of their own experiences in the present moment and of emotions that arise from thoughts, appear to prevent impulsive/compulsive responses. Research also indicates that mindfulness programs can reduce the consumption of substances such as alcohol, cocaine, amphetamines, marijuana, cigarettes and opiates.

Dual diagnosis

For example, someone with bipolar disorder that suffers from alcoholism would have dual diagnosis (manic depression + alcoholism). In such occasions, two treatment plans are needed with the mental health disorder requiring treatment first. According to the National Survey on Drug Use and Health (NSDUH), 45 percent of people with addiction have a co-occurring mental health disorder.

Behavioral models

Behavioral models make use of principles of functional analysis of drinking behavior. Behavior models exist for both working with the substance abuser (community reinforcement approach) and their family (community reinforcement approach and family training). Both these models have had considerable research success for both efficacy and effectiveness. This model lays much emphasis on the use of problem-solving techniques as a means of helping the addict to overcome his/her addiction.

Criticism

Despite ongoing efforts to combat addiction, there has been evidence of clinics billing patients for treatments that may not guarantee their recovery. This is a major problem as there are numerous claims of fraud in drug rehabilitation centers, where these centers are billing insurance companies for under delivering much needed medical treatment while exhausting patients' insurance benefits. In California, there are movements and laws regarding this matter, particularly the California Insurance Fraud Prevention Act (IFPA) which declares it unlawful to unknowingly conduct such businesses.

Under the Affordable Care Act and the Mental Health Parity Act, rehabilitation centers are able to bill insurance companies for substance abuse treatment. With long wait lists in limited state-funded rehabilitation centers, controversial private centers rapidly emerged. One popular model, known as the Florida Model for rehabilitation centers, is often criticized for fraudulent billing to insurance companies. Under the guise of helping patients with opioid addiction, these centers would offer addicts free rent or up to $500 per month to stay in their "sober homes", then charge insurance companies as high as $5,000 to $10,000 per test for simple urine tests. Little attention is paid to patients in terms of addiction intervention as these patients have often been known to continue drug use during their stay in these centers. Since 2015, these centers have been under federal and state criminal investigation. As of 2017 in California, there are only 16 investigators in the CA Department of Health Care Services investigating over 2,000 licensed rehab centers.

Alcohol and health

From Wikipedia, the free encyclopedia

 

Alcohol (also known as ethanol) has a number of effects on health. Short-term effects of alcohol consumption include intoxication and dehydration. Long-term effects of alcohol consumption include changes in the metabolism of the liver and brain and alcoholism. Alcohol intoxication affects the brain, causing slurred speech, clumsiness, and delayed reflexes. Alcohol stimulates insulin production, which speeds up glucose metabolism and can result in low blood sugar, causing irritability and possibly death for diabetics. Even light and moderate alcohol consumption increases cancer risk in individuals. A 2014 World Health Organization report found that harmful alcohol consumption caused about 3.3 million deaths annually worldwide. Negative efforts are related to the amount consumed with no safe lower limit seen. Some nations have introduced alcohol packaging warning messages that inform consumers about alcohol and cancer, as well as foetal alcohol syndrome.

 

The median lethal dose of alcohol in test animals is a blood alcohol content of 0.45%. This is about six times the level of ordinary intoxication (0.08%), but vomiting or unconsciousness may occur much sooner in people who have a low tolerance for alcohol. The high tolerance of chronic heavy drinkers may allow some of them to remain conscious at levels above 0.40%, although serious health hazards are incurred at this level. 

Alcohol also limits the production of vasopressin (ADH) from the hypothalamus and the secretion of this hormone from the posterior pituitary gland. This is what causes severe dehydration when alcohol is consumed in large amounts. It also causes a high concentration of water in the urine and vomit and the intense thirst that goes along with a hangover. 

Stress, hangovers, and the oral contraceptive pill may increase the desire for alcohol because these things will lower the level of testosterone and alcohol will acutely elevate it. Tobacco has the same effect of increasing the craving for alcohol.

Short-term effects

The short-term effects of alcohol consumption range from a decrease in anxiety and motor skills at lower doses to unconsciousness, anterograde amnesia, and central nervous system depression at higher doses. Cell membranes are highly permeable to alcohol, so once alcohol is in the bloodstream it can diffuse into nearly every cell in the body.

The concentration of alcohol in blood is measured via blood alcohol content (BAC). The amount and circumstances of consumption play a large part in determining the extent of intoxication; for example, eating a heavy meal before alcohol consumption causes alcohol to absorb more slowly. Hydration also plays a role, especially in determining the extent of hangovers. After excessive drinking, unconsciousness can occur and extreme levels of consumption can lead to alcohol poisoning and death (a concentration in the blood stream of 0.40% will kill half of those affected). Alcohol may also cause death indirectly, by asphyxiation from vomit. 

Alcohol can greatly exacerbate sleep problems. During abstinence, residual disruptions in sleep regularity and sleep patterns are the greatest predictors of relapse.

Long-term effects

According to the World Health Organization's 2018 Global Status Report on Alcohol and Health, there are more than 3 million people who die from the harmful effects of alcohol each year, which amounts to more than 5% of the burden of disease world-wide. The US National Institutes of Health similarly estimates that 3.3 million deaths (5.9% of all deaths) were believed to be due to alcohol each year.

Guidelines in the US and the UK advise that if people choose to drink, they should drink moderately.

Even light and moderate alcohol consumption increases cancer risk in individuals, especially with respect to squamous cell carcinoma of the esophagus, oropharyngeal cancer, and breast cancer.

