psychosocial aspects of hunger

PSYCHOSOCIAL ASPECTS OF HUNGER

MEDICAL RESEARCH IN THE BIBLE FROM THE VIEWPOINT OF CONTEMPORARY PERSPECTIVE

Professor Liubov Ben-Nun

Hunger has many negative effects. What is the mechanism for regulating hunger? What is the prevalence of hunger? What are the effects of hunger? What are psychosocial effects of hunger? How can hunger be managed? All biblical texts were examined and two verses relating to psychosocial aspects of hunger were studied. Exclusion criteria included other negative health effects of hunger.

60th Book About the Author Dr. Liubov Ben-Nun, the Author of dozens Books and Articles that have been published in scientific journals worldwide. Professor emeritus at Ben Gurion University of the Negev, Faculty of Health Sciences, Beer-Sheva, Israel. She has established the "LAHAV" International Forum for research into medicine in the Bible from the viewpoint of contemporary medicine.

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PSYCHOSOCIAL ASPECTS OF HUNGER Professor Liubov Ben-Nun

Ben-Gurion University of the Negev Faculty of Health Sciences Beer-Sheva, Israel

60th Book

B.N. Publication House. Israel. 2015. Fax: +(972) 8 6883376 Mobile 050 5971592 E-Mail: [email protected] Technical Assistance: Carmela Moshe. All rights reserved

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BIBLICAL EXEGESIS It should be noted and stressed that this research is in no way concerned with a discussion of any interpretations of the Bible by the great commentators such as Rambam, the sages of the Talmud and the Mishnah, or interpretation based on knowledge of the ancient world found in Julius Preuss’ book. The research is based solely on the actual words on the verses of the Bible.

CONTENTS MY VIEW PREFACE FOREWORD INTRODUCTION THE BIBLICAL DESCRIPTIONS FOOD INSECURITY PREVALENCE HUNGER REGULATION PSYCHOSOCIAL EFFECTS OF HUNGER/MALNUTRITION GESTATIONAL EXPOSURE INFANTS CHILDREN ADOLESCENTS ADULTS THE ELDERLY LENINGRAD SIEGE HUNGER IN NAZI CONCENTRATION CAMPS SOVIET GULAG FATAL CHILD MALTREATMENT ANOREXIA NERVOSA OBSESSIVE COMPULSIVE DISORDER HUNGER STRIKERS CESSATION OF EATING HANDLING HUNGER SUMMARY

8 9 10 12 16 17 21 30 37 42 42 53 59 65 68 80 85 87 90 90 91 97 98 106 109 121

ABBREVIATIONS ADHD AIDS ANBP ANR AOR ARR AN BMI BML CAARS CCHIP CCK CFPs C-HCFRA CI CMR

Attention deficit hyperactivity disorder Acquired immunodeficiency syndrome Anorexia nervosa-binge-purging Anorexia nervosa-restricting subtype Adjusted odds ratio Adjusted risk ratio Anorexia nervosa Body mass index Body mass loss Conners Adult ADHD Rating Scales Community Childhood Hunger Identification Project Cholecystokinin Community food programs Colonia Household and Community Food Resource Assessment Confidence intervals Crude mortality rate

CNS CPS-FSS CPT C-V DAP DSM ED EPDS FFQ GHQ G-I GLP-1 GTMO HFIAS HFSSM HIV HSCL IQ MDG MNA-SF MST MUST NHANES III NSI OCD OR PDS PSS PTSD RR RRR SD SNAP USDA VLFS VSED WHO WHO-ORS WWII

Central nervous system The Current Population Survey Food Security Supplement Conners Continuous Performance Test Cardiovascular Developmental assets profile Diagnostic and Statistical Manual of Mental disorders Emergency department Elevated levels of prenatal depressive symptoms Food frequency questionnaire General Health Questionnaire Gastrointestinal Glucagon-like peptide-1 Guantanamo Bay Household Food Insecurity Access Scale Household Food Security Survey Module Human immunodeficiency virus Hopkins Symptom Checklist Intelligent quotient Millennium Development Goal Mini Nutritional Assessment Short-Form Malnutrition Screening Tool Malnutrition Universal Screening Tool Third National Health and Nutrition Examination Survey Nutrition Screening Initiative Obsessive compulsive disorder Odds ratio Positive report on a maternal depression screen Perceived Stress Scale Post-traumatic stress disorder Relative risk Relative risk ratio Standard deviation Supplemental Nutrition Assistance Program United States Department of Agriculture Very low food security Voluntary stopping of eating and drinking World Health OrganizationWorld Health Organization-oral rehydration solution World War II

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Psychosocial aspects of hunger

MY VIEW MEDICINE IN THE BIBLE AS A RESEARCH CHALLENGE This is a voyage along the well-trodden routes of contemporary medicine to the paths of the Bible, from the time of the first man to the period of the People of Israel. It covers the connection between body and soul, and the unbroken link between our earliest ancestors, accompanied by spiritual yearning and ourselves. Through the verses of the Bible flows a powerful stream of ideas for medical research combined with study of our roots and the Ancient texts. It would not be too adventurous to state that if there is one book in the world that all Jews are proud of, that is the Book of Books, the greatest classic among all literary works, whose original language is not Greek or Latin, but the Hebrew that I and other Israelis speak every day, our mother tongue, the language of Eliezer Ben Yehuda. The Bible exists as evidence in the Book of Books, open to all humankind. For thousands of years it has been placed before us, still as fresh as before, the history of peoples who have disappeared and of the Jewish people, which has survived with its Holy Text that has been translated into hundreds of languages and dialects, and remains our eternal taboo. Many people ask me about the connection between the Bible and medical science. My reply is simple: the roots of science are buried deep in the biblical period and I am just the archeologist and medical researcher. This scientific medical journey to the earliest roots of the nation in the Bible has been and remains moving, exciting and enjoyable. It has created a kind of meeting in my mind between the present and those Ancient times, through examining events frozen in time. Sometimes it is important to stop, to look back a little. In real time, it is hard to study every detail, because time is passing as they appear. However, when we look back we can freeze the picture and examine every detail, see many events that we missed during that fraction of a second when they occurred. The Book of Books, the Bible, is not just the identity card of the Jewish, but an essential source for the whole world.

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PREFACE The purpose of this research is to analyze the medical situations and conditions referred to in the Bible, as we are dealing with a contemporary medical record. These are scientific medical studies incorporating verses from the Bible, without no interpretation or historical descriptions of places. Fundamentally, this Research is constructed purely from an examination of passages from the Bible, exactly as written. The research is part of a long series of published studies on the subject of biblical medicine from a modern medical perspective. This is not a laboratory research. The Research is built entirely on a secular foundation. With due to respects to people faith, this Research takes a modern look at medical practices. Each to his own beliefs.

