1. TF In the poor nations almost everyone is hungry; in the remainder almost everyone gets an adequate diet

2. TF Worldwide, more people have their lives shortened by overeating than by starvation

3. TF When poor nations now find a place on the ladder of development, they develop slower than rich nations did when they developed

4. TF Most NAm specialists in global health understand how the distribution of poverty & hunger are changing

5. TF Health & nutrition benefits are possible only after economic development occurs

6. TF People in regions of extreme hunger & poverty desperately need money7. TF 50% of children in US will, at some time, have to rely on charity for foof?8. TF Over half of the worlds hungry people live in Africa9. TF Discovery of rich mineral resources is of great help to the development of

an economically stressed nation10. TF The percentage of people who are hungry gets less and less very year11.TF Population growth has brought us to where the world cannot produce

enough food for everyone

Which THREE of the following are True?

Quick answers1. F In some nations hunger is the norm; in the remainder, an

adequate diet is the norm2. T Worldwide, more people have their lives shortened by overeating

than by starvation 3. 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?

4. F Most Canadian specialists in global health understand the how the distribution of poverty and hunger are changing?

5. F Health & nutrition benefits inevitably occurs after economic development rather than before

6. F People in regions of extreme hunger & poverty desperately need money

7. T 49.2% of children in the US are currently so poor that they must rely on charity for their meals?

Plan to spend 2-3 hours reviewing web info

What works & what doesn’t?toward evidence-based solutions

http://www.sfu.ca/global-nutrition

“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)

1 billion hungry (800m); 1 billion overweightMinefield Experts are living in the pastNothing in texts

Page 5Page 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.

Global Nutrition

We have a roadmap to a world without hunger

Where are we headed?

The ugly

We know what works

It wasn’t an accident

How did we get here?

Where are we now?

Can anything help? Yes

Stuffed & starved

The badWe keep doing what

we know doesn’t work?

The good

Most of you will see hunger in museums!

We are part of the problem

Overview of Nutrition in Global Health

1. Malnutrition and MDGs: cause, effect & cure3 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 37. Trends in nutrition, food security & globalization3

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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 8

3 Critical periods: nutrition in the life-cycle4 slides: 1. Perinatal nutrition: 0-6 mo: Breast vs. formula

1st 5 y Weaning & infancy –intellectual develop2. School years; ability to learn3. Work performance4. Elderly

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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.

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Note button

A click on the note button takes viewer

to the note

Nutrition through the life-cycle

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Stage Risks associated with malnutrition Prenatal & (pregnancy)

birth defects, birth weight, infant and peri-natal mortality, high maternal death rate

Infancy & early life

cognitive & physical development, bone malformation blindness, impaired immune response, risk of infections, faster progress of HIV, in protein-energy malnutrition, early death from causes the well-nourished would survive

Adolescence & adult life

risk of infection, anemia, diabetes, problems with heart, lungs, vision, risk of all cancers, anemia, blindness, beriberi, pellagra This stage of life lays a foundation for later good or ill health, osteoporosis, greatly diminished life-expectancy

Old age few chronically malnourished persons survive to old age. Those who do survive poor lifestyle and nutrition, often endure a very low quality of life

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!

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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/jccom/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 yearhttp://www2.unicef.org/nutrition/index_22657.html

• Page 13

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://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html

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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

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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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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.

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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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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 disordersberiberi, scurvy, etc, can range in severity from mild to fatal

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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 20

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.

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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.

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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 23

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 24

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 25

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 26

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

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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 28

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 29

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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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 ofdiabetes, 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

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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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Dietary patterns across cultures2. 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 33

Dietary patterns across cultures3. Indigent, landless crop plantersBenefits: 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 34

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 35

Dietary patterns across cultures5. 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 adultsdiabetes (carbohydrates), cholesterol, atheroma (lipid), strokes, heart disease diabetes, gout (uric acid - meat sources)

Page 36

Note J

5 Nutrition & disease cause vs effect4 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

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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 38

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 growthPage 39

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.htmIron, vitamin A, iodine – check the latest information at: http://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 40

4) Vitamin A deficiencyOver 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

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 41

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 42

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 43

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

The special importance of proteins

Page 44

• 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 45

• 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 46

... 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 47

• 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 48

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 49

• 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

Page 50

• 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: diagnosisWhen 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

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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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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)

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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

• 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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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 55

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

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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 57

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 58

Iron excess - dangerous to some

Page 59

• 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 60

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 nutritionIn 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 61

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

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 62

Iodine deficiency disorders

• The world’s major cause of preventable brain damageIn 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

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For latest data, see: http://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

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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

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