A systematic analysis of data from the Global Burden of Disease Study, which was an observational study, found that long term consumption of any amount of alcohol is associated with an increased of risk of death in all people, and that even moderate consumption appears to be risky. Similar to prior analyses, it found an apparent benefit for older women in reducing the risks of death from ischemic heart disease and from diabetes, but unlike prior studies it found those risks cancelled by an apparent increased risk of death from breast cancer and other causes. A 2016 systematic review and meta-analysis found that moderate ethanol consumption brought no mortality benefit compared with lifetime abstention from ethanol consumption. Risk is greater in younger people due to binge drinking which may result in violence or accidents.

Long-term heavy use of alcohol damages nearly every organ and system in the body. Risks include alcoholism, malnutrition, chronic pancreatitis, alcoholic liver disease and cancer. In addition, damage to the central nervous system and peripheral nervous system can occur from chronic alcohol abuse.

The developing adolescent brain is particularly vulnerable to the toxic effects of alcohol.

Pregnancy

Medical organizations strongly discourage drinking alcohol during pregnancy. Alcohol passes easily from the mother's bloodstream through the placenta and into the bloodstream of the fetus, which interferes with brain and organ development. Alcohol can affect the fetus at any stage during pregnancy, but the level of risk depends on the amount and frequency of alcohol consumed. Regular heavy drinking and binge drinking (four or more drinks on any one occasion) pose the greatest risk for harm, but lesser amounts can cause problems as well. There is no known safe amount or safe time to drink during pregnancy, and the U.S. CDC recommends complete abstinence for women who are pregnant, trying to become pregnant, or are sexually active and not using birth control.

Prenatal alcohol exposure can lead to fetal alcohol spectrum disorders (FASDs). The most severe form of FASD is fetal alcohol syndrome (FAS).^[29] Problems associated with FASD include facial anomalies, low birth weight, stunted growth, small head size, delayed or uncoordinated motor skills, hearing or vision problems, learning disabilities, behavior problems, and inappropriate social skills compared to same-age peers. Those affected are more likely to have trouble in school, legal problems, participate in high-risk behaviors, and develop substance use disorders themselves.

Cardiovascular disease

In 2010, a systematic review reported that moderate consumption of alcohol does not cause harm to people with cardiovascular disease. However, the authors did not encourage people to start drinking alcohol in hope of benefit. The position of the American Heart Association is that people who are currently nondrinkers should not start drinking alcohol.

Breastfeeding

The UK National Health Service states that "an occasional drink is unlikely to harm" a breastfed baby, and recommends consumption of "no more than one or two units of alcohol once or twice a week" for breastfeeding mothers (where a pint of beer or 50 ml drink of a spirit such as whisky corresponds to about two units of alcohol). The NHS also recommends to wait for a couple of hours before breastfeeding or express the milk into a bottle before drinking. Researchers have shown that intoxicated breastfeeding reduces the average milk expression but poses no immediate threat to the child as the amount of transferred alcohol is insignificant.

Alcohol education

Alcohol education is the practice of disseminating information about the effects of alcohol on health, as well as society and the family unit. It was introduced into the public schools by temperance organizations such as the Woman's Christian Temperance Union in the late 19th century. Initially, alcohol education focused on how the consumption of alcoholic beverages affected society, as well as the family unit. In the 1930s, this came to also incorporate education pertaining to alcohol's effects on health. Organizations such as the National Institute on Alcohol Abuse and Alcoholism in the United States were founded to promulgate alcohol education alongside those of the temperance movement, such as the American Council on Alcohol Problems.

Alcohol expectations

Alcohol expectations are beliefs and attitudes that people have about the effects they will experience when drinking alcoholic beverages. They are just largely beliefs about alcohol's effects on a person’s behaviors, abilities, and emotions. Some people believe that if alcohol expectations can be changed, then alcohol abuse might be reduced. Men tend to become more aggressive in laboratory studies in which they are drinking only tonic water but believe that it contains alcohol. They also become less aggressive when they believe they are drinking only tonic water, but are actually drinking tonic water that contains alcohol.

The phenomenon of alcohol expectations recognizes that intoxication has real physiological consequences that alter a drinker's perception of space and time, reduce psychomotor skills, and disrupt equilibrium. The manner and degree to which alcohol expectations interact with the physiological short-term effects of alcohol, resulting in specific behaviors, is unclear. 

A single study found that if a society believes that intoxication leads to sexual behavior, rowdy behavior, or aggression, then people tend to act that way when intoxicated. But if a society believes that intoxication leads to relaxation and tranquil behavior, then it usually leads to those outcomes. Alcohol expectations vary within a society, so these outcomes are not certain.

People tend to conform to social expectations, and some societies expect that drinking alcohol will cause disinhibition. However, in societies in which the people do not expect that alcohol will disinhibit, intoxication seldom leads to disinhibition and bad behavior.

Alcohol expectations can operate in the absence of actual consumption of alcohol. Research in the United States over a period of decades has shown that men tend to become more sexually aroused when they think they have been drinking alcohol—even when they have not been drinking it. Women report feeling more sexually aroused when they falsely believe the beverages they have been drinking contained alcohol (although one measure of their physiological arousal shows that they became less aroused).

Drug treatment programs

Most addiction treatment programs encourage people with drinking problems to see themselves as having a chronic, relapsing disease that requires a lifetime of attendance at 12-step meetings to keep in check. However, some people do not develop lifelong problems.

Alcohol abuse

Addiction experts in psychiatry, chemistry, pharmacology, forensic science, epidemiology, and the police and legal services engaged in delphic analysis regarding 20 popular recreational drugs. Alcohol was ranked 6th in dependence, 11th in physical harm, and 2nd in social harm.

Recommended maximum intake

Binge drinking is becoming a major problem in the UK. Advice on weekly consumption is avoided in United Kingdom.

Since 1995 the UK government has advised that regular consumption of three to four units (one unit equates to 10 mL of pure ethanol) a day for men and or two to three units for women, would not pose significant health risks. However, consistently drinking more than four units a day (for men) and three units (women), is not advisable.