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FOREWORD Famine, like poverty, has always been with us. No region and no century have been immune. Its scars — economic, psychological and political — can long outlast its immediate impact on mortality and health. Famines are a hallmark of economic backwardness, and were thus more likely to occur in the pre-industrialized past. Yet the twentieth century suffered some of the most devastating ever recorded. That century also saw shifts in both the causes and symptoms of famine. This new century's famines have been "small" by historical standards, and the threat of major ones seemingly confined to ever-smaller pockets of the globe. Are these shifts a sign of hope for the future? (1). In history, humankind has suffered from great famines. As recently as 1943, at least a million people died of famine in Bengal. In January 1943, many soldiers of the Royal Hungarian Army died in Russia, at the River Don, because of the lack of food supply and insufficient healthcare. The enormous advances of science in this century have made the prevention and relief of famine technically easier. Subsequently, in many parts of the world, famine conditions have arisen, but fortunately on a smaller scale (2). Famines are sustained, extreme shortages of food among discrete populations sufficient to cause high rates of mortality. Signs and symptoms of prolonged food deprivation include loss of fat and subcutaneous tissue, depression, apathy, and weakness, which progress to immobility and death of the individual, often from superimposed respiratory or other infections. The social consequences of famines are disruption from mass migrations of people in search of food, breakdown of social behavior, abandonment of cooperative effort, loss of personal pride and sense of family ties, and finally a struggle for individual survival. Famines have been common ever since the development of agriculture made human settlements possible. Food shortages due to crop failures caused by natural disasters including poor weather, insect plagues, and plant diseases; crop destruction due to warfare; and enforced starvation as a political tool are by no means the only causative factors. Many of the worst famines have been due to poor distribution of existing food supplies, either because of inequities

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that result in a lack of purchasing power on the part of the poor or because of political interference with normal distribution or relief movements of food. Europe and Asia, which in the past experienced frequent severe famines, sometimes with deaths in the hundreds of thousands or millions, have now largely eliminated famines through social and technological change. However, in Africa, political and social factors have destroyed the capacity of many populations to survive drought-induced variations in local food supplies and prices. Thus, famines are due to varying combinations of inadequacy of food supplies for whatever reason and the inability of populations to acquire food because of poverty, civil disturbances, or political interference. Despite the role of natural causes, the conclusion is inescapable that modern famines, like most of those in history, are man-made (3). Civilian-targeted warfare and famine constitute two of the greatest public health challenges of our time. Both have devastated many countries in Africa. Social services, and in particular, health services, have been destroyed. Dictatorial and military governments have used the withholding of food as a political weapon to exacerbate human suffering. Under such circumstances, war and famine are expected to have catastrophic impacts on child survival. This study examines the role of parental education in reducing excess child mortality in Africa by considering Tigrai-Ethiopia, which was severely affected by famine and civil war during 1973-1991. This study uses data from the 1994 Housing and Population Census of Ethiopia and on communities' vulnerability to food crises. Child mortality levels and trends by various subgroups are estimated using indirect methods of mortality estimation techniques. Although child mortality was excessively high (about 200 deaths per 1000 births), the results show enormous variations in child mortality by parental education. Child mortality was highest among children born to illiterate mothers and illiterate fathers. The role of parental education in reducing child mortality was great during famine periods. In the communities devastated by war, however, its impact was significant only when the father has above primary education. In conclusion, both mother's and father's education are significantly and negatively associated with child mortality, although this effect diminishes over time if the crisis is severe and prolonged. The policy implications include reducing armed conflict, addressing food

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security in a timely manner, and expansion of educational opportunities (4). Adult humans often undertake acute fasts for cosmetic, religious or medical reasons. For example, an estimated 14% of U.S. adults have reported using fasting as a means to control body weight and this approach has been advocated as an intermittent treatment for gross refractory obesity. There are unique historical data sets on extreme forms of food restriction that give insight into the consequences of starvation or semi-starvation in previously healthy, but usually non-obese subjects. These include documented medical reports on victims of hunger strike, famine and prisoners of war. Such data provide a detailed account on how the body adapts to prolonged starvation. Fasting for the period of 40 days and 40 nights is well within the overall physiological capabilities of a healthy adult. However, the specific effects on the human body and mind are less clearly documented, either in the short term (hours) or in the longer term (days). Thus, the three questions follow, pertinent to any weight-loss therapy, 1] how effective is the regime in achieving weight loss, 2] what impact does it have on psychology? and 3] does it work long-term? (5). References 1. Gráda CÓ. Famines past, famine's future. Dev Change. 2011;42(1):49-69. 2. Tamas R. Famine and war. West Indian Med J. 2008;57(1):73-4. 3. Scrimshaw NS. The phenomenon of famine. Annu Rev Nutr. 1987;7:1-21. 4. Kiros GE, Hogan DP. War, famine and excess child mortality in Africa: the role of parental education. Int J Epidemiol. 2001;30(3):447-55; discussion 456. 5. Johnstone AM. Fasting - the ultimate diet? Obes Rev. 2007;8(3):211-22.

INTRODUCTION The symposium entitled, "Food Insecurity and Health across the Lifespan" explored the latest research from the economic, medical, pediatric, geriatric, and nutrition literature concerning the measurement, prevalence, predictors, and consequences of food insecurity across the lifespan, with a focus on chronic disease, chronic disease management, and healthcare costs. Consideration of the health impacts of food insecurity is a new and timely area of research, with a considerable potential for translation of the findings

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into public policy surrounding alleviation of food insecurity. Although it is widely acknowledged that food insecurity and hunger are morally unacceptable, strategies to develop national policies to alleviate hunger must also approach this problem by considering the economic impact of food insecurity on health and well-being. The goals of this symposium were to: 1] learn about the prevalence and severity of food insecurity in the U.S. across the lifespan and how this is increasing with the continued economic downturn; 2] understand the growing body of research that documents the impact of varying degrees of food insecurity on physical and mental health across the lifespan; 3] examine how food insecurity is related to chronic disease; and 4] explore research methodology to determine the impact of food insecurity on healthcare costs and utilization (1). The purpose of this literature review is to discuss the concept of food insecurity and its impact on current global health policy and nursing practice. Food insecurity means a nonsustainable food system that interferes with optimal self-reliance and social justice. Individuals experiencing food insecurity lack nutritionally adequate and safe foods in their diet. Resources play a significant role in food insecurity by affecting whether or not people obtain culturally, socially acceptable food through regular marketplace sources as opposed to severe coping strategies, such as emergency food sources, scavenging, and stealing. Persons who are living in poverty, female heads of household, single parents, people living with many siblings, landless people, migrants, immigrants, and those living in certain geographical regions constitute populations at risk and most vulnerable to food insecurity. In conclusion, food insecurity influences economics through annual losses of gross domestic product due to reduced human productivity. Food insecurity affects individuals and households and is largely an unobservable condition, making data collection and analysis challenging. Policy and research have focused on macronutrient sufficiency and deprivation, making it difficult to draw attention and research dollars to food insecurity. Persons experiencing food insecurity exhibit clinical signs such as less healthy diets, poor health status, poor diabetes and chronic disease management, and impaired cognitive function (2). Climate change projections indicate that droughts will become more intense in the 21 century in some areas of the world. The El Niño Southern Oscillation is associated with drought in some

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countries, and forecasts can provide advance warning of the increased risk of adverse climate conditions. The most recent available data from EMDAT (a global database on natural and technological disasters that contains essential core data on the occurrence and effects of more than 21,000 disasters in the world from 1,900 to present) (3) estimates that over 50 million people globally were affected by drought in 2011. Documentation of the health effects of drought is difficult, given the complexity in assigning a beginning/end and because effects tend to accumulate over time. Most health impacts are indirect because of its link to other mediating circumstances like loss of livelihoods. The following databases were searched: MEDLINE; CINAHL; Embase; PsychINFO, and Cochrane Collection. Key references from extracted papers were hand-searched, and advice from experts was sought for further sources of literature. Inclusion criteria include: explicit link made between drought as exposure and human health outcomes; all study designs/methods; all countries/contexts; any year of publication. Exclusion criteria include: drought meaning shortage unrelated to climate; papers not published in English; studies on dry/arid climates unless drought was noted as an abnormal climatological event. No formal quality evaluation was used on papers meeting inclusion criteria. Eighty-seven papers meet the inclusion criteria. Additionally, 59 papers not strictly meeting the inclusion criteria are used as supporting text in relevant parts of the results section. Main categories of findings include: nutrition-related effects (including general malnutrition and mortality, micronutrient malnutrition, and anti-nutrient consumption); water-related disease (including E coli, cholera and algal bloom); airborne and dust-related disease (including silo gas exposure and coccidioidomycosis); vector borne disease (including malaria, dengue and West Nile Virus); mental health effects (including distress and other emotional consequences); and other health effects (including wildfire, effects of migration, and damage to infrastructure). In conclusion, the probability of droughtrelated health impacts varies widely and largely depends upon drought severity, baseline population vulnerability, existing health and sanitation infrastructure, and available resources which mitigate impacts as they occur. The socio-economic environment in which drought occurs influences the resilience of the affected population. Forecasting can be used to provide advance warning of the increased

