Nutrition in Global Health Prepared as part of an education project of the Global Health Education Consortium & collaborating partners Allan J Davison.

Nutrition in Global Health Prepared as part of an education project of the Global Health Education Consortium & collaborating partners Allan J Davison PhD, Professor, Biochemist, Faculty of Sciences, Simon Fraser University Department of Biomedical Sciences & Kinesiology June 2011 Roadmap to the world’s nutritional health: Causes, mechanisms, solutions

Nutrition Module Sections 1.Global malnutrition: prevalence, cause, effect, remedy 4 2.Major categories & measures of nutritional status4 3.Nutrition & crucial periods in the life-cycle; 4 4.Determinants of nutrition, dietary patterns & culture2 5.Nutrition and its relationship to disease4 6.Making hunger history - breaking the poverty-trap 3 7.Trends in nutrition, food security & globalization3 Page 2

Learning goals - to provide understanding of The global distribution of malnutrition To help answer these, we will emphasize: Patterns and specifics of nutritional problems Nutritional assessment, prevention, treatment Local & external causes Prevention & pathways toward solutions Interactions between malnutrition, poverty, & ill-health What causes have brought such inequities? What initiatives contribute to a resolution? t

Section 1 Perspective on malnutrition Prevalence, causes, consequences On completing this section you will be able to: 1.Describe the extent of malnutrition & its impact on people of the planet, and understand how MDGs depend on nutrition 2.Analyze the factors that determine nutritional health 3.Identify nutritional problems among individuals & populations, identify causes & appropriate solutions 4.Assess risks at various stages of the life cycle & recommend strategies for diminishing risk 5.Compare competing theories accounting for the inequities 6.Predict outcomes by projecting current trends into the future & foresee a pathway toward a world without hunger

A vicious cycle for malnutrition poverty, health, economic deprivation Page 5 Development: Marginalization  inability to provide for self or family Access to the ladder of development Poverty:  Diminished access to agricultural & food resources  malnutrition high birth rate Health: Physical & cognitive impairment, susceptibility to disease, early death  inability to earn an income nutrition

When the only tool you have is a hammer … every problem becomes a nail Page 6 It’s natural to focus on our immediate space-time: rash, diarrhea., edema. Then etiology: infection, nutrition, endocrine Meanwhile, causes further back are invisible: poverty, invasion, drought, economic Are you bored yet? You’d better not be! This module will reiterate the more enduring global causes, poverty & lack of will to change the net flow of wealth from the dispossessed to the powerful. Also the ways in which this imbalance is being overcome. Reference: Ban-Ki Moon, Noam Chomsky, The Nation Malnutrition: “spatial & temporal myopia” sees proximate, not ultimate causes

Routes to famine Having resources Externally initiated armed conflict Uncertain rainfall & drought Being landlocked Bad governance Israel, Afghanistan Lesotho or being on a trade or pipeline route Zimbabwe, Italy, USA Dafur, Afghanistan Sahel, Palestine Blaming the bonsai tree... Yunus: So.Africa Nigeria, Iraq To learn about the “Resource Trap” read or google Paul Collier Sometimes to overthrow a populist government (Allende, Aristide) and install a puppet, or bribable government

The astonishing background to hunger – a world growing spectacularly rich Page 8 Next slide shows century by century growth in GDP per capita For half a century we’ve had enough food to nourish everyone Almost a billion are overweight while an equal number cannot get enough food to sustain life. Because the flow of wealth is overwhelmingly from the poor to the rich, & the rich are able to keep it that way Yet … Why? BanKi Moon

World GDP $PPP per cap (est) 1500-2100 http:// ers.usda.gov/Data/Macroeconomics / “Manifest destiny” of world - wealth China + India 2040? 9

Eliminating hunger may be the main requirement for a world at peace Page 10 MDG 1 is elimination of extreme poverty and hunger, most if not all the others depend on this, the primary, one In the following vicious circle, note how malnutrition, ill health, & poverty exacerbate each other Food is a primary human drive. Lack → social instability Health & economic development depend on nutrition GW Bush