Previously (from 1992 until 1995), the advice was that men should drink no more than 21 units per week, and women no more than 14. (The difference between the sexes was due to the typically lower weight and water-to-body-mass ratio of women.) This was changed because a government study showed that many people were in effect "saving up" their units and using them at the end of the week, a phenomenon referred to as binge drinking. The Times reported in October 2007 that these limits had been "plucked out of the air" and had no scientific basis.

Sobriety

A midshipman is subjected to a random breathalyzer test to determine sobriety.

 

Sobriety is the condition of not having any measurable levels, or effects from mood-altering drugs. According to WHO "Lexicon of alcohol and drug terms..." sobriety is continued abstinence from psychoactive drug use. Sobriety is also considered to be the natural state of a human being given at a birth. In a treatment setting, sobriety is the achieved goal of independence from consuming or craving mind-altering substances. As such, sustained abstinence is a prerequisite for sobriety. Early in abstinence, residual effects of mind-altering substances can preclude sobriety. These effects are labeled "PAWS", or "post acute withdrawal syndrome". Someone who abstains, but has a latent desire to resume use, is not considered truly sober. An abstainer may be subconsciously motivated to resume drug use, but for a variety of reasons, abstains (e.g. such as a medical or legal concern precluding use). Sobriety has more specific meanings within specific contexts, such as the culture of Alcoholics Anonymous, other 12 step programs, law enforcement, and some schools of psychology. In some cases, sobriety implies achieving "life balance".

Injury and deaths

Injury is defined as physical damage or harm that is done or sustained. The potential of injuring oneself or others can be increased after consuming alcohol due to the certain short term effects related to the substance such as lack of coordination, blurred vision, and slower reflexes to name a few. Due to these effects the most common injuries include head, fall, and vehicle-related injuries. A study was conducted of patients admitted to the Ulster Hospital in Northern Ireland with fall related injuries. They found that 113 of those patients admitted to that hospital during that had consumed alcohol recently and that the injury severity was higher for those that had consumed alcohol compared to those that had not. Another study showed that 21% of patients admitted to the Emergency Department of the Bristol Royal Infirmary had either direct or indirect alcohol related injuries. If these figures are extrapolated it shows that the estimated number of patients with alcohol related injuries are over 7,000 during the year at this emergency department alone.

In the United States alcohol resulted in about 88,000 deaths in 2010. The World Health Organization calculated that more than 3 million people, mostly men, died as a result of harmful use of alcohol in 2016. This was about 13.5 % of the total deaths of people between 20 and 39. More than 5% of the global disease burden was caused by the harmful use of alcohol.

Genetic differences

Alcohol flush and respiratory reactions

Alcohol flush reaction is a condition in which an individual's face or body experiences flushes or blotches as a result of an accumulation of acetaldehyde, a metabolic byproduct of the catabolic metabolism of alcohol. It is best known as a condition that is experienced by people of Asian descent. According to the analysis by HapMap Project, the rs671 allele of the ALDH2 gene responsible for the flush reaction is rare among Europeans and Africans, and it is very rare among Mexican-Americans. 30% to 50% of people of Chinese and Japanese ancestry have at least one ALDH*2 allele. The rs671 form of ALDH2, which accounts for most incidents of alcohol flush reaction worldwide, is native to East Asia and most common in southeastern China. It most likely originated among Han Chinese in central China, and it appears to have been positively selected in the past. Another analysis correlates the rise and spread of rice cultivation in Southern China with the spread of the allele. The reasons for this positive selection aren't known, but it's been hypothesized that elevated concentrations of acetaldehyde may have conferred protection against certain parasitic infections, such as Entamoeba histolytica. The same SNP allele of ALDH2, also termed glu487lys, and the abnormal accumulation of acetaldehyde following the drinking of alcohol, is associated with the alcohol-induced respiratory reactions of rhinitis and asthma that occur in Eastern Asian populations.

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Metabolism of alcohol (ethanol) to acetaldehyde (ethanal) and then acetic acid (ethanoic acid)

American Indian alcoholism

While little detailed genetic research has been done, it has been shown that alcoholism tends to run in families with possible involvement of differences in alcohol metabolism and the genotype of alcohol-metabolizing enzymes.

Genetics and amount of consumption

Having a particular genetic variant (A-allele of ADH1B rs1229984) is associated with non-drinking and lower alcohol consumption. This variant is also associated with favorable cardiovascular profile and a reduced risk of coronary heart disease compared to those without the genetic variant, but it is unknown whether this may be caused by differences in alcohol consumption or by additional confounding effects of the genetic variant itself.

Gender differences

Historically, according to the British Medical Journal, "men have been far more likely than women to drink alcohol and to drink it in quantities that damage their health, with some figures suggesting up to a 12-fold difference between the sexes". However, analysis of data collected over a century from multiple countries suggests that the gender gap in alcohol consumption is narrowing, and that young women (born after 1981) are consuming alcohol more than their male counterparts. Such findings have implications for the way in which alcohol-use prevention and intervention programs are designed and implemented.

Alcoholism

Based on combined data from SAMHSA's 2004-2005 National Surveys on Drug Use & Health, the rate of past year alcohol dependence or abuse among people aged 12 or older varied by level of alcohol use: 44.7% of past month heavy drinkers, 18.5% binge drinkers, 3.8% past month non-binge drinkers, and 1.3% of those who did not drink alcohol in the past month met the criteria for alcohol dependence or abuse in the past year. Males had higher rates than females for all measures of drinking in the past month: any alcohol use (57.5% vs. 45%), binge drinking (30.8% vs. 15.1%), and heavy alcohol use (10.5% vs. 3.3%), and males were twice as likely as females to have met the criteria for alcohol dependence or abuse in the past year (10.5% vs. 5.1%). Over time the difference between males and females has narrowed. According to a 2016 systematic review, for those born at the end of the 20th century men were 1.2 times as likely to drink to problematic levels, and 1.3 times as likely to develop health problems from drinking.