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risk of adverse climate conditions and can support the disaster risk reduction process (4). Hunger has been a concern for generations and has continued to plague hundreds of millions of people around the world. It is associated with poverty, lack of assessment in agriculture, devastating climate, weather changes, displacement, racism, ethnocentrisms, gender discrimination, unstable wastage, and food wastage (4). My previous research deals with dehydration and hunger effects on humans. Water is an essential nutrient for all persons, and is important for human health; it is used for hydration, and treatment of various diseases. Maintaining an optimal hydration is recognized to provide health benefits. Fluid balance is maintained via thirst, a feedback-controlled variable, regulated acutely by central and peripheral mechanisms. Voluntary drinking is a behavior influenced by numerous social and psychological cues (5). The Bible tells us that "They wandered in the desert in a solitary way; they found no city to dwell" (Psalms 107:4). Subsequently, "Hungry and thirsty, their soul fainted (‫ )תתעטף‬in them" (Psalms 107:5). and "Their soul abhorred )‫ )יתענו‬all manner of meat (‫ ;)כל אכל‬for they have come near the gates of death"(107:18). We see that people in extremely hard condition walking in the desert, with no water and no food, suffered from severe dehydration and hunger. The people were exhausted severely and were near to their death. Another encounter deals with a young Egyptian man: "And they (David and his men) found an Egyptian in the field, and brought him to David, and gave him bread, and he did eat; and they made him drink water. And they gave him a piece of a cake of figs, and two clusters of resins: and when he had eaten, his spirit came again to him: for he had eaten no bread, not drunk any water, three days and three nights" (I Samuel 30:11,12). Here an Egyptian man who was dehydrated suffering from hunger. This miserable man was left alone without fluids and food and was near to death. After receiving water and food, he recovered. This case describes the negative effect of severe dehydration and lack of food (5). The Bible gives precise descriptions of dehydrated and fasting individuals. The basic principles of dehydration, effects of dehydration, including physiological changes, intake of water, special

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risk groups such as children, the elderly, pilots, individuals working in hot climates, athletes engaged in competitive sports, as well as fasting, hunger effects, types of fasting, causes, management of dehydration and fasting, all these issues can be applied to ancient as well as to contemporary individuals (5). We see that hunger has many negative effects. What is the mechanism for regulating hunger? What is the prevalence of hunger? What are the effects of hunger? What are psychosocial effects of hunger? How can hunger be managed? All biblical texts were examined and two verses relating to psychosocial aspects of hunger were studied. Exclusion criteria included other negative health effects of hunger. References 1. Lee JS, Gundersen C, Cook J, et al. Food insecurity and health across the lifespan. Adv Nutr. 2012;3(5):744-5. 2. Kregg-Byers CM, Schlenk EA. Implications of food insecurity on global health policy and nursing practice. J Nurs Scholarsh. 2010;42(3):278-85. 3. Frequently asked questions. Available 26 June 2015 at http://www.emdat.be/frequently-asked-questions. 4. Stanke C, Kerac M, Prudhomme C, et al. Health effects of drought: a systematic review of the evidence. PLoS Curr. 2013 Jun 5;5. 5. Ben-Nun L. In: Ben-Nun L. (ed.). Dehydration and Hunger. B.N. Publication House. Israel. 2015.

THE BIBLICAL DESCRIPTIONS The psychological effect of hunger is indicated in this verse: "I humbled (‫ (עיניתי‬my soul with fasting" (Psalms 35:13). The verse shows that hunger causes significant suffering to humans and is associated with mental distress, tension, and negative emotions. An additional verse indicates that it is imperative to save humans from impending death in famine: "To deliver )‫ )להציל‬their soul from death, and to keep them alive in famine" (Psalms 33:19).

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FOOD INSECURITY Food insecurity is a leading public health challenge in the U.S. today. This is primarily due to the magnitude of the problem, ∼50 million persons are food insecure (i.e., they were uncertain of having, or unable to acquire, enough food because they had insufficient money or other resources), and the serious negative health and other outcomes associated with being food insecure. This paper defines the measure used to delineate whether a household is food insecure. The measure, the Core Food Security Module, is based on 18 questions about a household's food situation. From the responses, a household is defined as food secure, low food secure, or very low food secure, with the latter two categories defined as "food insecure." The extent of food insecurity in the U.S. across various dimensions and the key determinants of food insecurity are presented. The key policy tool used to address food insecurity is the SNAP, formerly known as the Food Stamp Program. During the current economic downturn, >40 million persons are enrolled in SNAP, with total benefits of >$70 billion. This makes it the largest food assistance program and the largest near-cash assistance program in the U.S. After defining the eligibility criteria, the literature demonstrated the effectiveness of SNAP in addressing its key goal, namely the alleviation of food insecurity in the U.S. In conclusion, SNAP can maintain and even improve its effectiveness in alleviating food insecurity (1). Food security exists when all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life. Food insecurity is the converse state, is often associated with poverty and low income, and has important implications for the health and nutrition of individuals. Given their contribution to food production and preparation, their role in society as child bearers and caregivers, the increasing number of female-headed households worldwide, and their disproportionately poor economic status, women needs special consideration in discussions of food insecurity and its effect on health, nutrition, and behavior. Food insecurity is associated with obesity, anxiety, and depressive symptoms; risky sexual behavior; poor coping strategies; and negative pregnancy outcomes in women, although evidence about the direction and causality of associations is unclear. There is a lack of evidence and

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understanding of the effects of food insecurity in resource-poor settings, including its effect on weight, nutritional outcomes, and pregnancy outcomes, as well as its effect on progression of diseases such as HIV infection. More research is needed to guide efficient interventions that address food insecurity among women. However, practical experience suggests that both short-term assistance and longer-term strategies that improve livelihoods, address behavioral and coping strategies, acknowledge the mental health components of food insecurity, and attempt to ensure that women have the same economic opportunities, access to land, and economic power as men are important (2). Food security occurs when all members of a household have reliable access to food in sufficient quantity and quality to maintain an active and healthy lifestyle. Given the important biological and social value of food for humans, food and food sufficiency have been traditional topics of study among biological anthropologists. The focus on food insecurity, however, has emerged within the past two decades and recent global events, including the food crisis of 2007/2008, have led to renewed interests in the topic of food insecurity and wellbeing. Current and novel threats to food security, current thinking on measurement and definitions are reviewed, and a model that links food insecurity to coping strategies and then to health outcomes is outlined. Coping strategies are typically contextspecific and can be food and nonfood based. Coping strategies may affect health quite broadly, not just through nutritional pathways. There is the relationship between food insecurity and nutritional status, chronic diseases, infectious diseases, and mental health. There are the far-reaching consequences of food insecurity for human wellbeing but also the considerable variability in its effect and our limited empirical knowledge of the pathways through which food insecurity affects health. In conclusion, biological anthropologists might contribute to growing understanding of food insecurity and human health and wellbeing (3). Food insecurity is a daily reality for hundreds of millions of people around the world. Although its most extreme manifestations are often obvious, many other households facing constraints in their access to food are less identifiable. Operational agencies lack a method for differentiating households at varying degrees of food insecurity in order to target and evaluate their interventions. This

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overview highlights three main conceptual developments associated with practical approaches to measuring constraints in access to food: 1] a shift from using measures of food availability and utilization to measuring "inadequate access"; 2] a shift from a focus on objective to subjective measures; and 3] a growing emphasis on fundamental measurement as opposed to reliance on distal, proxy measures. Further research is needed regarding 1] how well measures of household food insecurity designed for chronically food-insecure contexts capture the processes leading to, and experience of, acute food insecurity, 2] the impact of short-term shocks, such as major floods or earthquake, on household behaviors that determine responses to food security questions, 3] better measurement of the interaction between severity and frequency of household food insecurity behaviors, and 4] the determination of whether an individual's response to survey questions can be representative of the food insecurity experiences of all members of the household (4).