We know in detail the causes of hunger & how to eliminate it Page 11 the “poverty trap”the “resource trap” Unfettered free trade favours the powerful Trickledown is overpowered by a torrent of wealth in the other direction We will assume you know the mechanisms in The cures are laid out in detail in the MDGs, MVs, Grameen Foundation The chain of cause and effect, and influences are not rooted in the availability of food, nor are they an accident. You must see “starve” as a transitive verb to understand the link between extreme wealth and extreme poverty

We know what kinds of aid work and what kinds don’t Page 12 Aid designed to benefit the giver rather than the recipient Fraction of the amount promised, nothing compared with warfare Promises that evaporate

1 Malnutrition – cause, effect, cure 3+3 slides: 1.Trends in nutrition, food security & globalization 2.Agricultural trends 3.Nutritional inequities - Cause & consequence 4.Food security; Prospects for having enough food Page 13

2 Categories & measures of nutritional status 4 slides: Malnutrition, undernutrition, Overnutrition / Overweight, Obesity Energy requirements: calories, carboh, proteins, fats macronutrients, micronutrients Page 14

3 Critical periods: nutrition in the life-cycle 4 slides: 1.Perinatal nutrition: 0-6 mo: Breast vs. formula 1 st 5 y Weaning & infancy –intellectual develop 2.School years; ability to learn 3.Work performance 4.Elderly Page 15

Nutrition through the life-cycle Page 16

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! Page 17

Factors in perinatal nutrition ( see also Module on Acute malnutrition) Delaying clamping the umbilical cord until it stops pulsing  iron stores see: www.naturalchildbirth.org/natural/resources/labor/labor04.htm http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/jcco m/en/index.html www.naturalchildbirth.org/natural/resources/labor/labor04.htm http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/jcco 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 http://www2.unicef.org/nutrition/index_22657.html http://www2.unicef.org/nutrition/index_22657.html Page 18

Perinatal nutrition requires attention 1 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: 1 http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html Page 19

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 Page 20

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? Page 21

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. Page 22

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 Page 23

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 Page 24

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. Page 25

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. Page 26

Differential nutritional vulnerability of females Women suffer 80% of hip fractures; lifetime risk 30 - 40% 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. Page 27

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 Page 28

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 Page 29

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”. Page 30

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….. Page 31

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 Page 32

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 Page 33

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% Page 34

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. Page 35

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 Page 36

Nutrition in later life and old age Old age can be cut short by many kinds of malnutrition Deficiencies of calcium, iron, water, vit. B 12 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 Page 37

4 Determinants of nutrition, diet & culture 2 slides: 1. Page 38

Dietary patterns across cultures 1. Hunter gatherers – the earliest category Benefits: mixed diet, well nourished in good times Risks: famine or drought, warfare & plunder, resource- depletion through population pressure Prevalent problems: starvation, thirst,  life- expectancy Page 39 Note I

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 Page 40

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 Page 41

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 Page 42

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) Page 43 Note J

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 Page 44

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 Page 45 Note H

Top 6 global manifestations of malnutrition 1)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 Page 46 We begin with a perspective, then we take each of the 6 in turn The material in this section is well reviewed at: http://www.pitt.edu/~super1/lecture/lec0141/index.htmhttp://www.pitt.edu/~super1/lecture/lec0141/index.htm Iron, vitamin A, iodine – check the latest information at: http://www.micronutrient.org/English/view.asp?x=1http://www.micronutrient.org/English/view.asp?x=1

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 Page 47 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

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! http://www.who.int/vmnis/iodine/status/en/index.html http://www.who.int/vmnis/iodine/status/en/index.html 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 Page 48 Top 6 global manifestations of malnutrition (cont.) For categories of at risk people across countries, see Note K

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 Page 49 Top 6 global manifestations of malnutrition (cont.)

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 Page 50 http://www.who.int/water_sanitation_health/mdg1/en/index.html

The special importance of proteins Page 51 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

Dietary deficiency of proteins is deadly Page 52 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

Humans adapt to low protein intakes... Page 53... 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.

