1. Which THREE of the following are True?
TF In the poor nations almost everyone is hungry; in the remainder almost everyone gets an adequate diet
TF Worldwide, more people have their lives shortened by overeating than by starvation
TF When poor nations now find a place on the ladder of development, they develop slower than rich nations did when they developed
TF Most NAm specialists in global health understand how the distribution of poverty & hunger are changing
TF Health & nutrition benefits are possible only after economic development occurs
TF People in regions of extreme hunger & poverty desperately need money
TF 50% of children in US will, at some time, have to rely on charity for foof?
TF Over half of the worlds hungry people live in Africa
TF Discovery of rich mineral resources is of great help to the development of an economically stressed nation
TF The percentage of people who are hungry gets less and less very year
TF Population growth has brought us to where the world cannot produce enough food for everyone

2. Quick answers
F In some nations hunger is the norm; in the remainder, an adequate diet is the norm
T Worldwide, more people have their lives shortened by overeating than by starvation
F In the present era, when poor nations find a place on the ladder of development, they develop slowly compared with the rich nations in their phase of development?
F Most Canadian specialists in global health understand the how the distribution of poverty and hunger are changing?
F Health & nutrition benefits inevitably occurs after economic development rather than before
F People in regions of extreme hunger & poverty desperately need money
T 49.2% of children in the US are currently so poor that they must rely on charity for their meals?

3. What works & what doesn’t? toward evidence-based solutions
Plan to spend 2-3 hours reviewing web info
“This is a problem we can solve at a fraction the cost of ignoring it” (Senator Geo McGovern: US Ambassador to UN Food & Ag Org)

4. 1 billion hungry (800m); 1 billion overweight
Be interested. Be sceptical when one tells you experts are wrong! Look for evidence we’ll be covering
1 billion hungry (800m); 1 billion overweight
Nothing in texts
Minefield
Experts are living in the past

5. Nutrition in global health - Overview
Inequities in food distribution  global hunger & starvation
One billion are too hungry to live productive lives - an equal number are adversely affected by overweight!
6 major deficiencies impact health through the life cycle: water, protein, iron, vitamin A, iodine, folic acid
Childbearing women & their children are hardest hit
Meanwhile, overnutrition & inactivity risk of heart disease, osteoporosis, cancer, diabetes, strokes, etc.
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6. Global Nutrition The ugly Where are we now? Stuffed & starved
We keep doing what we know doesn’t work?
The bad
How did we get here?
The good
It wasn’t an accident
Can anything help? Yes
We are part of the problem
Even if I totally mess this up, I don’t know how you could find it boring. Mainly tell things you don’t know. Change the way you frame your own nutrition, and the worlds. Could change the life direction of 1 or 2
We know what works
Where are we headed?
We have a roadmap to a world without hunger
Most of you will see hunger in museums!

7. Overview of Nutrition in Global Health
Malnutrition and MDGs: cause, effect & cure3
Major categories & measures of nutritional status4
Nutrition & crucial periods in the life-cycle; 4
Determinants of nutrition, dietary patterns & culture2
Nutrition and its relationship to disease4
Making hunger history - breaking the poverty-trap 3
Trends in nutrition, food security & globalization3

8. Preface: Nutrition is crucial to global health
Among the immediately modifiable factors that affect individual & public health … nutrition is of prime importance
Nutrition at every stage of life lays a foundation for health in the ensuing stage
For all nations, rich & poor, nutrition determines physical health & development through the life-cycle, including:
Success in childbearing, cognitive function, socio-economic independence, education, disease resistance & employability
Health & economic development are contingent on provision of adequate food, nutritional resources & support

9. 3 Critical periods: nutrition in the life-cycle
4 slides:
Perinatal nutrition: 0-6 mo: Breast vs. formula 1st 5 y Weaning & infancy –intellectual develop
School years; ability to learn
Work performance
Elderly

10. Maternal mortality (Demonstration index slide for a note)
Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death.
The major direct causes of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor.
A click on the note button takes viewer to the note
Note button

11. Nutrition through the life-cycle

12. Factors in perinatal nutrition (see also Acute malnutrition module)
Nutritional health begins in the womb – a healthy outcome to a pregnancy requires that mother be well nourished; good feeding must initiated early
The most common birth defects result from a deficiency of folic acid in the diet of the pregnant mother, Best outcomes require folic acid supplementation before conception!