Sensitivity

Several biological factors make women more vulnerable to the effects of alcohol than men.

• Body fat. Women tend to weigh less than men, and—pound for pound—a woman’s body contains less water and more fatty tissue than a man’s. Because fat retains alcohol while water dilutes it, alcohol remains at higher concentrations for longer periods of time in a woman’s body, exposing her brain and other organs to more alcohol.
• Enzymes. Women have lower levels of two enzymes—alcohol dehydrogenase and aldehyde dehydrogenase—that metabolize (break down) alcohol in the stomach and liver. As a result, women absorb more alcohol into their bloodstreams than men.
• Hormones. Changes in hormone levels during the menstrual cycle may also affect how a woman metabolizes alcohol.

Metabolism

Females demonstrated a higher average rate of elimination (mean, 0.017; range, 0.014–0.021 g/210 L) than males (mean, 0.015; range, 0.013–0.017 g/210 L). Female subjects on average had a higher percentage of body fat (mean, 26.0; range, 16.7–36.8%) than males (mean, 18.0; range, 10.2–25.3%).

Depression

The link between alcohol consumption, depression, and gender was examined by the Centre for Addiction and Mental Health (Canada). The study found that women taking antidepressants consumed more alcohol than women who did not experience depression as well as men taking antidepressants. The researchers, Dr. Kathryn Graham and a PhD Student Agnes Massak analyzed the responses to a survey by 14,063 Canadian residents aged 18–76 years. The survey included measures of quantity, frequency of drinking, depression and antidepressants use, over the period of a year. The researchers used data from the GENACIS Canada survey, part of an international collaboration to investigate the influence of cultural variation on gender differences in alcohol use and related problems. The purpose of the study was to examine whether, like in other studies already conducted on male depression and alcohol consumption, depressed women also consumed less alcohol when taking anti-depressants. According to the study, both men and women experiencing depression (but not on anti-depressants) drank more than non-depressed counterparts. Men taking antidepressants consumed significantly less alcohol than depressed men who did not use antidepressants. Non-depressed men consumed 436 drinks per year, compared to 579 drinks for depressed men not using antidepressants, and 414 drinks for depressed men who used antidepressants. Alcohol consumption remained higher whether the depressed women were taking anti-depressants or not. 179 drinks per year for non-depressed women, 235 drinks for depressed women not using antidepressants, and 264 drinks for depressed women who used antidepressants. The lead researcher argued that the study "suggests that the use of antidepressants is associated with lower alcohol consumption among men suffering from depression. But this does not appear to be true for women."

Nutritional anthropology

From Wikipedia, the free encyclopedia

Nutritional anthropology is the interplay between human biology, economic systems, nutritional status and food security, and how changes in the former affect the latter. If economic and environmental changes in a community affect access to food, food security, and dietary health, then this interplay between culture and biology is in turn connected to broader historical and economic trends associated with globalization. Nutritional status affects overall health status, work performance potential, and the overall potential for economic development (either in terms of human development or traditional western models) for any given group of people.

General economics and nutrition

General economic summary

Most scholars construe economy as involving the production, distribution, and consumption of goods and services within and between societies.^{[citation needed]} A key concept in a broad study of economies (versus a particular econometric study of commodities and stock markets) is social relations. For instance, many economic anthropologists state that the reciprocal gift exchange, competitive gift exchange, and impersonal market exchange are all reflective of dominant paradigms of social relations within a given society. The main forms of economy extant around most of the world today, in terms of a simple production, distribution, consumption model, are subsistence based and market economies. Subsistence refers to production and consumption on a small-scale of the household or community, while a market-based economy implies a much broader scale of production, distribution, and consumption. A market economy also entails the exchange of goods for currency, versus bartering commodities or being under continuing reciprocal gift exchange obligations. This is not to say that market economies do not coexist with subsistence economies and other forms, but that one type usually dominates within a given society. However, a broad array of scholarship exists, stating that market economies are rapidly increasing in importance on a global scale, even in societies that have traditionally relied much more heavily on subsistence production. This economic shift has nutritional implications that this entry will explore further.

Modes of production and nutrition

The most important step in understanding the links between economics and nutrition is to understand major modes of production that societies have used to produce the goods (and services) they have needed throughout human history; these modes are foraging, shifting cultivation, pastoralism, agriculture, and industrialism (Park 2006). 

Foraging, also known as hunting and gathering, is a subsistence strategy in which a group of people gathers wild plants and hunts wild animals in order to obtain food. This strategy was the sole mode of existence for human beings for the vast majority of human history (inclusive of the archeological and fossil record) and continued to be practiced by a few groups at least into the middle part of the 20th century. This mode of production is generally associated with small, nomadic groups of no more than fifty, also known as bands. The vast majority of foraging societies do not acknowledge exclusive ownership of land or other major resources, though they do acknowledge primary use rights for groups and people may individually possess small objects or tools such as a bow or cutting tools. Because foraging usually involves frequent movement and taking food naturally available rather than altering landscapes for production, many scholars state the foraging has a minimal negative environmental impact compared to other modes of production. Though foragers are generally limited in absolute amount of food available in a given area, foraging groups such as the !Kung in the Kalahari Desert have often been cited as having a more diverse diet and spending less time per week procuring food than societies that practice other modes of production such as intensive agriculture.