Protein & energy nutrition are inseparable Page 54 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

Protein-energy malnutrition - in adults Page 55 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

Hungry kids – difficulties in diagnosis Page 56 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

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 Protein malnutrition is different

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 1 st 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 Page 58

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 Page 59

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) Page 60 Note L

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 http://rehydrate.org/ors/made-at-home.htm#recipes http://rehydrate.org/ors/made-at-home.htm#recipes Powdered milk protein in boiled water can be very helpful as an emergency measure Acute fatality rate can be 25% even with prompt treatment Page 61

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 … Page 62 Note M http://www.micronutrient.org/English/view.asp?x=579

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 Page 63

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 Page 64

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 Page 65

Iron excess - dangerous to some Page 66 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

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: http://www.micronutrient.org/english/View.asp?x=577 Page 67

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 Page 68 *This issue is under active investigation. For the status at time of writing see Lancet, Volume 376, Issue 9744, p 873 - 874, 11 September 2010Volume 376, Issue 9744

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. Page 69

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 Page 70 For latest data, see: http://www.micronutrient.org/english/View.asp?x=578http://www.micronutrient.org/english/View.asp?x=578

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 Page 71

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 Page 72

6 Making hunger history - breaking the vicious cycle of the poverty-trap 3 slides: Worldwide distribution of malnutrition & its relation to poverty Societal costs of malnutrition including effects on young children Page 73

7 Malnutrition & MDGs: cause, effect, cure 3 slides: 1.Trends in nutrition, food security & globalization 2.Agricultural trends 3.Nutritional inequities - Cause & consequence 4.Food security; Prospects for having enough food Page 75

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.

Other GHEC modules contribute to our understanding of Nutrition in Global Health Page 77 This module does not stand alone. “Roadmap to a world without hunger” will follow (see note) Two other GHEC modules deal with poverty & hunger a) Module 48: Acute malnutrition – Clinical aspects (deals with treatment) b) Why is the 3 rd world the 3 rd world? (underlying and diverse causes of poverty & hunger) http://globalhealthedu.org/resources/Pages/default.aspx http://globalhealthedu.org/resources/Pages/default.aspx To see this module in the context of what will follow, see Note A Note A

Pre-quiz (pending completion of “quiz” feature in GHEC’s server) As a reality check, and to create “teachable moments” for what follows, we now invite you to take a 5-minute pre-quiz You will be offered 10 true-or-false questions to dispel some common misconceptions Some of this misinformation is spread by those who have something to gain from it After completing the pre-quiz, we hope you will continue this module with greater interest and renewed clarity Page 78

To get the most out of this module If you are….. a nutritionist or student of nutrition a student of one of the health professions planning a project in regions with severe nutritional problems a public health practitioner Pay attention to global & public health & policy implications. Pay attention to perspectives & realities in desperate situations Emphasize check-lists to prepare for field work & gather information to recommend/advocate for intervention Use these slides & resources in your information / teaching sessions Page 79 You may want to …

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 Page 80

A vicious cycle: economics, hunger, health Page 81 Economic marginalization  inability to provide for self or family Poverty  diminished access to agricultural & food resources  malnutrition Physical & cognitive impairment, susceptibility to disease, early death  inability to earn an income nutrition

Nutrition in Global Health Course overview 1.Overview of nutrition across humankind 2. Nutrition fundamentals in global context 3. Top six nutrition problems, & their solutions 4. Nutrition across the life cycle in rich & poor nations 5. Cause & effect in population nutrition 6. Overview and where we are now Bridge to Part 2, Roadmap to a world without hunger

Universal limitations & health consequences We can’t survive without about 15 essential mineral elements, so they are needed in our diets, most in trace amounts We can’t manufacture about 15 vitamins, so they must be provided in our diets And in addition…… Page 83

Universal limitations & health consequences In addition: We lost key metabolic abilities our evolutionary ancestors had. Thus we are vulnerable to 2 dietary risks: 1)In early life – a period of rapid growth, we are vulnerable to “kwashiorkor” (protein insufficiency) because we can’t synthesize 8 “essential” amino acids missing from our diet 2) In later life: we are vulnerable to obesity & diabetes – in part because we can make fat from carbohydrate, but we can’t easily convert stored fats back to carbohydrates Page 84 Note B

Categories of nutritional status Nutritional status is assessed as one of four categories 1.Good nutritional status: All nutrients (right quantities, time & place) allow optimal, growth, maintenance, & reproduction 2.Overnutrition: An excess of a nutrients (usually calories) is being consumed, so that health is negatively impacted 3.Undernutrition: Insufficient food is consumed to allow for the energy needs of the individual. Inevitably dietary (& then body) protein is burned for energy. A secondary protein deficiency ensues – thus: "protein-energy-malnutrition" 4.Malnutrition: Energy consumption is adequate, but there is an imbalance among constituents of the diet and health is impacted Page 85 Note C