13. Factors in perinatal nutrition (see also Module on Acute malnutrition)
Delaying clamping the umbilical cord until it stops pulsing iron stores see: m/en/index.html
Ideally, babies should receive vitamins E & K injections at birth
A baby who’s healthy at birth may experience "failure to thrive" (or "growth faltering") in the first year of life. So …..
Good infant feeding behaviors must start early. Most importantly, breast- feeding should be initiated within an hour of birth & maintained exclusively for 6 months.
Breastfeeding could prevent 1.3 million deaths each year
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14. Perinatal nutrition requires attention1
Malnutrition in pregnancy  birth defects & low birth-weight
Failure to thrive is an early danger sign, requiring investigation
Nutrition in infancy to early life impacts physical & cognitive development. It determines immediate & future risks of blindness, thyroid function, bone development, & more
Under-nutrition or deficiencies of many micronutrients can cause failure to thrive“
Iron, vitamins K and E are of particular importance. Refer to:
1http://

15. Malnutrition in early childhood
Children are at special need because they are at the fastest-growing stage of life. Problems an adult could survive can be lethal to a child
This is the most vulnerable period – a child is developing physically & mentally. Damage can be permanent
Most importantly, they are unable to fend for themselves & depend on others (parents, others) for health & survival
They are the planet’s future. We owe it to them & to ourselves to ensure that they grow well, with a sense that they have reason to invest in the future, in a caring world

16. Parenthetically – a personal perspective
How easily we see the moral failings of the past. Slavery, the holocausts & genocides, conquests motivated by greed When future generations look amazed at the moral blindness of this generation, what will stand out? Clearly child hunger Where life expectancy is short, toddlers are orphans. In war or famine a region may lack necessities. You can’t blame a child Yet in rich countries, yes, the US & Canada, we turn our empty eyes and hands away from those outside our borders A napalmed child turned a nation’s mind to peace. What will it take to open our eyes to children dying of hunger?
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17. Nutrition through the life cycle - adolescence
Adolescence carries risks for both poor & affluent
Adolescent & adult patterns of food consumption & activity massively impact immediate & future health risks
Adolescents are notoriously careless about health. Their eating patterns can lead quickly to obesity or anorexia.

18. Nutrition through the life cycle - adolescence
Adolescence carries risks for both poor & affluent
Dieting can lead to deficiencies of vit. C, protein, folic acid in a sedentary person. Even if a good mix of foods is consumed, total food intake may be insufficient.
A pattern of healthy eating in adolescence sets a pattern that can promote lifelong health
A foundation for healthy bones is set by exercise, calcium, & vitamin D. After early adult life, bones go slowly downhill
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19. Nutrition through the life cycle – adult life
Nutrition & acute & infectious diseases
Malnutrition depletes immunity leading to increased risk & severity of infections & parasites: AIDS, malaria, etc.
Flagrant deficiencies of specific micronutrients can put at risk the life & health of the mother in pregnancy & lactation
Nutritional anaemias, pellagra, blindness, skin disorders beriberi, scurvy, etc, can range in severity from mild to fatal
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20. Adult life - degenerative diseases
In late life, risk of breast, prostatic, & most other cancers are predicted by diet, obesity, inactivity or smoking in adult life
Also heart disease, strokes, osteoporosis, diabetes
Cancers and diabetes are now leading causes of death & disability in low- and middle-income countries (see Lancet August 13, 2009)
Nearly two-thirds of the world’s 7.6 million cancer- related deaths now occur in developing nations.

21. Differential nutritional vulnerability of females
Women are much more prone to nutritional anaemias since they need to replace red cells lost in menstruation
Women are the majority of elders, increasingly so in Asia and Africa. Osteoporosis is more common in the elderly
Osteoporosis is a major cause of illness, disability and death. The annual number of hip fractures worldwide will rise from 1.7 million in 1990 to around 6.3 million by 2050.