Shifting cultivation is a mode of production involving the low intensity production of plant-based foods; this mode is also known as horticulture or ‘slash and burn agriculture’ in some texts. Horticultural societies are generally situated in semi-sedentary villages of a few hundred that clear a field and burn the cleared vegetation in order to use the ashes to nourish the soil (hence the phrase slash and burn). Next, the group plants a crop or crops in this clearing and uses it for cultivation for several years. At the end of this period, the entire village relocates and starts the process anew, leaving the old clearing fallow for a period of decades in order to allow regeneration through the regrowth of wild vegetation. These food items can be supplemented through the raising of livestock, hunting wild game, and in many cases with the gathering of wild plants (Miller 2005; Park 2006). Though periodic movement precludes absolute permanent ownership of land, some horticultural societies fiercely defend current territories and practice violence against neighboring groups. For instance, Napoleon Chagnon (1997) depicts the Yanamamo of Venezuela and Brazil as the “Fierce People”, though others have been highly critical of Chagnon's account of this society. Horticulture can also produce a broad diet, and in some cases more food per unit of land area than foraging. Though populations of horticulturalists tend to have greater density than those of foragers, they are generally less dense than those which practice other modes of production. If practiced on a small scale, over a large area, with long fallow periods, horticulture has less negative environmental impact than agriculture or industrialism, but more than foraging (Miller 2005). Generally, horticulture coincides with a subsistence type of economy in terms of production, distribution. 

Pastoralism, defined as reliance on products from livestock coupled with a seasonal nomadic herding tradition, is similar to horticulture in that it is extensive in its use of land area. Social groups in pastoral societies tend to have similar numbers and population density to horticultural societies. Pastoral societies often trade animal products with agricultural societies for plant based foods to augment their diet. Frequent movement often means that pastoralism has a similar environmental impact to horticulture, though instances of overgrazing, and consequent land degradation (see later subsection under Globalization and Nutrition), have been sited in some cases. Pastoralism generally entails a greater reliance on meat or other animal products, such as milk or blood, than other modes of production. This mode of production has a similar use rights profile to shifting cultivation. Traditionally, pastoralism has coincided with a subsistence based economy, but in the last several decades, some pastoralist societies, such as Mongolia, have herded animals and practiced nomadic living patterns but have produced livestock primarily for market exchange. 

Agriculture, sometimes referred to as intensive agriculture, involves clearing and using the same plot of land for an extended period, sometimes several generations; it also involves the use of plows and draft animals in the preparation of land for planting and the cultivation of crops. Agriculture often supports much higher population densities than other modes of production (except industrialism) and agricultural societies can range in population from a few thousand into the millions. Though agriculture produces more food per unit of land area than the previously mentioned modes, the tendency of agricultural societies to focus on relatively few crops has often meant that these societies have much less diverse diets than foraging and horticultural societies. There is some archaeological and fossil evidence that populations in transition from foraging to agriculture have tended to suffer reduced stature, reduced musculature, and to exhibit other markers of malnutrition. Research has suggested that agriculture paradoxically allows a higher, but less healthy population for a given area. The advent of agriculture has marked that advent of social stratification in many parts of the world, with marked differentials in access to resources between segments of the same society. This mode of production also is more likely to entail permanent individual or family ownership of particular tracts of land than previously mentioned modes of production. Agriculture has co-occurred with both subsistence and market economies, often with a single society exhibiting some degree of both types of economies and has a more negative impact on the environment than the aforementioned modes of production.

Industrialism combines agriculture with mechanized industrial production of goods through the use of fossil fuels. Additionally, industrial societies use mechanized equipment in order to prepare land for planting, harvest crops, and distribute food to locations distant from where the original crops were planted. Industrialism shows similar trends to agriculture in terms of population density, and environmental impact, except to a much greater degree. Dietary diversity can be highly variable under an industrial mode of production and can depend on access to foods produced for local subsistence on the one hand, or to income level and purchasing power visa vie foods available in food markets (Leatherman and Goodman 2005). Dietary diversity and nutritional health often correlate with the degree of social stratification within an industrial society and sometimes between societies. With the exception of Soviet model states, industrial societies are heavily based on the concept of private property rights and the accumulation of profit through “free enterprise”. 

The general trend for many societies over the past several millennia has been toward agriculture, and in the past two centuries, toward industrialism. Though these two modes of production are by no means superior to other modes in every respect, the fact that societies that practice them tend to have larger populations, higher population densities, and a more complex social structure has correlated with the geographic expansion of agricultural and industrial societies at the expense of societies emphasizing other modes of production. Concurrent with this trend toward intensified agricultural and industrial production has been the rise of the social and economic paradigm of capitalism, which entails the production and sale of goods and services in the market place in order to produce a profit. These trends have had profound implications for nutritional status for human beings on a global scale. In order to discern how broader economic and environmental trends affect a community's food systems, food security, and nutritional status, it is important to summarize one of the most significant economic and ecological phenomena today, globalization. The next section will treat the linkages between economic and ideological trends over the last several centuries and environmental and political economic factors affecting access to food and nutritional status.

Globalization and nutrition

General summary of globalization

Though the scope and dimensions of globalization as most people currently construe it are of fairly recent origin, the broader phenomenon of global interconnections through cultural diffusion and trade is several centuries old. Starting in the late Fifteenth century, European powers expanded beyond the European sub-continent to found colonies in the Americas, East Asia, South Asia, Australia and Oceania. This expansion has had a profound impact in terms of wealth creation in Europe and extraction elsewhere, cultural changes in most of the world's societies, and biological phenomena such as the introduction of several infectious diseases into the Western Hemisphere, which caused tremendous disruption and population reduction for indigenous societies there. These events, far from occurring coincidentally, have had synergistic relationships, in one vivid example, the decimation of Amerindian populations through infectious disease often preceding and facilitating subsequent conquest by European powers. Such conquests in turn have often had significantly negative impacts on internal cohesion, ability of populations to attain adequate resources for their own subsistence and traditional social obligations, and local environments for colonized societies. In order to understand the effects of globalization on nutritional status and food security, it is important to understand the historical circumstances that have led to contemporary globalization, and that still manifest themselves in political, social, material, and physical/health differentials between (and within) the different peoples of the world today.