Worldwide distribution of malnutrition Over 20 million children suffer from acute malnutrition WHO. Page 86 Scientific American, Sept 2007

Worldwide, nutritional inequities follow poverty (as do health inequities & life expectancy) Globally, there is plenty of food for everyone but …those who have more than they need find reasons not to share The result – in the time you spend on this module over 1000 children will have died of hunger Each day 1500 children go forever blind from lack of vitamin A The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency). About 2 billion people (56% of pregnant women) have iron deficiency. Their babies have low birth- weight, &  mortality Page 87 Note D

“The bottom billion” (title of a book by Paul Collier ) “The poorest of the poor” - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day We define this subclass as people who don't get enough to meet the ordinary demands of life They lack the resources to earn a living, or obtain what’s needed for normal, growth, maintenance & reproduction It goes without saying that they are unable to provide the necessities for those who depend on them Page 88

“The bottom billion” (title of a book by Paul Collier ) Their lack of access to resources is such that a significant fraction will be unable to stay alive They live mostly in isolated rural areas and most are subsistence farmers This means that what they eat this month is what they can take out of the ground from last month's planting Page 89

Unhelpful misconceptions about aid Page 90 False: “Most aid money goes into the Swiss bank accounts of corrupt African dictators” “Aid creates dependence & impedes self-sufficiency” “Despite all the aid $, the problems are only getting worse” The truth is : Overwhelmingly African leaders are not corrupt. When they are, most bribes come from the West Well planned aid builds capacity & self-sufficiency Overall, hunger worldwide is diminishing. MDGs go forward because of the countries that honour their pledges! Note E

Money? Useless - no nearby shops It’s hard to imagine a malnourished community and you may want to experience field conditions in advance No commerce! Try it at a Medecins sans Frontieres site: http://www.starvedforattention.org/ http://www.starvedforattention.org/ No shops to spend money in, no one to employ anyone, no one to sell things to Hungry children are all too visible, and those who didn’t survive are in tiny unmarked graves Their needs are much more immediate than money We don’t need studies to learn what they need - read on! Page 91

If they don’t need money – what do they need? Short term they likely need emergency rations, safe water In conflict zones, shelter & safety to live, plant, harvest Medium term they need to become self-sufficient, with: good seeds, fertilizer, usable water, sanitation, low technology agricultural info & resources, health services, mosquito nets, pharmaceuticals Long term they need the prerequisites of sustainable economic development - tools for development – see Part 2 Kids need particular attention – see note below & later slides Page 92 Note F

The goal is to see everyone self-sufficient People in the poverty trap live from hand to mouth, with no opportunity to put resources aside to build a better future Such communities cannot access the ladder of economic development without external help. The MDG promises of 0.7% of rich country GDP for aid was chosen to eliminate extreme poverty & hunger in 3 decades But there are many nations that failed to meet this goal, including both the US and Canada Thanks to the nations that keep their promises, widespread hunger may be eliminated, but only after 30-50 years. This not, however, cause for undiluted joy. See Note G. Page 93 Note G

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 Page 94 Note H

Nutrition in Global Health C auses, mechanisms, solutions Nutrition is crucial to global health & MDGs 1.Overview of nutrition across humankind 2. Human nutrition fundamentals in global context 3. Top Six nutrition problems, & their solutions 4. Nutrition across the life cycle in rich & poor nations 5. Cause & effect in population nutrition 6. Overview and where we are now Bridge to Part 2, Roadmap to a world without hunger

Human Nutrition Fundamentals in Global Context Page 96 The next set of slides covers the critical skill set needed for understanding nutritional issues in the context of global health They are not a substitute for nutritional training, but rather a catalog of nutritional tools applicable to problems a health practitioner might encounter in the field From this you can learn when to call in a nutritional expert, what kind, & what to you might reasonably ask for & receive If you have learned nutrition in a developed country, this may help you to expand your knowledge of nutrition and public health in the context of 3 rd world health problems

Dietary patterns across cultures 1. Hunter gatherers – the earliest category Benefits: mixed diet, well nourished in good times Risks: famine or drought, warfare & plunder, resource- depletion through population pressure Prevalent problems: starvation, thirst,  life- expectancy Page 97 Note I

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 Page 98

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 Page 99

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 Page 100

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) Page 101 Note J

Nutrition in Global Health C auses, mechanisms, solutions Nutrition is crucial to global health & MDGs 1.Overview of nutrition across humankind 2. Human nutrition fundamentals in global context 3. Top six nutrition problems & their solutions 4. Nutrition across the life cycle in rich & poor nations 5. Cause & effect in population nutrition 6. Overview and where we are now Bridge to Part 2, Roadmap to a world without hunger 1.