22. Differential nutritional vulnerability of females
Women suffer 80% of hip fractures; lifetime risk % compared with 13% for men.
Osteoporosis prevention (exercise, calcium, & vitamin D) must start well before age 30 when bones still respond.
Negative calcium balance in later life is not very responsive to nutritional measures.
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23. Under- & over-nutrition occur in all cultures
Disparities in income, nutrition & health care are increasing between countries & within groups in the same country
In addition, in low and middle income countries diseases of overnutrition are increasingly common
Obesity related disorders, including diabetes, are now as important in some lower to middle income countries as in North America and the European Union

24. Also, under-nutrition occurs in many rich nations
In rich nations, enormous wealth for some has left others ravaged by health costs, unemployment, foreclosures
Developed countries have marginalized cultural groups. Hunger is common in N & S America, China & E Europe
For example, ~49% of US children (and over 80% of black children) require food-aid at some time during childhood
Scandinavia & few western European countries are almost the only exceptions
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25. Overnutrition is no longer limited to rich countries
Obesity is a growing problem worldwide, particularly among those who lack resources for a wide range of food choices.
All too often, the cheapest foods are high calorie, poor in nutrients, rich in sugar, salt, fat, & trans-fats
The predominant cause of obesity is under- exercising rather than overeating. On average, overweight people eat slightly fewer calories than lean people, but are much less active
Obesity increases risk of many disorders, most notably cardiovascular disease, cancer, adult-onset diabetes. “Prevention is much better than cure”.

26. Overnutrition is no longer limited to rich countries
Previously, the poorest were almost immune to diabetes, hypertension, gout, & atherosclerosis & heart disease
No longer. These are growing problems, impacting health worldwide. In the next few slides we’ll consider prevention.
Diabetes has reached epidemic proportions threatening, vision, kidney function, mobility, heart-health & life itself.
A cluster of symptoms, hypertension, hyperlipidemia, and hyperglycemia is sometimes called “metabolic syndrome”
Each of them increases risk of heart disease, and together the risk is greatly amplified. Read on…..
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27. Prevention of heart attacks and strokes
Risk factors : hypertension, hyperlipidemias (LDL / “bad” cholesterol), inactivity & diabetes. All correlated with obesity
Smoking is the most life-shortening risk factor of all
These risks can be changed earlier or later, by modification of diet & other life-style changes or medication
In the past 5 years research has established that exercise & a lean body are the most powerful predictors of a long healthy life, and also of clear thinking into old age

28. Prevention of heart attacks and strokes
There is no easy solution to obesity. In a typical study: <10% of people dieting, <10% of those exercising, and <15% of those exercising & dieting, lost weight.
However, over 80% of those who underwent stomach stapling or banding lost weight!
Not very encouraging, for lifestyle treatment. Many argue that surgery to control weight should be done more often
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29. Measures to diminish cardiovascular risks
Lifestyle measures: have greatest impact in older people!
Increasing consumption of fruit & vegetables by one to two servings can cut cardiovascular risk by 30%
Reduction of blood pressure by 6 mm Hg reduces stroke risk by 40% & heart attack by 15%. Hydrochlorthiazides (diuretics) are inexpensive and effective
Moreover, a 10% reduction in LDL cholesterol reduces the risk of coronary heart disease by 30%

30. Measures to diminish cardiovascular risks
Modest cutbacks in saturated fat & salt improve blood pressure & lipids; & diminish risk of cardiovascular disease
Lifestyle measures are, optimally, combined with pharmaceutical intervention
Best practices in the area of diabetes & cardiovascular disease are a moving target. Anyone teaching or practicing in this area needs skills in finding evidence-based information in an ocean of misinformation.
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31. Nutrition in later life and old age
Worldwide, the proportion of people over 60 is increasing. By 2025, the world will have more than 1.2 billion older persons – two-thirds of them in low income countries
The foundation laid in earlier life determines risk of diabetes, heart disease, hypertension, strokes, osteoporosis, cancer, etc. All these bring special nutritional concerns.
Many of the diseases of late life are diagnosed too late for effective treatment. Prevention at an early age is the goal

32. Nutrition in later life and old age
Old age can be cut short by many kinds of malnutrition
Deficiencies of calcium, iron, water, vit. B12 can severely compromise old age
Loss of taste and smell can render the elderly at risk for food poisoning from spoiled food
Loss of thirst sensitivity in this age group makes dehydration (inadequate water intake) a common cause of confusion, headache, & occasionally kidney stones
Prevention is better than cure, & symptomatic treatments that are effective ,are often unavailable to the aged in LMICs
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33. Dietary patterns across cultures
2. Peasant agriculturalists – successful small scale farmers (currently the largest group)
Benefits: close to food sources; if no punitive taxes or rents; usually well adapted to their traditional diets
Risks: single crop emphasis  malnutrition, plagues (locusts, rodents), exploitation, warfare and plunder
Prevalent problems: vitamin deficiency, starvation, alcoholism
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34. Dietary patterns across cultures
3. Indigent, landless crop planters Benefits: Community, share with family, neighbors, income is typically less than a dollar a day Risks: Crop failure, drought or famine, erosion, soil- exhaustion, pestilence, economic exploitation (by landlords, seed providers, loan-sharks), displacement, forced migration, civil unrest or foreign invasion Problems: multiple vitamin deficiencies, kwashiorkor (protein malnutrition), infectious disease epidemics. Too poor, powerless to help themselves, most of them will never escape their circumstances, nor achieve full health