“The Rise of the Merchant, Industrialist, and Capital Controller,” written by Richard Robbins in 2005, uses a hypothetical scenario of the reader as a “merchant adventurer” to detail economic world history starting in 1400. In 1400, China was arguably the most cosmopolitan and technologically complex society in the world. It was a center of trade, along with the Middle East, East Africa, and ports on the Mediterranean Sea. Western Europe, while playing a part in this network, did not dominate it by any means; one could argue for European marginalization in fact. This circumstance began to change when the Europeans “discovered” the Americas, setting in motion a process that would disrupt many societies and devastate indigenous populations of the Western Hemisphere. The dominant economic paradigm of this period was mercantilism, whereby European merchants began to achieve power in world markets and in relation to European governing aristocracies. Robbins cites example of government protections that facilitated mercantilism in the form of exclusive proprietary rights to trading companies and armies used to protect trade by force if necessary. He details instances of government protection such as the example of how Great Britain destroyed India's textile industry and turned that society into an importer of textiles is especially illustrative. In dealing with imperialism, capitalism, and the rise of corporations, Robins further details the manner in which the “West” transformed various regions/peoples from proactive participants on global trade networks into sources of raw materials and consumers of European or North American exports. This history of world trade is important to the consideration of current issues of disparity of power and wealth.

There are many critiques the policies of the World Bank and the International Monetary Fund (IMF) in the promotion of high intensity capital investment in developing nations (e.g. Weller et al. 2001; Fort et al. 2004). Disparities within nations and growing poverty rates in many nations also provide compelling evidence of the idea that the rewards of economic globalization are uneven at best. There is a great deal of literature about globalization and increases in health disparities both between and within countries. 

Finally, there is Amartya Sen with Development as Freedom (1999); here Sen disagrees about whether or not the world's poor are getting poorer, but also maintains that this criterion is not the most important. He argues that relative disparities and power differentials are the most important problems of globalization. Sen states that the increasing interconnection of the Worlds societies can have positive benefits, but that the disparities and opportunities for exploitation must be mitigated to the greatest extent possible, if they can not be eliminated outright. Sen provides groundwork for a nuanced middle ground between unabashed proponents and opponents of globalization. 

Far from being universally decried, the recent accelerated expansion of western capitalism, geographically, politically, and ideologically, has been lauded in many quarters. International and bilateral agencies such as the World Bank, IMF, and the United States Agency for International Development (USAID) have utilized free market capitalist theories extensively in development programs in many corners of the globe whose state aims are to promote economic growth for communities and nation-states and to alleviate poverty. Likewise prominent individuals such as former U.S. Federal Reserve Board Chair Alan Greenspan and U.S. based journalist Thomas Friedman have held forth extensively about the possibilities of economic and social improvement in developed and developing nations alike, mainly through increased access to appropriate education, sophisticated communications and transportation technology, and a paradigm of social and economic “flexibility”, where individuals and communities who can best adapt to rapid changes in the role of governments and the particular economic base of a given location would be in the best position to take advantage of the opportunities offered by economic, political, and cultural globalization. This free market ideology is also predominant in the policies and procedures of the World Trade Organization (WTO) and many transnational corporations (TNC's), most of which are headquartered in developed nations. The rise of Capitalism and the free market society have indeed increased and exacerbated food insecurity in the world's poor due to the structure and function of a Capitalist society where only those who can afford to buy food to feed themselves are the only ones with access to a secure and adequate food supply. Food is no longer a human right to life and health due to the Capitalist approach to commodifying food in the free market society that as a result of globalization has spread all over the world. Transnational corporations and trade organizations such as NAFTA facilitate this approach of commodifying our world's food supply by enforcing laws and regulations which further deepen the inequality of wealth and unequal distribution of common goods such as food between the rich and the poor.

In contrast to the “western” economic model, most early social scholarship about economics stressed the predominance of reciprocity as a primary driving force in traditional non-Western societies. Marcel Mauss referred to the gift as a “total social phenomenon”, fraught with ritual and socio political as well as material significance. Though some objects, such as armbands or shell necklaces in the kula ring that runs through several island groups off the coast of Papua New Guinea, might induce some form of prestige based competition, the terms of exchange are significantly different than a monetary transaction under a modern capitalist system. While Appadurai actually describes ritual objects as a type of commodity, he couches them as such under significantly different terms than the market-based types of commodity normally treated by economists. Annette Wiener criticizes earlier works in anthropology and sociology that depicted “simple” societies utilizing a simple version of reciprocity. Whatever the theoretical stance of social scholars on non-western traditional economies, there is a consensus that such essentials as food and water tended to be shared more freely than other types of goods or services. This dynamic tends to change with the introduction of a market-based economy into a society, with food coming to be increasingly treated as a commodity, rather than a social good or an essential component of health and survival.

Regardless of one's overall perspective on the costs and benefits of economic globalization, there are several examples in social scholarship of groups of people suffering a decline in nutritional statues subsequent to the introduction of a capitalist market-based economy into an area that has previously practiced an economy based more on subsistence production and reciprocity. Although some people's food security may improve with access to more steady income, many people in communities that have heretofore practiced a subsistence economy may experienced greater food insecurity and nutritional status due to insufficient income to replace the foods no longer produced by a household. Whether the growth of food insecurity and socioeconomic disparities in many parts of the world in recent decades is an inherent part of globalization or a temporary “growing pain” until economic development attains its full efficacy is a matter of debate, but there are many empirical examples of communities being dissociated from traditional means of food production and not being able to find sufficient wages in a new market economy to achieve a balanced and calorically sufficient diet. Several factors affecting food security and nutritional status range on a continuum from more physical phenomena such as land degradation and land expropriation, to more culturally and socio-politically driven things such as cash cropping, dietary delocalization, and commoditization of food; one important caveat is that all of these trends are interconnected and fall under a broad category of socio-cultural and economic disruptions and dislocations under the current paradigm of globalization.