A conceptual framework showing the household and social implications of food insecurity was elicited from a qualitative and quantitative study of 98 households from a heterogeneous low income population of Quebec City and rural surroundings; the study was designed to increase understanding of the experience of food insecurity in order to contribute to its prevention. According to the respondents' description, the experience of food insecurity is characterized by two categories of manifestations, i.e., the core characteristics of the phenomenon and a related set of actions and reactions by the household. This second category of manifestations is considered here as a first level of consequences of food insecurity. These consequences at the household level often interact with the larger environment to which the household belongs. On a chronic basis, the resulting interactions have certain implications that are tentatively labeled "social implications". Their examination suggests

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that important aspects of human development depend on food security. It also raises questions concerning the nature of socially acceptable practices of food acquisition and food management, and how such acceptability can be assessed. Findings underline the relevance and urgency of working toward the realization of the right to food (5). There is considerable interest in the link between household food insecurity and child wellbeing, and the extent to which caregiver wellbeing mediates the relationship between food insecurity and child wellbeing. The aim of this was to assess these relationships among a rural population in Ethiopia. Existing survey data from a maximum of 1,006 children less than five years of age with matched data on household-level data on food insecurity, caregiver distress, and asset ownership, along with other sociodemographic information were used. All respondents lived in a predominately rural, primarily subsistence-based area in southwest Ethiopia. Household food insecurity, distress, and socioeconomic status predicted children's weight for age and undernutrition, defined as weight for age Z less than -2 SD from the reference median. A small portion of the household food insecurity effect was mediated by caregiver distress but these were largely independent effects. Maternal distress was associated with greater odds of a child having any illness, and any illness was associated with lower weight for age Z and higher odds of being undernourished. The effect of maternal distress on undernutrition was mediated by diarrhea. In conclusion, household food insecurity, maternal distress, and household socioeconomic status are independent contributors to children's undernutrition. These results are consistent with others but are not generally consistent with the hypothesis that maternal distress is a primary pathway through which food insecurity impacts on child nutritional wellbeing (6). Food insecurity is recognized as an increasing problem in disadvantaged and marginalized groups. The aim of this study was to investigate issues associated with food insecurity and nutrition in young people experiencing, or at risk of, homelessness in metropolitan Australia. Eight focus group discussions were conducted with 48 young people (aged between 15 and 25 years) in specialist homelessness services in central and southwestern Sydney. Participants described daily experiences of food insecurity, persistent

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hunger and poverty. Structural barriers to food security and nutrition were identified and included poverty and reduced physical access to fresh foods. Participants also described a desire to save time, for convenience and to be socially connected. Despite the hardships and the chaos of youth homelessness, the groups were defined by their strength of character, resilience and hope for the future. In conclusion, homeless young people within central and southwestern Sydney report varying degrees of food insecurity, despite being supported by specialist youth homelessness services. So what? A collaborative, multistrategic approach with youth participation is required to enhance the capacity of youth services to improve food security, food access and the availability of nutritious foods for homeless young people. A greater focus on advocacy and policy action is required to bring food security and nutrition to the forefront of national efforts to improve the health and welfare of disadvantaged groups (7). References 1. Gundersen C. Food insecurity is an ongoing national concern. Adv Nutr. 2013; 4(1):36-41. 2. Ivers LC, Cullen KA. Food insecurity: special considerations for women. Am J Clin Nutr. 2011;94(6):1740S-1744S. 3. Hadley C, Crooks DL. Coping and the biosocial consequences of food insecurity in the 21st century. Am J Phys Anthropol. 2012;149 Suppl 55:72-94. 4. Webb P, Coates J, Frongillo EA, et al. Measuring household food insecurity: why it's so important and yet so difficult to do. J Nutr. 2006;136(5):1404S-8S. 5. Hamelin AM, Habicht JP, Beaudry M. Food insecurity: consequences for the household and broader social implications. J Nutr. 1999;129(2S Suppl):525S-8S. 6. Hadley C, Tessema F, Muluneh AT. Household food insecurity and caregiver distress: equal threats to child nutritional status? Am J Hum Biol. 2012;24(2):149-57. 7. Crawford B, Yamazaki R, Franke E, et al. Sustaining dignity? food insecurity in homeless young people in urban Australia. Health Promot J Austr. 2014;25(2):71-8.

PREVALENCE This study examines the extent to which food insecurity and hunger in U.S. households are occasional, recurring, or frequent/chronic. The federal food security scale measures the severity of food insecurity in surveyed households and classifies households as to their food security status during the previous year. CPS-FSS collects the data elements used to calculate the food security

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scale. Supplementary data on the frequency of occurrence of the behaviors and experiences comprising the food security scale are also collected by CPS-FSS, but most of this information is not included in the food security scale. This study analyzes these supplementary data along with the food security scale and its constituent items using data from the nationally representative CPS-FSS conducted in August 1998. About two thirds of households classified as food insecure by the federal food security scale experience the condition as recurring, and around one fifth experience these conditions as frequent or chronic. The monthly prevalence of hunger is about 60% of the annual prevalence, and the daily prevalence is about 13% to 18% of the annual prevalence. In conclusion, nutritionists can use these findings to enhance the informative value of food insecurity and hunger statistics from national, state, and local surveys when interpreting them to policy makers and to the public (1).

Hunger in America

Residents of the Lower Mississippi Delta of Arkansas, Louisiana, and Mississippi are at risk for food insecurity since a high proportion of the population live in households with incomes below the poverty level and have reduced access to food and decreased availability of a variety of foods. However, the magnitude of the problem is unknown because presently only nationwide and state estimates of food insecurity are available. This study was conducted by the LowerMississippi Delta Nutrition Intervention Research Consortium to determine the prevalence of household food insecurity, identify highrisk subgroups in the Lower Delta, and compare to national data. A 2-stage stratified cluster sample representative of the population in

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36 counties in the Lower Delta was selected using list-assisted random digit dialing telephone methodology. A cross-sectional telephone survey of 1,662 households was conducted in 18 of the 36 counties using the U.S. Food Security Survey Module. Twenty-one percent of Lower Delta households were food insecure, double the 2000 nationwide rate of 10.5%. Within the Lower Delta, groups with the highest rates of food insecurity were households with income below $15,000, black households, and households with children. The prevalence of hunger in Delta households with white children was 3.2% and in households with black children was 11.0%, compared to nationwide estimates of 0.3% and 1.6%. In conclusion, the Lower Mississippi Delta is characterized by a high prevalence of food insecurity and hunger (2). This study was undertaken to understand food insecurity from the perspective of households who experienced it. The results of group interviews and personal interviews with 98 low-income households from urban and rural areas in and around Québec City, Canada, elicited the meaning of "enough food" for the households and the range of manifestations of food insecurity. Two classes of manifestations characterized the experience of food insecurity: 1] its core characteristics: a lack of food encompassing the shortage of food, the unsuitability of both food and diet and a preoccupation with continuity in access to enough food; and a lack of control of households over their food situation; and 2] a related set of potential reactions: socio-familial perturbations, hunger, physical impairment, and psychological suffering. The results substantiate the existence of food insecurity among Québecers and confirm that the nature of this experience is consistent with many of the core components identified in upstate New York. This study underlines the monotony of the diet, describes the feeling of alienation, differentiates between a lack of food and the reactions that it engenders, and emphasizes the dynamic nature of the experience (3). Food insecurity is the situation where people do not have, at all times, access to sufficient, safe and nutritious food that meets their dietary needs for an active and healthy life. The objectives of this study were to estimate the prevalence of food insecurity in the Paris area by using, for the first time in France, a specific food insecurity questionnaire and to identify the characteristics of food-insecure households, taking into account a potential neighborhood effect.