35. Dietary patterns across cultures
4. Urban slum dwellers – fastest growing group Benefits: hope for jobs, escape from drought or crop failure Risks: overcrowding, poverty, poor hygiene, limited food choice, social disruption  loss of traditional diets, crime Prevalent problems: deficiencies of essential nutrients, alcoholism, obesity, kwashiorkor, epidemics

36. Dietary patterns across cultures
5. Affluent urbanites – most recent category
Benefits: many food choices (appropriate and inappropriate)
Risks: inactivity along with high fat, sugar, alcohol intakes
Prevalent problems: overnutrition, obese babies and adults diabetes (carbohydrates), cholesterol, atheroma (lipid), strokes, heart disease diabetes, gout (uric acid - meat sources)
Note J
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37. 5 Nutrition & disease cause vs effect
4 slides:
Acute and chronic malnutrition;
Socio-cultural determinants of malnutrition
Undernutrition as contributor to much childhood mortality / morbidity
Micronutrient deficiencies: Iron, Vitamin A, iodine, calcium, etc.
Nutrition &major diseases: CV, strokes, diabetes
Over-nutrition, obesity

38. Some communities subsist in the “poverty trap”
Even among the richest there are some individuals so marginalized that there seems little hope for them The larger culture, if it is compassionate, takes long-term responsibility for ensuring them the necessities of life
Globally there are communities that have been denied the resources to ever become wealthy. Often from geography, climate, invasion, or appropriation of their natural resources
Regardless, a world community of compassion can provide the necessities of life, & offer new life to the dispossessed, as North America once opened its doors to the poor
Note H

39. Top 6 global manifestations of malnutrition
We begin with a perspective, then we take each of the 6 in turn
Water is a food (“food” is the material we eat & drink”) In hot climates, we can die in a few hours from a lack of it
2) Protein-energy malnutrition
The machinery of life, sculpted from 20 different amino acids
Deficiency is most serious in children (time of fastest growth):  "failure to thrive", stunted growth
The material in this section is well reviewed at:
Iron, vitamin A, iodine – check the latest information at:

40. Top 6 global manifestations of malnutrition (cont.)
3) Iron deficiency - prevalent in Africa and Asia
Women & children are the most seriously affected
In parts of Africa 60% of children have  blood iron
About a quarter of these have symptoms of anaemia
4) Vitamin A deficiency
Over 100 million children under 5 suffer vitamin A deficiency
In high deficiency areas vit. A tabs  child mortality by 23 %
&  child blindness by 80%. Night-blindness is an early sign
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41. Top 6 global manifestations of malnutrition (cont.)
5) Don’t underestimate iodine deficiency disorders
WHO 2003: “1.6 billion people don’t get enough iodine”. This is the major cause of preventable brain damage.
Thanks to MDG programmes the problem is shrinking!
In addition nutrition determines chronic disease risk
Heart disease, osteoporosis, cancer, diabetes, strokes, etc.
We’ll go through these one at a time in the following slides
For categories of at risk people across countries, see Note K
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42. Top 6 global manifestations of malnutrition (cont.)
6) Folic Acid is required for healthy babies
A deficiency causes spina-bifida – a common birth defect
Supplements are recommended before start of pregnancy
50% of pregnancies are unintentional!
Women who might become pregnant, need advice
More details on these nutrients in the ensuing slides
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43. Water: one of our most important foods
Adequate safe water is most important dietary component
9 million worldwide have water-borne diseases
In India, contaminated water kills 300,000 children annually
Problems relating to water supply & safety have simple, relatively inexpensive solutions
Water “ownership” is, however, contentious & usually follows military power (e.g. in Middle East)
In hot humid conditions workers may need over 5 l / day & also need to replace the NaCl lost along with water in sweat