Top 6 global manifestations of malnutrition 1)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 Page 103 We begin with a perspective, then we take each of the 6 in turn The material in this section is well reviewed at: http://www.pitt.edu/~super1/lecture/lec0141/index.htmhttp://www.pitt.edu/~super1/lecture/lec0141/index.htm Iron, vitamin A, iodine – check the latest information at: http://www.micronutrient.org/English/view.asp?x=1http://www.micronutrient.org/English/view.asp?x=1

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 Page 104 4) Vitamin A deficiency Over 100 million children under 5 suffer vitamin A deficiency In high deficiency areas vit. A tabs  child mortality by >20% &  child blindness by 80%. Night-blindness is an early sign

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! http://www.who.int/vmnis/iodine/status/en/index.html http://www.who.int/vmnis/iodine/status/en/index.html 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 and Note K lists categories of at risk people across countries Page 105 Top 6 global manifestations of malnutrition (cont.) Note K

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 Page 106 Top 6 global manifestations of malnutrition (cont.)

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 liters / day & to replace the NaCl lost along with water in sweat Page 107 http://www.who.int/water_sanitation_health/mdg1/en/index.html

The special importance of proteins Page 108 Proteins are the machinery of life. We have no storage form. If we must use protein “stores”, 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 and 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

Dietary deficiency of proteins is deadly Page 109 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 one 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

Humans adapt to low protein intakes... Page 110... 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 (ages 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 home to same diet, & reaches adolescence, usually without recurrence.

Protein & energy nutrition are inseparable Page 111 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. Do an internet search on “protein-sparing effects of carbohydrates” if you want to understand this further

Protein-energy malnutrition - in adults Page 112 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

Hungry kids – difficulties in diagnosis Page 113 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

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 Protein malnutrition is different

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 1 st 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 Page 115

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 Page 116

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) Page 117 Note L

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 http://rehydrate.org/ors/made-at-home.htm#recipes http://rehydrate.org/ors/made-at-home.htm#recipes Powdered milk protein in boiled water can be very helpful as an emergency measure Acute fatality rate can be 25% even with prompt treatment Page 118

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 Page 119 Note M http://www.micronutrient.org/English/view.asp?x=579

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 -- >50% of pregnant women are affected in the developing world – 3 times as many as in developed countries 25% of men also are deficient in iron in the developing world Page 120

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 Page 121

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 Page 122

Iron excess - dangerous to some Page 123 Those with haemolytic anaemias: (e.g., 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

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: http://www.micronutrient.org/english/View.asp?x=577 Page 124

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 Page 125 *This issue is under active investigation. For the status at time of writing see Lancet, Volume 376, Issue 9744, p 873 - 874, 11 September 2010Volume 376, Issue 9744

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. Page 126

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 Close to 40 million children have mental impairment from lack of iodine As a result of the micronutrient initiative, this number is falling Page 127 For latest data, see: http://www.micronutrient.org/english/View.asp?x=578http://www.micronutrient.org/english/View.asp?x=578

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 Page 128

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 Page 129

Healthy diet Optimal health: physical & mental development reproduction, survival Absence of disease... food & water... health services Access to...... peri- natalcare Good nutritional status Precursors Foundations Agricultural productivity Economic development Infrastructure non-exploitive investment intellectual property Geography, stability, climate absence of conflict, natural resources access to markets, etc Education NB women # of mouths to be fed

Case study Note to authors : You could pose the case on a PowerPoint slide, ask the student to address the question, and then provide a supplementary note that reviews how the case resolved, or could resolve. Several considerations: –What actually happened? –What factors should be considered, and their relative importance? –Or how would you, the expert, approach answering the case? If you opt for this response you can acknowledge that yours is just one answer of many, that every situation is different, and that there is no perfect answer Page 132