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This study is based on data from the third wave of the SIRS cohort study (Health, Inequalities and Social Ruptures study) that were analyzed using a cross-sectional design. In 2010, 3,000 individuals in the Paris metropolitan area were interviewed. Food insecurity was investigated by means of the USDA's HFSSM. Stratified multilevel models across three household income categories to identify populations at risk for food insecurity were used. In 2010, 6.30% (95% CI 4.99-7.97) of the households in the Paris metropolitan area experienced food insecurity (up to 13.6% in the most underprivileged neighborhoods). About 2.5% of the households experienced severe food insecurity and 2.9% of household living with an income above 1666 € experienced food insecurity, whereas the percentage raises to 23.4% among those living below the poverty threshold (1,900 kcal/day with a progressive increase during the course of hospitalization. It appeared that additional tube feeding increased the maximum energy intake and led to greater interim or discharge weight; however, this was also associated with a higher incidence of adverse effects. Overall, the level of available evidence was poor, and therefore consensus on the most effective and safe treatment for weight restoration in inpatient children and adolescents with AN is not currently feasible (8). AN is associated with several serious medical complications related to malnutrition, severe weight loss, and low levels of micronutrients. The re-feeding phase of these high-risk patients bears a further threat to health and potentially fatal complications. The objective of this study was to examine complications due to refeeding of patients with AN, as well as their mortality rate after the implementation of guidelines from the European Society of Clinical Nutrition and Metabolism. Retrospective, observational data of a consecutive, unselected AN cohort during a 5-year period were analyzed. The sample consisted of 65 inpatients, 14 were admitted more than once within the study period, resulting in 86 analyzed cases. Minor complications associated with re-feeding during the first 10 days (replenishing phase) were recorded in nine cases (10.5%), four with transient pretibial edemas and three with organ dysfunction. In two cases, a severe hypokalemia occurred. During the observational phase of 30 days, 16 minor complications occurred in 14 cases (16.3%). Six infectious and 10 non-infectious complications occurred. None of the patients with AN died within a follow-up period of three months. In conclusion, the seriousness and rate of complications during the replenishment phase in this high-risk population can be kept to a minimum. Evidence-based re-feeding

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regimens, such as the guidelines are able to reduce complications and prevent mortality. Despite AN, this sample was affected by serious comorbidities, no case met the full diagnostic criteria for refeeding syndrome (9). Assessment: AN is perhaps the most lethal mental disorder, in part due to starvation-related health problems, and of high suicide rates. Two potential routes to suicidal behavior in AN include repetitive experience with provocative behaviors for ANBP, and exposure to pain through the starvation of restricting in ANR. Self-starvation with accompanying low body weight serves as a dysfunctional behavior to regulate aversive emotions in AN. Suicide attempts in AN are associated with the intention to die, occur less frequently in persons with the restricting subtype of the illness, and after controlling for depression are associated with a constellation of behaviors and traits associated with behavioral and affective dyscontrol. Restoration of weight and nutritional rehabilitation are fundamental steps in the therapeutic treatment of children and adolescent inpatients with AN. The seriousness and rate of complications during the replenishment phase in this high-risk population can be kept to a minimum. References 1. Bemporad JR. Self-starvation through the ages: reflections on the pre-history of anorexia nervosa. Int J Eat Disord. 1996;19(3):217-37. 2. Hällström T. Self-starvation over 1500 years: the work of God, the devil or weight-control? Lakartidningen. 1999;96(43):4648-53. 3. Starzomska M. Psychiatry throughout ages: rethinking anorexia nervosa as a viable behavior in a specific sociocultural context? Psychiatr Pol. 2001;35(4):669-79. 4. Selby EA, Smith AR, Bulik CM, et al. Habitual starvation and provocative behaviors: two potential routes to extreme suicidal behavior in anorexia nervosa. Behav Res Ther. 2010;48(7):634-45. 5. Brockmeyer T, Holtforth MG, Bents H, et al. Starvation and emotion regulation in anorexia nervosa. Compr Psychiatry. 2012;53(5):496-501. 6. Nordbø RH, Espeset EM, Gulliksen KS, et al. The meaning of self-starvation: qualitative study of patients' perception of anorexia nervosa. Int J Eat Disord. 2006; 39(7):556-64. 7. Bulik CM, Thornton L, Pinheiro AP, et al. Suicide attempts in anorexia nervosa. Psychosom Med. 2008;70(3):378-83.

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8. Rocks T, Pelly F, Wilkinson P. Nutrition therapy during initiation of refeeding in underweight children and adolescent inpatients with anorexia nervosa: a systematic review of the evidence. J Acad Nutr Diet. 2014;114(6):897-907. 9. Hofer M, Pozzi A, Joray M, et al. Safe refeeding management of anorexia nervosa inpatients: an evidence-based protocol. Nutrition. 2014;30(5):524-30.

OBSESSIVE COMPULSIVE DISORDER OCDs are a complex group that can have a variety of manifestations. In an obsessive compulsive spectrum disorder many other specific diagnostic entities such as trichotillomania, tic disorders and body dysmorphic disorder are considered to be related and linked disorders. A case of a 22-year-old Sri Lankan male was presented with life threatening self starvation due to severe OCD. The diagnosis was not considered until late due to the atypical presentation of the patient. While his symptoms bordered on a delusional psychosis, a decision was made to treat him as for OCD with behavioral therapy which was successful in the end. In conclusion, in analysis of a patient with severe anorexia, the psychological causes should not be forgotten. In fact, if the feeding pattern of the patient was observed at the beginning, unnecessary investigating and life threatening worsening of the condition could have been avoided (1). The objective of this study was to describe a case of an atypical eating disorder with a diagnosis of OCD and discuss the phenomenological and neurobiological aspects links between the disorders. A 20-year-old Caucasian woman presented with OCD followed by altered eating habits with major weight loss and amenorrhea. Using cognitive-behavioral therapy, clomipramine and enteral nutrition, weight gain and disappearance of restrictive and obsessive-compulsive behaviors were obtained. In conclusion, available evidence in the literature suggests a continuum in eating disorder and OCD. This case illustrates that an OCD may precede or precipitate the development of an eating disorder and highlights the importance of a precise differential diagnosis in eating disorders clinics (2). This report describes an unusual presentation of OCD with predominant religious obsessions and compulsions (scrupulosity) in which the patient starved himself by keeping fast excessively to the

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extent of emaciation and extreme weakness even in walking and became bedridden (3). Assessment: OCDs are a complex group that can have a variety of manifestations. Some severe OCD, patients can present with the clinical picture of self-starvation. References 1. Rodrigo C, Henegama T, Hanwella R. Life threatening self starvation; a case report. BMC Res Notes. 2013 Jan 31;6:36. 2. Garcia FD, Houy-Durand E, Thibaut F, Dechelotte P. Obsessive compulsive disorder as a cause of atypical eating disorder: a case report. Eur Eat Disord Rev. 2009;17(6):444-7. 3. Sharma DD, Kumar R, Sharma RC. Starvation in obsessive-compulsive disorder due to scrupulosity. Indian J Psychiatry. 2006;48(4):265-6.