Land degradation

Though Blakie and Brookfield acknowledge the problematic aspects of defining land degradation, with definitional variation depending in large part on the scholar or stakeholder in question, they do outline a general idea of reduced soil fertility and reduced ability of a given area of land to provide for people's subsistence needs, as compared to earlier periods in human history on that same land area. Paul Farmer discusses the effects of land degradation in central Haiti on local people's ability to produce sufficient food for their families within the environs of their own communities. Farmer links malnutrition in a Haitian village with vulnerability to infectious diseases, including tuberculosis and HIV/AIDS, both in terms of chance of infection and severity of symptoms for those infected. While the extremely low percentage of the U.S. population involved in agriculture strongly suggests that direct access to arable land is not an absolute necessity for food security and nutritional health, land degradation in many developing nations is accelerating the rate of rural to urban migration at a more accelerated rate than most major cities are equipped to handle. Leatherman and Goodman also allude to land degradation co-occurring with decreases in food security and nutritional status in some communities in the Mexican state of Quintana Roo. Walter Edgar discusses the correlation between land degradation and economic disruption, as well as nutritional hardship, in the U.S. state of South Carolina in the decades following the Reconstruction Period. Coupled with land expropriation, land degradation has the effect of thrusting unprepared subsistence producers or other peasant farmers into a fast-paced and complex market economy heavily influence by policy makers who are far removed from the concerns and worldview of small scale farmers in developing countries.

Land expropriation

Occurring for a variety of reasons, land expropriation, or the disruption of traditional ownership of land by more powerful interests such as local elites, governments, or transnational corporations, can also markedly affect nutritional status. Robbins details examples in Mexico of peasants facing land expropriation in the face of agribusiness consolidation under the North American Free Trade Agreement (NAFTA); in many cases, these subsistence producers are forced either to migrate to cities or work sporadically as agricultural labors. Since most if not all food must be purchased under these circumstances, the food security and nutritional status of these newer additions to the pool of poor unskilled labor often declines. Another common impetus for expropriation is non-agricultural “economic development”, often in the form of tourism. In one Example, Donald MacLeod details curtailment of subsistence activities, mainly fishing and cultivation, in areas of the Canary Islands in the face of pressures from tourism interests wishing to monopolize the “pristine” beauty of locations catering to Germans and other tourists from EU nations. Ironically, local people see relatively little monetary benefit from the rise in tourism, as many vacations are planned by German tour companies (linked with all inclusive German owned resorts in the Canary Islands) and are paid for before tourists ever arrive at their vacation destination. Leatherman and Goodman and Daltabuit point to circumscription of land available for traditional milpa horticultural production in communities in the Mexican state of Quintana Roo in the face of growing demands for land for resorts by tourism interests, under the auspices of the Mexican national government. One expropriation scenario with a long history is cash cropping, where crops grown for revenue from exports are prioritized over crops grown for local consumption.

Cash cropping

In Sweetness and Power, written by Sidney Mintz in 1985, details examples of mono-cropping, or planting massive areas with one cash crop, in several Caribbean Islands, including Cuba. He states that Cuba went from being an economically diverse place with many small scale subsistence producers to a mono-crop plantation system dependent on cash from its sugar crop and substantial food imports for the later centuries of the Spanish Colonial Period. He describes Cuba as an example of growing impoverishment and malnutrition concurrent with increasing concentration of land and other resources in fewer hands. Gross and Underwood illustrate the mid Twentieth Century example of the advent of sisal production in Northeastern Brazil. These authors detail a vicious cycle of the unfulfilled promises of sisal production for smallholders; because owners of sisal processing machines did not think small farms worth their time, small holders could not process and sell their sisal and were often forced to work as laborers on large farms. Sisal is cited as being particularly insidious because it is hard to eradicate once introduced and makes subsequent subsistence production virtually impossible. This article treats a common situation of households prioritizing working males in food allocation, exposing growing children to malnutrition, particularly under nutrition and micronutrient deficiency, and all of its attendant ills. Edgar discusses how exclusive planting of cotton in the Southeastern United States during the late Nineteenth and early Twentieth Centuries caused substantial land degradation, lead to a great deal of land expropriation from small scale farmers, and occurred in a context of widespread malnutrition. Especially in Today's complex, accelerated version of globalization, cash cropping is intimately linked with the delocalization of diets and the commoditization of food and has profound, though varied, implications for food security and nutritional status.

Delocalization and commoditization

In “Diet and Delocalization: Dietary Challenges since 1750”, Pelto and Pelto trace the concurrent historical development of global capitalism and dietary delocalization, a process in which increasing portions of diet for a household or community come from an increasing distance away from that same community. Nutritional scholars explicitly state that delocalization does not necessarily entail increased food insecurity and malnutrition, but that access to an adequate diet becomes increasingly removed from local control and increasingly contingent on access to hard cash or some other non-food precious resource. Leatherman and Goodman discuss the ironic result of their study in Quintana Roo that both the groups with the best and worst food security and nutritional status worked in service industries related to tourism, with the median group being a milpa community. They differentiate between those with stable employment and income who have access to a wide variety of foods on a regular basis and those with sporadic employment who struggle for caloric sufficiency within the household and have low dietary diversity. The main import of these examples is not that delocalization is universally negative, but that it tends to increase disparities of food security and nutritional status within and between social groups, with some segments suffering marked degradation of both. 