Supplementary note Note to authors : A “note” supplements the information provided on a slide. It allows the author to provide additional text, graphics, case studies, or other resources about a topic without filling the module with content likely to be of interest only to the more advanced or curious learner. This slide and the next several slides are blank pages, without special formatting. To provide a supplementary note scroll through the next several slides to see a demonstration of how to provide a note. You can then select and erase these slides or insert blank slides to provide a note. Do the following: 1) Prepare the slide to which you wish to append a supplementary note. 2) Immediately after that slide provide the note. Either draft the note text yourself or go to a source for your note, select and copy it, and then paste it into a box on an otherwise blank slide. If your note is large, paste it, select the entire note and reduce the font size so that it fits and then bring in the box margins so that the note is contained on the slide. Add pictures or graphics as desired. When GHEC converts your PowerPoint file into the module platform the note layout and font size will be formatted appropriately. If the note is very long you can also provide it in a Word file, making it clear through letter codes, A, B, C, etc., the PowerPoint slide to which it relates. 3) In processing the file GHEC will link the note to the appropriate slide and provide buttons for accessing the note and returning to its reference slide. The following slides give examples of what can be done.

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. Page 134 Note button A click on the note button takes viewer to the note

Supplementary note to the preceding slide Every day, 1500 women die from pregnancy- or childbirth- related complications. In 2005, there were an estimated 536 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable. (1) Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations Millennium Summit in 2000. In Millennium Development Goal 5 (MDG5), countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. However, between 1990 and 2005 the maternal mortality ratio declined by only 5%. Achieving Millennium Development Goal 5 requires accelerating progress. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www. who.int/reproductive- health/publications/maternal_mortality_2005/index.html, accessed 14 August 2008). Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html Photo credits

Supplementary note to the preceding slide Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html

Supplementary note to a preceding slide Why do mothers die? Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are: severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia and HIV.(2) Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies.

Supplementary note to a preceding slide Semmelweis's observations conflicted with the established scientific and medical opinions of the time. The theory of diseases was highly influenced by ideas of an imbalance of the basic "four humours" in the body, a theory known as dyscrasia, for which the main treatment was bloodlettings. Medical texts at the time emphasized that each case of disease was unique, the result of a personal imbalance, and the main difficulty of the medical profession was to establish precisely each patient's unique situation, case by case.diseasesfour humoursdyscrasiabloodlettings The findings from autopsies of deceased women also showed a confusing multitude of various physical signs, which emphasised the belief that puerperal fever was not one, but many different, yet unidentified, diseases. Semmelweis's main finding — that all instances of puerperal fever could be traced back to only one single cause: lack of cleanliness — was simply unacceptable. His findings also ran against the conventional wisdom that diseases spread in the form of "bad air", also known as miasmas or vaguely as "unfavourable atmospheric-cosmic-terrestrial influences". Semmelweis's groundbreaking idea was contrary to all established medical understanding.miasmas As a result, his ideas were rejected by the medical community. Other more subtle factors may also have played a role. Some doctors, for instance, were offended at the suggestion that they should wash their hands; they felt that their social status as gentlemen was inconsistent with the idea that their hands could be unclean. [6]:9[Note 7] [6][Note 7] Specifically, Semmelweis's claims were thought to lack scientific basis, since he could offer no acceptable explanation for his findings. Such a scientific explanation was made possible only some decades later, when the germ theory of disease was developed by Louis Pasteur, Joseph Lister, and others.germ theoryLouis PasteurJoseph Lister During 1848, Semmelweis widened the scope of his washing protocol to include all instruments coming in contact with patients in labor, and used mortality-rate time series to document his success in virtually eliminating puerperal fever from the hospital ward.time series Note to authors: This page provides an example of a long note associated with a picture. The font and picture can be made as small as necessary to fit on the slide. They will be enlarged as necessary on the processed note.