HUNGER STRIKERS Hunger strike is described as voluntary refusal of food and/or fluids. Prolonged starvation may produce many adverse events including even death in rare circumstances. Three fatal cases (all males, 25-38 years) died from hunger strike. In all corpses, obvious muscle wasting with reduced subcutaneous and internal fat deposits, and atrophy in some organs were demonstrated at autopsy. The extraordinary long starvation period before death could presumably be linked to the thiamine uptake in this period, which had been discontinued by all subjects before the death occurred. Prolonged caloric deficiency with subsequent complications such as multiple organ failure, severe sepsis and ventricular fibrillation could account as major causes of death in these subjects. The competence of the physicians working with hunger strikers about the processes and potential problems is of great importance since they have to acknowledge about them to their patients (1). Hunger strike is not a disease but a common situation in prisons. This article takes a historical look at medical practices in connection with the forced feeding of hunger strikers. Depending on the context and the political situation in the country, the fate of these people, mostly political prisoners, is humiliating and abominable frequently ending in death or irreparable consequences. Particularly difficult for

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health professionals, this act raises clinical, ethical and legal questions and refers to the fundamental principles of medicine (2). Neurological findings in 41 prisoners (mean age: 28.6 years) who participated in a hunger strike between 2000 and 2002 were investigated. All cases were evaluated using neuropsychological, neuroradiological, and electrophysiological methods. The total duration of fasting ranged from 130 to 324 days (mean 199 days). All cases had 200-600 mg/day thiamine orally for 60-294 days (mean 156) during the hunger strike, and had neurological findings consistent with Wernicke-Korsakoff syndrome. All 41 patients exhibited altered consciousness which lasted from three to 31 days. All patients also presented gaze-evoked horizontal nystagmus and truncal ataxia. Paralysis of lateral rectus muscles was found in 14. Amnesia was apparent in all cases. Abnormal nerve conduction study parameters were not found in the patient group, but the amplitude of compound muscle action potential of the median and fibular nerves and sensory nerve action potential amplitude of the sural nerve were lower than the control group, and distal motor latency of the posterior tibial nerve was significantly prolonged as compared with the control group. The latency of visual evoked potential was prolonged in 22 cases. Somatosensory evoked potential (P37) was prolonged but statistically insignificant. The most significant finding was that the effect of hunger was more prominent on the CNS than on the neuromuscular system, despite the fact that all patients were taking thiamine. In conclusion, only partial recovery of neurological, and neurocognitive signs in prolonged hunger could be a result of permanent neurological injury (3). The objective of this study was to evaluate existing ethical guidelines for the treatment of hunger strikers in light of findings on psychological changes that accompany the cessation of food intake. Electronic databases were searched for 1] editorials and ethical proclamations on hunger strikers and their treatment; 2] studies of voluntary and involuntary starvation, and 3] legal cases pertaining to hunger striking. Additional studies were gathered in a snowball fashion from the published material cited in these databases. Material was included if it 1] provided ethical or legal guidelines; 2] shed light on psychological changes accompanying starvation, or 3] illustrated the practice of hunger striking. In conclusion, although the heterogeneous nature of the sources precluded statistical analysis,

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starvation appears to be accompanied by marked psychological changes. Some changes impair competence, in which case physicians are advised to follow advance directives obtained early in the hunger strike. More problematic are increases in impulsivity and aggressivity, changes which, while not impairing competence, enhance the likelihood that patients will starve themselves to death (4). Hunger strikes are not infrequent occurrences in military and civilian prisons. Although practicing clinicians are familiar with the management of patients who have limited oral intake, managing hunger strikers is unfamiliar to most. The psychological, physiological, and social events that surround hunger strikes are very complex and need to be understood by those caring for hunger strike patients. To provide adequate medical care to hunger strike patients, clinicians most understand the physiological events that ensue after prolonged starvation. Careful vigilance for development of re-feeding syndrome is of key importance. A multidisciplinary approach to hunger strikes is of utmost importance, and involvement of a multidisciplinary clinical team as well as prison officials is essential (5). In the Middle European medico-legal climate, the moral rule 'salus aegroti suprema lex' has been accepted for a long time. In the last few years, under the pressure of fear of accusation of a paternalistic attitude, this postulate has been changed to 'voluntas aegroti suprema lex'. The question stands: Is this valid in each case and in all the situations? For example, it is possible to use compulsory treatment with those who have not given their informed consent. Even the charter of basic human rights and freedom states in its article six that everyone has a right of life. The law specifies in which cases an individual can be accepted or can be held in a health care institution without his/her consent. In cases of so-called 'hunger strikers', the strikers refuse food and expose themselves to extreme starvation in order to reach some political goals or to express their views. If, in such situations, the patient endangers his/her life, the physician who is facing this problem is, according to Czech law and similarly to some other Central European laws, and according to the Ethical Code of the Czech Medical Chamber, bound to act to protect and restore the life and the health of that person. The Health Care Act No. 540/1991 of the Czech Republic states the obligation to provide emergency care to anyone whose life or health is threatened. Compulsory treatment is possible, for example, if an individual shows

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signs of mental disease or if intoxication threatens him or his neighborhood (6). Hunger strike is a regularly reported problem in prison. Although clinical situations are rarely severe, hospitalization is often considered. In consequence, it is not only physicians working in prisons, but also hospital medical teams who face challenges related to hunger strike, involving somatic, psychological, legal and human rights aspects. Deontological rules must be strictly respected when delivering care, particularly in prison setting. Starvation involves metabolic changes and can cause severe, and sometimes even irreversible or fatal complications. The phase of re-alimentation should not be trivialized, as re-feeding syndrome is a potentially fatal phenomenon (7). Entering prison can feed pre-existent behavior of demands or generate them. Several means of expression are then used. Hunger strike is an average privileged act. It belongs to prison culture. The objective of this study was to estimate how practitioners working in prison take care of the hunger strikers. This study, conducted in 2008, was led with all the Units of Consultations and Ambulatory Care in France. It is a declarative investigation where a medical testimony by unit was asked. From 174 "maisons d'arrêt" and establishments for punishment in France, 95 answers were obtained. This situation was already seen by 98.8% of the doctors. The motives for hunger strike were mainly judicial for "maisons d'arrêt" (70,1%) and prison motives for detention centers (68,7%). Mainly, doctors opted for a neutral attitude (63% of the cases). The hunger strikes were mostly brief (less than a week in 85% of the cases). Only 5.5% of the doctors proposed written information concerning the risks incurred during a fast. A doctor in four approximately (23%) was already witness to complications due to fasting. The fact that a patient may refuse care makes the medical approach difficult. Faced with such a situation, 45% of the doctors privileged their duty of care, 28% respected the patient's wishes, and 27% did not pronounce. The place of treatment using vitamins was rarely recognized (32.7%). Hunger strike is rarely severe, but it is rather frequent in prison so that every doctor working there will be confronted with it. The refeeding syndrome seems often ignored. The coverage of hunger strike is governed by the law, but ethical questions stay in the appreciation of every doctor (8).

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Physicians and other licensed health professionals are involved in force-feeding prisoners on hunger strike at the U.S. Naval Base at Guantanamo Bay, Cuba, the detention center established to hold individuals captured and suspected of being terrorists in the wake of September 11, 2001. The force-feeding of competent hunger strikers violates medical ethics and constitutes medical complicity in torture. Given the failure of civilian and military law to end the practice, the medical profession must exert policy and regulatory pressure to bring the policy and operations of the U.S. Department of Defense into compliance with established ethical standards. Physicians, other health professionals, and organized medicine must appeal to civilian state oversight bodies and federal regulators of medical science to revoke the licenses of health professionals who have committed prisoner abuses at Guantanamo Bay (9). The treatment of hunger strikers is always contentious, chaotic and complex. The management is particularly difficult for health professionals as it raises unprecedented clinical, ethical, moral, humanitarian, and legal questions. There are never any easy answers. The current situation of prisoners from the Iraq and Afghanistan Wars currently at the Guantanamo Bay Detention Center in Cuba demands unprecedented transparency, accountability and multilevel coordination to ensure that the rights of the strikers are properly met. There are scant references available in the scientific literature on the emergency management of these tragedies. This historical perspective documents the complex issues faced by emergency physicians in Hong Kong surrounding refugee camp asylum seekers from Vietnam in 1994 and is offered as a useful adjunct in understanding the complex issues faced by emergency health providers and managers (10). Hunger strikes have confronted physicians with complex ethical dilemmas throughout history. Asylum seekers under threat of forced repatriation have emerged as a new category of hunger strikers, posing novel challenges for management. The management of three Cambodian asylum seekers on hunger strike admitted to a hospital in Sydney, New South Wales, Australia, posted important ethical dilemmas for the physicians and mental health experts involved in their care. Several factors confounded the task of assessment and decision-making, including language and cultural barriers, the patients' past exposure to persecution by authorities, and the