44. The special importance of proteins
Proteins are the machinery of life. We have no storage form. If we must use our protein “stores”, our tissues lose function
Plasma, liver and kidney lose function first. Their proteins are the most “labile”. Then, digestive tract, muscle & heart
Proteins are made up of 20 amino acids. 12 are non- essential – they can be made from other dietary components
8 amino acids are “essential”. If even one is missing, no protein can be synthesized. A protein lacking any one essential amino acid has zero “biological value

45. Dietary deficiency of proteins is deadly
When any essential amino acid is missing, all the rest are burned & no protein synthesis can occur – zero!
All essential aa’s must be there at the same time. Meeting an amino acid need 1 day later is useless
A diet previously adequate in essential amino acids becomes inadequate if non-essential amino acids are removed. Because, although the body can make missing non-essential aa, it uses up essential amino acids to do so
Protein complementarity, de-emphasized in nutrition courses, can be vital where protein intake is compromised

46. Humans adapt to low protein intakes ...
... otherwise impact of protein deficiency would be even higher
Endocrine changes improve the recycling of proteins. As tissues repair, the released amino acids are reused more efficiently
In the African presentation of kwashiorkor, a child is exposed to a protein deficient diet (age 1 to 5) & adapts successfully
Then a 1-week lack of protein (parent loses job, baby is fed glucose-water only, or a gastro-intestinal infection)  kwash
Child is treated for kwash, sent back to the home to same diet, & reaches adolescence, usually without recurrence.

47. Protein & energy nutrition are inseparable
When the diet lacks carbohydrates, it uses some amino acids to make glucose for brain, muscle, etc.
When a diet lacks total calories, proteins are co- opted, first dietary, then plasma, liver, kidney, etc.
For these reasons, a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed.
Google “protein-sparing effects of carbohydrates” if you want to understand this further
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48. Protein-energy malnutrition - in adults
Tissues are raided, with the following consequences:
Loss of plasma proteins  oedema*
Loss of liver & kidney function  diminished inactivation & excretion of carcinogens and toxins
Loss of immune function  gastro-intestinal infections
Loss of digestive tract / liver function  amino acids can’t be utilized for proteins. No treatment can prevent death
Loss of muscle and heart tissue  weakness, heart failure
*Oedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities

49. Hungry kids – difficulties in diagnosis
Marasmic babies may not seem undernourished until a check for “pitting oedema” reveals that what appear to be strong arms and legs, are in reality oedematous
Another diagnostic complication is that most deficiencies are combined, as in protein energy malnutrition “PEM” with multiple vitamin deficiencies
The distinctions are crucial both in determining treatment, and in determining if the underlying problem in the community is scarcity of food, a protein, or many nutrients
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50. Protein malnutrition is different
In uncomplicated kwashiorkor, only protein is lacking - “Malnourished, not undernourished”
The risk of death or permanently retarded development is great, and the risk is increased because its easier to miss the diagnosis
Kwashiorkor babies may have more than adequate calories in their diets. They may be chubby, with substantial subcutaneous fat
Kwashiorkor may go unnoticed even when urgent hospitalization is needed, or when death is imminent

51. Protein malnutrition: diagnosis
When there are many sick kids in a community, but none look undernourished be sure to look for protein deficiency. Why?
It’s important not to miss the diagnosis. Kwashiorkor has a high fatality rate even with hospitalization
The 1st symptom to present is often diarrhoea, or oedema
The child may be treated for a gastrointestinal infection while the underlying cause, kwashiorkor, goes undiagnosed
Oedema is an early symptom, and may be mistaken for chubby limbs, so test if nutrition may be compromised

52. Tracking protein-energy malnutrition in kids
Failure to thrive may be an early warning of flagrant PEM in an individual child or a community. Always investigate the cause
Growth charts give weight for stature / length across age. They provide criteria to estimate severity. Proper use requires training!
Change in position on a chart shows effectiveness of treatment & probability of survival
If many children in a community show up at risk on growth charts, authorities must be alerted to endemic problems
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53. Early measures required on PEM diagnosis
Treatment is urgent - hospitalization is preferred if available
Delayed physical growth is often restored in catch- up growth when a good diet is provided
Cognitive disabilities may be irreversible if prolonged
Ready-to use foods (RTUF) for PEM have saved many lives
Oral rehydration salt (ORS) therapy is also life- saving when there is accompanying diarrhoea (which is usually the case)
Note L