At a conference of German physicians and natural scientists, most of the speakers rejected his doctrine, including the celebrated Rudolf Virchow, who was a scientist of the highest authority of his time. Virchow’s great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time. [13]natural scientistsRudolf Virchow [13] It has been contended that Semmelweis could have had an even greater impact if he had managed to communicate his findings more effectively and avoid antagonising the medical establishment, even given the opposition from entrenched viewpoints. [18] [18] Supplementary note -- Example of extensive text Author note: You can copy/paste and reduce font size to put text in a slide. It will later be converted by GHEC into a supplementary note

Thought or discussion questions Note to authors: These can be very useful and may be used at multiple locations. Two varieties: –Thought question: This is a “stop and think” question that invites the learner, before proceeding to the next slide, to think about the question and perhaps provide a short answer. For example: “Before going to the next slide take one minute to write down words or terms that indicate the kinds of factors a donor organization will want to consider when responding to a request for funding support by a potential recipient.” –Discussion question: This can be a more general question, especially suitable for use when the module has been assigned prior to a class. Page 140

Special features Note to authors: We hope authors will make use of some of the special features allowed in PowerPoint and the following sections illustrate several of them. –Voiceovers –Video and YouTube clips –Hotlinks to other resources If you would like to use one or another of such features but need assistance please let us know. Page 141

Audio voiceover This slide describes, and the following slide demonstrates, an audio voiceover. You’ll need a microphone (low cost) plugged into your computer. –Click on the loudspeaker and hear brief text. Voiceovers allow you to comment or expand on a slide and, in the process, ‘humanize’ your presence to the learner. Clicking on the loudspeaker initiates the recording. Both the 2003 and 2007 versions of PowerPoint allow voiceovers though the procedures are somewhat different. Review the instructions and experiment a bit until you master the technique. If you encounter problems we may be able to help. Page 142

Box 1 Five common shortcomings of health-care delivery Inverse care. People with the most means – whose needs for health care are often less – consume the most care, whereas those with the least means and greatest health problems consume the least10. Public spending on health services most often benefits the rich more than the poor11 in high- and low income countries alike12,13. Impoverishing care. Wherever people lack social protection and payment for care is largely out-of-pocket at the point of service, they can be confronted with catastrophic expenses. Over 100 million people annually fall into poverty because they have to pay for health care14. Fragmented and fragmenting care. The excessive specialization of health-care providers and the narrow focus of many disease control programmes discourage a holistic approach to the individuals and the families they deal with and do not appreciate the need for continuity in care15. Health services for poor and marginalized groups are often highly fragmented and severely under-resourced16, while development aid often adds to the fragmentation17. Unsafe care. Poor system design that is unable to ensure safety and hygiene standards leads to high rates of hospital-acquired infections, along with medication errors and other avoidable adverse effects that are an underestimated cause of death and ill-health18. Misdirected care. Resource allocation clusters around curative services at great cost, neglecting the potential of primary prevention and health promotion to prevent up to 70% of the disease burden19,20. At the same time, the health sector lacks the expertise to mitigate the adverse effects on health from other sectors and make the Demonstration voiceover; click on the loud speaker The sound reproduction in this example is not good. It was done on the microphone of a laptop. If you can’t get good reproduction then either don’t use a voiceover or ask your university’s IT staff for help.

Quiz, format options – Author note The next slides demonstrate six types of question options that you can use as “pop ups” or as section and final quizzes. Please provide your questions on individual slides inserted in the location where you want the questions to appear. For each question indicate the desired option style if not readily apparent. Indicate which answer(s) are correct, and provide short feedback answers that you want to appear when a student’s response is not correct. Do not be concerned with formatting; we will handle that at the time of assembling your module.

Quiz, format option 1 How many women die each year due to pregnancy-related conditions? a. abc -- incorrect; correct answer is…. b. def -- incorrect; correct answer is…. c. ghi -- correct d. jkl -- incorrect; correct answer is…. e. mno -- incorrect; correct answer is….