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complexities of the legal procedures being pursued. Different rules appeared to govern the actions of the hunger strikers, the medical team, and the immigration authorities, creating a malignant triangle of mounting confrontation. Recent recommendations for the management of asylum-seeking hunger strikers include the appointment of an external physician of confidence and the writing of a confidential advance directive specifying the hunger strikers wishes about resuscitation in the event of collapse. In addition, the value of constituting an ad hoc ethics committee to advise the responsible physician on points of conflict in managing the hunger strike is considered (11). Hunger strikers resuming nutritional intake may develop a lifethreatening refeeding syndrome. Consequently, hunger strikers represent a core challenge for the medical staff. The objective of this study was to test the effectiveness and safety of evidence-based recommendations for prevention and management of refeeding syndrome during the refeeding phase. This was a retrospective, observational data analysis of 37 consecutive, unselected cases of prisoners on a hunger strike during a 5-year period. The sample consisted of 37 cases representing 33 individual patients. In seven cases (18.9%), the hunger strike was continued during the hospital stay, in 16 episodes (43.2%) cessation of the hunger strike occurred immediately after admission to the security ward, and in 14 episodes (37.9%) during hospital stay. In the refeed cases (n=30), nutritional replenishment occurred orally, and in 25 (83.3%) micronutrients substitutions were made based on the recommendations. The gradual refeeding with fluid restriction occurred over 10 days. Uncomplicated dyselectrolytemia was documented in 12 cases (40%) within the refeeding phase. One case (3.3%) presented bilateral ankle edemas as a clinical manifestation of moderate RFS. Intensive medical treatment was not necessary and none of the patients died. Seven episodes of continued hunger strike were observed during the entire hospital stay without medical complications. In conclusion, seriousness and rate of medical complications during the refeeding phase can be kept at a minimum in a hunger strike population. This study supported use of recommendations to optimize risk management and to improve treatment quality and patient safety in this vulnerable population (12).

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The Ethics of the Israel Medical Association authorized a position paper in 2005 that was based on the Malta Declaration. This paper successfully underwent two ancillary deliberations by the Israel Medical Association Ethics Bureau, the last in 2013 (13). The wording of the position paper is as follows: 1]. A hunger striker is a competent individual who expresses the desire to refuse food and/or liquids for an indeterminate period, and understands that it is life threatening. 2]. The attending physician must receive complete medical records for the hunger striker and be allowed to thoroughly examine the striker prior to the commencement of a hunger strike. 3]. The physician must explain to the hunger striker the dangers and risks involved with engaging in a hunger strike, particularly the fear that it might end up costing him his life. 4]. The physician must inform the hunger striker of his acquiescence to the striker’s request to refuse all food and/or liquid including artificially feeding if the striker loses consciousness. 5]. The physician is forbidden to assert any pressure to coerce the striker to desist from continuing the hunger strike. 6]. The physician will not participate in force feeding of a hunger striker. 7]. The hunger striker is entitled to a “second medical opinion” and may request that the second physician assume care. If the hunger striker is incarcerated, this will be coordinated with the .prison physician. 8]. The physician may recommend to the hunger striker to continue with any treatments involving medications, if these were prescribed prior to the strike and if he agrees to receive fluids during the hunger strike. 9]. The physician may demand, in the case of external influences, that the patient be isolated from friends, other hunger strikers. 10]. The physician must make sure on a daily basis that the hunger striker is willing and able to continue the hunger strike, and that his decision is undertaken from his own free will and without any external coercion. 11]. The physician must consult with the hunger striker on a daily basis, what is allowable to be performed should the patient lose consciousness. The physician will document this in his records and these will remain confidential 12]. If the hunger striker loses consciousness and is unable to express his desires, the physician is free to decide according to his conscience and best judgment how to proceed treatment of the hunger striker while optimally observing the position and wishes of the patient as expressed during the strike. 13]. The physician shall inform the family of the hunger striker of the

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hunger strike unless specifically forbidden to do so by the hunger striker himself (14). In Israel, experience treating hunger-striking detainees was acquired during May and June 2014. In April 2014, prisoners started a hunger strike in prison to which 290 prisoners joined. Like others before, it was a partial hunger strike. Seventy strikers were transferred to public hospitals after 24–28 days, no one died. The longest hunger strike lasted 137 days. Most of the hunger strikes among detainees lasted 63 days (14). Assessment: In cases of so-called 'hunger strikers', the strikers refuse food and expose themselves to extreme starvation in order to reach some political goals or to express their views. Hunger strike is described as voluntary refusal of food and/or fluids. Prolonged starvation may produce many adverse events including death. Hunger strikes have confronted physicians with complex ethical dilemmas throughout history. Hunger strike is rarely severe, but it is rather frequent in prison so that every doctor working there will be confronted with it Starvation appears to be accompanied by marked psychological changes. The psychological, physiological, and social events that surround hunger strikes are very complex and need to be understood by those caring for hunger strike patients. Starvation involves metabolic changes and can cause severe, and sometimes even irreversible or fatal complications. Physicians and other licensed health professionals are involved in force-feeding prisoners on hunger strike at the U.S. Naval Base at Guantanamo Bay, Cuba. Asylum seekers under threat of forced repatriation have emerged as a new category of hunger strikers, posing novel challenges for management. Seriousness and rate of medical complications during the refeeding phase can be kept at a minimum in a hunger strike population. The Ethics of the Israel Medical Association authorized a position paper on a hunger striker in 2005 based on the Malta Declaration and received the support of the Israel Medical Association.

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References 1. Altun G, Akansu B, Altun BU, et al. Deaths due to hunger strike: post-mortem findings. Forensic Sci Int. 2004;146(1):35-8. 2. Rieder JP, Huber-Giseke T, Getaz L, et al. Hunger strike and forced feeding: a historical look at medical practices. Rev Med Suisse. 2010;6(273):2313-8. 3. Başoğlu M, Yetimalar Y, Gürgör N, et al. Neurological complications of prolonged hunger strike. Eur J Neurol. 2006;13(10):1089-97. 4. Fessler DM. The implications of starvation induced psychological changes for the ethical treatment of hunger strikers. J Med Ethics. 2003;29(4):243-7. 5. Chalela JA, Lopez JI. Medical management of hunger strikers. Nutr Clin Pract. 2013;28(1):128-35. 6. Neoral L. Ethical and medico-legal problems concerning so-called hunger strikers. Forensic Sci Int. 1994;69(3):327-8. 7. Gétaz L, Rieder JP, Nyffenegger L, et al. Hunger strike among detainees: guidance for good medical practice. Swiss Med Wkly. 2012;142:w13675. 8. Fayeulle S, Renou F, Protais E, et al. Management of the hunger strike in prison]. Presse Med. 2010;39(10):e217-22. 9. Dougherty SM, Leaning J, Greenough PG, Burkle FM Jr. Hunger strikers: ethical and legal dimensions of medical complicity in torture at Guantanamo Bay. Prehosp Disaster Med. 2013;28(6):616-24. 10. Burkle FM Jr, Chan JT, Yeung RD. Hunger strikers: historical perspectives from the emergency management of refugee camp asylum seekers. Prehosp Disaster Med. 2013;28(6):625-9. 11. Silove D, Curtis J, Mason C, Becker R. Ethical considerations in the management of asylum seekers on hunger strike. JAMA. 1996;276(5):410-5. 12. Eichelberger M, Joray ML, Perrig M, et al. Management of patients during hunger strike and refeeding phase. Nutrition. 2014;30(11-12):1372-8. 13. Fessler DMT. The implications of starvation induced psychological changes for the ethical treatment of hunger strikers. J Med Ethics. 2003;29:243-7. 14. Tami Karni. Hunger Striking Inmates and Detainees, and Medical Ethics. IMAJ. 2015;17:179-181.