Closely linked with delocalization is food commoditization, or the treatment of food primarily as a market commodity, rather than prioritizing other uses, such as sustenance, human rights entitlement, or social relations. Dewey describes the deleterious effects of food commoditization for rural communities in Central America, to include reductions in food security and nutritional status. Much of tourism literature details marked increases in the commoditization of food subsequent to the introduction of tourism as a form of market based economic development. Dewey and Robbins also state that when food is primarily seen as a commodity by powerful interests, not only does such an ideology increase delocalization, but also land degradation and expropriation as elite land owners or transnational corporations cause massive social and ecological disruptions in the process of mono-cropping food crops over broad swaths of land in order to reap maximum profits from overseas sales. Indeed, delocalization and commoditization have significant potential to diminish food security and nutritional status in poor communities over broad areas of the world.

Dietary health

In terms of food security and dietary diversity, which are defined as reliable access to a caloric sufficiency and access to a wide variety of macro and micro nutrients in order to maintain nutritive balance, respectively, the commoditization of food plays a key role in diminishing the control local populations have over their own subsistence production. Delocalization of food systems, which Pelto and Pelto define as taking production of food out of a local subsistence context and tying it to geographically broader market systems, can precipitate marked cultural and nutritional disruption. Likewise commoditization of food systems, defined as a paradigm shift from one of subsistence or social significances shift toward one which treats food primarily as a market commodity, can affect dietary health as well as collective identity. Commoditization tends to shift food security and dietary diversity away from integrated kinship or other reciprocal distribution networks toward being an issue of who can best compete in a free market to achieve these ends; indeed, commoditization has often been linked to breakdowns in food entitlements, which are defined as cultural or social norms that ensure food access for all members of a given social group.

The deleterious effects of mild to moderate malnutrition (MMM) not only pertain to caloric insufficiency (often closely associated with food insecurity) but also to poor dietary diversity; in particular, curtailed access to protein, complex carbohydrates, zinc, iron, and other micronutrients. The ways in which undernutrition and micronutrient deficiency interact with other health effects are myriad. The most obvious manifestation of MMM, stunting is defined as height and or weight below the standard range for a particular age group. However, far from being a mere difference in height and weight, stunting was correlated with a wide variety of health effects. Closely related to stunting, level of physical activity closely articulates with nutritional status and affects childhood development. Chronically malnourished infants and toddlers showed decreased physical activity compared to supplemented groups or those who are adequately nourished.

Perhaps, the most critical facets of human development correlated to nutrition levels are behavior and cognition; development in these two areas could have profound effects on life chances for individuals and populations. In comparing a group of southern Mexican children subject to MMM and a group in the same region who received dietary supplements, Chavez et al. show a relation between MMM and poorer school performance; unsupplemented children showed poorer participation, greater degree of in-class distraction, more sleeping in class, and poorer performance on standardized tests. In addition, malnourished children showed poorer scores on intelligence quotient (I.Q.) tests than their supplemented counterparts.

Of all the aspects of human existence, sexual reproduction may have the most detailed articulation with malnutrition. In populations subject to MMM, menarche occurs later (15.5 years) than in adequately nourished populations; an early average menopause (40.5 years) makes for a relatively short reproductive period for women in the study area for Chavez et al. Because of longer postpartum periods of amenorrhea, birth spacing was an average of 27 months, versus 19 months. Though longer birth spacing can help control population growth, the evidence that Chavez et al. present suggest a curtailing of reproductive choice and adaptability due to malnutrition. This study also linked maternal MMM with higher infant and young child mortality.

Another effect of MMM crucial to life chances is work capacity; MMM shows a cyclical pattern of decreasing work capacity and its rewards, further exacerbating the problem. Allen found a correlation between reduced VO2 max rates among MMM populations and decreased muscular strength and endurance in the performance of strenuous manual labor. Although personal motivation can have a strong positive impact on individual work performance, better muscular development associated with a history of adequate nutrition increases overall work capacity, irrespective of effort. Among Jamaican cane cutters, those within normal size range cut more cane than those who showed stunting. One cultural variation in this trend was found among MMM Guatemalan workers who put forth work effort comparable to better nourished counterparts, but were likely to engage in resting behavior than in recreational or social activity during off hours. In wage economies where workers get paid in proportion to productive output, reduced work capacity can translate to reduced food security, increasing the risk of MMM. 

Additionally, malnutrition and infectious disease have a synergistic relationship that can lead to spiraling health deterioration. According to Allen, the incidence of infectious disease does not vary significantly between MMM and adequately nourished populations, but the duration and severity of disease episodes is greater for MMM populations. A key reason for this disparity is that infectious disease often results in poor food intake and nutrient absorption. Not only do sick people generally eat little, but what they do eat is often of minimal benefit due to nausea and diarrhea.

Aside from MMM due to under-nutrition or micro-nutrient deficiency, over-nutrition, defined as the consumption of too many calories for one's body size and physical activity level, is also becoming an increasingly significant problem for much of the World. Overnutrition has been associated with obesity, which the USDA and McEwen and Seeman correlate with increased risk of type II diabetes, cardiovascular disease, and stroke. Overnutrition is also often associated with the co-occurrence of caloric sufficiency (or over-sufficiency) and micronutrient deficiency, as is often the case where processed foods that are high in calories, but low in most nutrients, increase in dietary prominence. Leatherman and Goodman and Guest and Jones discuss the growing coincidence of stunting and other symptoms of MMM and obesity within developing nations, sometimes within the same community. This trend can be linked to changing economies and food practices in much of the World under contemporary economic globalization. 

Also the study conducted by Baten and Blum have illustrated changes in the effects from a particular diet of the population between 1870 and 1989. Important finding of the study was that the effect of the protein on heights of the individuals became less significant during the second half of the period under observation (i.e. 1950-1989). Moreover, the main sources of the protein were also modified. This was caused by the development of the technologies and global trade, which have likewise reduced the food shortage.