Quiz, format option 2 Which two of the following answers are major risk factors for pregnancy-related morbidity? a. abc -- incorrect; correct answers are…. b. def -- incorrect; correct answers are…. c. ghi -- correct d. jkl -- incorrect; correct answers are…. e. mno -- correct

Quiz, format option 3 Which word or phrase best fills in the blank? _________ would be the most effective single measure to reduce maternal morbidity due to hemorrhage? a. abc -- incorrect; correct answer is…. b. def -- incorrect; correct answer is…. c. ghi -- incorrect; correct answer is…. d. jkl -- incorrect; correct answer is…. e. mno -- correct

Quiz, format option 4 Match each item on the left with the appropriate line on the right Abc Def Ghi Jkl Mno Pqr 123 456 789 987 654 321 Page 148 Note: Be sure to indicate which items are linked

Quiz option 5 – ranking Rank the below answers starting from most important to least important Abc Def Ghi Jkl Mno Pqr Page 149 Note: Be sure to show the correct ranking

Quiz option 6 – true/false Indicate whether each answer is true or false. (When response is incorrect a brief explanation as to why it is incorrect should be provided) Abc [true] Def [false] Ghi [false] Jkl [true] Mno [true] Pqr [false] Page 150

Quiz Now we invite you to take the module quiz and test your recent learning. This module quiz includes: –[Add a brief reference to the respective module quiz. How many questions, the type and scope of questions, and any other information and instruction for the students.] After completing your quiz, come back for the summary of this module presentation.

Summary [Add content to your summary slide(s) ] [State what has been learned and if appropriate, ways to apply the learning ] [Make sure you cover the most important points in your module objectives…]

Further readings & other resources Note to authors: Provide a listing, briefly annotated if useful, of additional resources relevant to the module’s topic. Especially useful are recent journal reviews and good online material Source abc Source def Source ghi Source, etc.

Acknowledgments Note to authors: This slide is for acknowledging help received from persons and organizations that were especially useful in preparating the module. Named authors will not be listed on the “Credits” slide

Credits [for named authors; you can include contact information if desired] [Add author 1 information] [Add author 2 information] [Add … ]

End of module [Reserved for GHEC notes and acknowledgment of donor organizations]

Structural elements & instructions to authors Page 157

Module parts (Delete this slide when no longer necessary) Author note: This file provides a PowerPoint template for your module. Duplicate each of the below template forms as necessary and replace the illustrative text and figures with your own content. The template forms are: –Title page –Module goals –List of module sections –Learning objectives –Section content –Case study –Supplementary note –Thought or discussion questions –Special features (voiceovers, video clips, etc.) –Quiz (including several quiz options) –Section or Module summary –Further readings and other resources –Acknowledgements –Credits Page 158

Module overview (Delete this slide when no longer necessary) Formatting. Template defaults are Tahoma 32 font for slide titles and Arial 28, 24, and 20 fonts for lower levels of text. Please use these defaults wherever possible but you may deviate from them in individual slides as appropriate. Components. If your topic can be logically divided into several major subtopics we suggest that each subtopic have its own learning objectives, content, and if useful, case study, quiz, and/or summary. Some of these components may not be appropriate or would unduly complicate or clutter your module and hence may be omitted or modified to meet you needs. Page 159

Module processing procedure (Delete this slide when no longer necessary) Module submission. Send draft module to Tom Hall (thall@epi.ucsf.edu) and to Glenn Nordehn (gnordehn@gmail.com) for review. Use placeholder slides, inserted immediately before the slides to which they refer, to provide instructions for the use of special eLearning features. Examples of such features are given later in this file. GHEC will initiate the review process and arrange for clarification of any questions that arise.thall@epi.ucsf.edu Processing and posting. On completion of the initial review and revision the module will be sent to an IT specialist for processing your module into the appropriate application platform and then posting on GHEC’s website. Page 160

Module features (Delete this slide when no longer necessary) Your module can accommodate these features: –PowerPoint-like slides with text, graphics and buttons that will take viewers to supplementary notes & resources –Ability to highlight by arrows, circles, colors or other means selected features of any slide –Voiceovers, in which you give audio explanations or commentary of selected slides. Voiceovers allow you to expand on a slide without using a lot of text. –Video and YouTube clips. We can provide you with help in how to add these features –Pop quizzes and end-of-module quizzes that provide answers, feedback and tabulation of correct answers –Links to any URLs on the internet Page 161

Nutrition in Global Health Prepared as part of an education project of the Global Health Education Consortium & collaborating partners Allan J Davison.

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Nutrition in Global Health Prepared as part of an education project of the Global Health Education Consortium & collaborating partners Allan J Davison.

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Presentation on theme: "Nutrition in Global Health Prepared as part of an education project of the Global Health Education Consortium & collaborating partners Allan J Davison."— Presentation transcript:

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