CESSATION OF EATING Voluntarily stopping eating and drinking, in which death occurs within one to three weeks of beginning the fast, is increasingly explored in the literature and mainstream media as an option to be discussed with "decisionally capable," suffering patients who want to hasten their dying (1). There is an acknowledged difficulty in distinguishing between some morally and legally accepted acts that hasten dying, such as refusing life-sustaining treatment, and other acts that also hasten dying that are labeled as acts of "suicide." Recent empirical findings

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suggest that most terminally ill and suffering patients who voluntarily chose to stop eating and drinking as a means to hasten their dying generally experienced a "good" death. The moral and legal status of a decision to stop eating and drinking is means to hasten dying that is voluntarily chosen by a competent, terminally ill and suffering patient. The option of voluntarily forgoing food and fluid will be compared to other end-of-life clinical practices known to hasten dying, with emphasis on the issue of whether such practices can or should be distinguished from suicide (2). The terminally ill person's autonomy and control are important in preserving the quality of life in situations of unbearable suffering. VSED at the end of life has been discussed over the past 20 years as one possibility of hastening death. This article presents a 'systematic search and review' of published literature concerned with VSED as an option of hastening death at the end of life by adults with decisionmaking capacity. Electronic databases PubMed, EBSCOhost CINAHL and Ovid PsycINFO were systematically searched. Additionally, Google Scholar was searched and reference lists of included articles were checked. Data of the included studies were extracted, evaluated and summarized in narrative form. Overall, out of 29 eligible articles 16 were included in this review. VSED can be defined as an action by a competent, capacitated person, who voluntarily and deliberately chooses to stop eating and drinking with the primary intention of hastening death because of the persistence of unacceptable suffering. An estimated number of deaths by VSED was only provided by one study from the Netherlands, which revealed a prevalence of 2.1% of deaths/year (on average 2,800 deaths/year). Main reasons for patients hastening death by VSED are: readiness to die, life perceived as being pointless, poor quality of life, a desire to die at home, and the wish to control the circumstances of death. The physiological processes occurring during VSED and the supportive care interventions could not be identified through this search. In conclusion, the included articles provide marginal insight into VSED for hastening death. Research is needed in the field of theory building and should be based on qualitative studies from different perspectives (patient, family members, and healthcare workers) about physiological processes during VSED, and about the prevalence and magnitude of VSED. Based on these findings supportive care

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interventions for patients and family members and recommendations for healthcare staff should be developed and tested (3). VSED as a legal means to hasten death has been is an option for persons who wish to end their lives. A case is presented of a woman who elected to forgo eating and drinking to end intractable suffering. There is the potential for benefit and harm in physicians discussing VSED. Physicians working with terminally ill patients need to consider the discussion of VSED as a therapeutic tool in their support and care of patients with intractable suffering (4). Assessment: most terminally ill and suffering patients who voluntarily chose to stop eating and drinking as a means to hasten their dying generally experienced a "good" death. VSED, in which death occurs within one to three weeks of beginning the fast, is an option for suffering patients who want to hasten their dying. The moral and legal status of a decision to stop eating and drinking is means to hasten dying that is voluntarily chosen by a competent, terminally ill and suffering patient. Main reasons for patients hastening death by VSED are: readiness to die, perception of life as pointless, poor quality of life, a desire to die at home, and the wish to control the circumstances of death. References 1. Schwarz JK. Stopping eating and drinking. Am J Nurs. 2009;109(9):52-61; quiz 62. 2. Schwarz J. Exploring the option of voluntarily stopping eating and drinking within the context of a suffering patient's request for a hastened death. J Palliat Med. 2007;10(6):1288-97. 3. Ivanovid N, Büche D, Fringer A. Voluntary stopping of eating and drinking at the end of life - a 'systematic search and review' giving insight into an option of hastening death in capacitated adults at the end of life. BMC Palliat Care. 2014; 13(1):1. 4. Berry ZS. Responding to suffering: providing options and respecting choice. J Pain Symptom Manage. 2009;38(5):797-800.

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HANDLING HUNGER Ending food insecurity, hunger and malnutrition is a pressing global ethical priority. Despite differences in food production systems, cultural values and economic conditions, hunger is not acceptable under any ethical principles. Yet, progress in combating hunger and malnutrition in developing countries has been discouraging, even as overall global prosperity has increased in past decades. A growing number of people are deprived of the fundamental right to food, which is essential for all other rights as well as for human existence itself. The food and nutrition crisis has deepened in recent years, as increased food price volatility and global recession affected the poor. In a strategic agenda, it will be necessary to promote pro-poor agricultural growth, reduce extreme market volatility and expand social protection and child nutrition action (1). The concept of food insecurity is complex and goes beyond the simplistic idea of a country's inability to feed its population. The global food situation is redefined by many driving forces such as population growth, availability of arable lands, water resources, climate change and food availability, accessibility and loss. The combined effect of these factors has undeniably affected global food production and security. This article reviews the key factors influencing global food insecurity and emphasizes the need to adapt science-based technological innovations to address the issue. Although anticipated benefits of modern technologies suggest a level of food production that will sustain the global population, both political will and sufficient investments in modern agriculture are needed to alleviate the food crisis in developing countries. In this globalised era of the 21st century, many determinants of food security are trans-boundary and require multilateral agreements and actions for an effective solution. Food security and hunger alleviation on a global scale are within reach provided that technological innovations are accepted and implemented at all levels (2). The management of hunger has to look into the issues of availability, accessibility and adequacy of food supply. From an ethical perspective, favor of the right to food is argued. But, for this to become viable, the state has to come up with an appropriate and effective bill on food and nutrition security, address the issue of inadequate provisioning of storage space by state agencies leading to

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rotting of food grains - a criminal waste when people are dying of hunger; and rely on local level institutions involving the community, that complement the administrative structure to identify the poor and reduce exclusion and inclusion errors (3). A food crisis occurs when rates of hunger and malnutrition rise sharply at local, national, or global levels. This definition distinguishes a food crisis from chronic hunger, although food crises are far more likely among populations already suffering from prolonged hunger and malnutrition. A food crisis is usually set off by a shock to either supply or demand for food and often involves a sudden spike in food prices. It is important to remember that in a market economy, food prices measure the scarcity of food, not its value in any nutritional sense. Except in rare circumstances, the straightforward way to prevent a food crisis is to have rapidly rising labor productivity through economic growth and keep food prices stable while maintaining access by the poor. The formula is easier to state than to implement, especially on a global scale, but it is good to have both the objective, reducing short-run spikes in hunger, and the deep mechanisms, pro-poor economic growth and stable food prices, clearly in mind. A coherent food policy seeks to use these mechanisms, and others, to achieve a sustained reduction in chronic hunger over the long run while preventing spikes in hunger in the short run (4). Severe acute malnutrition arises as a consequence of a sudden period of food shortage and is associated with loss of a person's body fat and wasting of their skeletal muscle. Many of those affected are already undernourished and are often susceptible to disease. Infants and young children are the most vulnerable as they require extra nutrition for growth and development, have comparatively limited energy reserves and depend on others. Undernutrition can have drastic and wide-ranging consequences for the child's development and survival in the short and long term. Despite efforts made to treat severe acute malnutrition through different interventions and programs, it continues to cause unacceptably high levels of mortality and morbidity. Uncertainty remains as to the most effective methods to treat severe acute malnutrition in young children. The objective of this study was to evaluate the effectiveness of interventions to treat infants and children aged