54. Early measures required on PEM diagnosis
Both RTUF and ORS can be given at home in a bottle (Wikipedia). World production of ORS is around 500 million sachets / year. Improvisation of ORS is described at
Powdered milk protein in boiled water can be very helpful as an emergency measure
Acute fatality rate can be 25% even with prompt treatment
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55. Iron deficiency affects 500 million globally
Causes: insufficient availability of dietary iron, or increased iron requirements to meet reproductive demands, haemmorhage, parasitic infections (often concurrently).
The result is an increasingly severe anaemia, reduced work productivity → poverty, diminished learning ability, increased susceptibility to infection
For more on consequences of iron deficiency, see …
Note M

56. Iron deficiency affects 500 million globally
Iron deficiency is best diagnosed in the preclinical stage, by measurement of transferrin saturation
Females > males due to iron loss at menstruation -- 56% of pregnant women are affected – 3 x as many as in developed countries
25% of men also are deficient in iron in the developing world
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57. Treatment of iron deficiency: rebuilding iron reserves
Iron tablets are effective within weeks, but non-compliance is common so compliance must be checked
Increase iron intake through combining iron-rich foods with agents that  iron absorption (like vitamin C)
Encourage availability and consumption of iron-fortified foods

58. Treatment of iron deficiency: rebuilding iron reserves
Weekly / daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
Treat causes of diminished iron reserves: haemorrhage, parasites (including malaria), and hemolytic conditions.
Be alert! Iron may be lethal in some inherited anaemias (thalassemias, sickle cell, or Hb M) common in Africa & Asia
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59. Iron excess - dangerous to some
Those with haemolytic anaemias: (eg thalassaemia – common in people of African or Asian descent). Iron should not be prescribed until the cause of an anaemia is known
Where iron pots are used for cooking or beer: Siderosis: iron deposition in liver, kidney, heart, pancreas  organ failure
Children: Parents' iron pills are attractive to kids in developed countries. The most common of fatal childhood poisonings
Those with familial haemochromatosis: This common inherited disease has symptoms similar to siderosis (above) The first sign of this disease is often inoperable liver cancer
Note N

60. Vitamin A deficiency in public health
Vit. A deficiency is a public health problem in over 70 countries, especially in Africa, SE Asia & the W Pacific where it affects 250 million mostly aged 0- 4 years
Night blindness may predict vitamin A deficiency, with risk of permanent total blindness if it progresses.
There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
Vitamin A supplements can be beneficial when given as seldom as once a year. Check the latest information at:

61. Vitamin A deficiency & perinatal health
Vit. A is crucial for maternal & child survival, supplements in high-risk areas can dramatically decrease maternal mortality*
In pregnant women Vit. A deficiency is seen in the last trimester when demands by unborn child & mother are highest
Partnerships for progress in vitamin A nutrition In 1998 WHO, UNICEF, CIDA, USAID (ia) launched a global initiative in 40 countries that has to date averted 1.25 million deaths, by giving vitamin A to kids at clinics
*This issue is under active investigation. For the status at time of writing see Lancet, Volume 376, Issue 9744, p , 11 September 2010

62. Vitamin A deficiency & perinatal health
Night blindness in pregnant women - an early danger sign
In children, the cost-effective prevention is breast-feeding
Genetically engineered high Vit. A rice crops could help
Caution: Vit. A supplements as retinol are controversial. It can be toxic & teratogenic ( birth defects). However, given as carotene, vitamin A supplements are safe, leading only to an orange tinge in skin colour.
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63. Iodine deficiency disorders
The world’s major cause of preventable brain damage In 1990: 1.6 billion people were at risk in over 100 countries, mainly in parts of Africa and Asia where soil is iodine-deficient
38 Million children have mental impairment from lack of iodine
As a result of the micronutrient initiative, this number is falling
For latest data, see:

64. Iodine deficiency disorders
Consequences start before birth and continue afterward
In utero, spontaneous abortion, congenital abnormalities & retarded foetal development
In early childhood and progress toward adolescence iodine deficiency causes cretinism, an irreversible retardation. Impacts home, school, & work
Today we are on the verge of eliminating iron deficiency a major public health triumph like getting rid of smallpox & polio
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65. Toward iodine sufficiency – iodized salt
A cost-effective low-tech therapy, iodized salt costs just $0.05 per person per year
UNICEF, ICCIDD (International Council for Control of IDD), & the salt industry have set up iodization programmes. Globally, 66% of households have access to iodized salt.
As of 2009 the number of at risk countries has been halved!
However, progress has slowed and we are a decade behind promises of the international community.
54 countries are still affected – efforts must continue